Full Transcript Hormone Therapy: When to Taper or Stop 0:00 So for those women, they can really pretty much safely stay on into their 60s as long as they don't develop another problem, 0:08 such as high blood pressure, which puts them at a higher risk for stroke or actually get a blood clot. 0:13 Then we just have to stop hormones. 0:14 In that group, That was one of the groups that should not be on them forever because between ages 70 and 80 women that were taking hormones in the Women's 0:24 Health Initiative and who had a hysterectomy and who were taking estrogen only had a higher mortality. 0:30 It was one of the few groups that had a higher mortality risk. 0:33 Have you made it past menopause, or are you going through it now? 0:37 I'm Dr. 0:38 Pat McShane, and on the Women's Health Span Voices podcast, I'll guide you through the health challenges of the menopausal years and beyond, 0:47 guiding the way to thriving in this powerful era of your womanhood. 0:51 Hello and welcome. 0:52 I'm Dr. 0:53 Pat McShane and I'm delighted to have with me today Dr. 0:56 Nanette Santoro, who is a long standing colleague and friend and my boss at the moment. 1:04 She is a professor at the University of Colorado and the E. 1:10 Stuart Taylor Chair of OBGYN, as well as the member of the Division of Reproductive Endocrine and Infertility and Reproductive Science. 1:21 Dr. 1:22 Santoro is a well-known, internationally renowned researcher, especially in the area of menopause, which is what we're going to be talking about today. 1:31 And she's, besides all that, a wonderful clinician and a good colleague to have around to ask hard questions about difficult patients. 1:40 So Nanette, great to have you with us. 1:43 Thanks so much. 1:45 Thanks, Pat. 1:45 You have been seeing clinically for many years menopausal women before and during the menopause transition, as well as some women who are post-menopausal, 1:57 besides the other endocrine problems that we deal with in our unit on a frequent basis. 2:04 And so in addition to that, you've been a researcher in several large national studies funded by the NIH and other major funding agencies. 2:15 So today we're going to ask you to draw upon both your clinical experience as well as your research knowledge. 2:24 I thought we would start with women who have been happy on their hormone replacement. 2:31 And now the time has come to start thinking about stopping that replacement. 2:37 And the first question is, what age do you think that that normally should occur? 2:45 The age that it should occur really depends on a number of different things. 2:48 First of all is when was it started? 2:51 But one of the biggest factors is duration and also the type of hormones that patient was using. 2:58 And then that's combined with some of her background risks. 3:01 So I can give you the first story I can give you is the generic story.
Vaginal Estrogen for Ongoing Symptoms 3:05 So this would be for the Jane average patient of average risk. 3:09 If a woman is of average risk for breast cancer and has no other health problems, that would make hormones a bad idea for her. 3:18 Women that continue them from the onset of menopause up to about age 60. is reasonable. 3:27 The average duration of hot flashes is about seven years and for some women it lasts for 10. So usually after about five years on hormone therapy for women 3:36 that have begun when they are, say, 50 years old, we start trying to wean. 3:41 So I'll have a patient say, you know, why don't you try cutting back on those hormones? 3:45 You may be one of those people who has an earlier dissipation of your hot flashes. 3:50 If that's the case, you may not even notice that you've stopped them. 3:53 There are theoretical benefits for women taking them in their 50s, but those are not proven by randomized trials. 3:59 So really the only thing that the patient is doing is A, relieving symptoms and B, increasing her breast cancer risk. 4:05 That's what we have good data on. 4:07 So we want to balance those things. 4:10 If symptoms aren't there anymore, then there's no reason to increase the risk part of that equation. 4:15 And this is a woman who has a uterus who's taking estrogen and progesterone. 4:19 So at about that point, we'll start to try weaning. 4:22 Often it doesn't work and we'll just continue to try every year or two. 4:26 And sometimes my patients will tell me that, you know, I ran out of my prescription for a couple of weeks and we're not stopping this year. 4:33 We're just not going to stop. 4:35 And that's not a terrible thing. 4:37 I mean, breast cancer risk is a small incremental increase every year. 4:42 But it does add up such that by the time a woman has been taking estrogen and progestin for 10 years, she has doubled her breast cancer risk. 4:51 If she's at lower average risk, that's acceptable to some of my patients because their symptoms are so bad. 4:57 But if she's at very high risk, sometimes women will have a really pretty unacceptable risk of breast cancer after 10 years. 5:03 So we're going to want to stop that sooner. 5:05 The case is a little bit different for women who've had a hysterectomy. 5:08 They're taking estrogen only. 5:10 And what we know from the Women's Health Initiative is that those women do not have an increased breast cancer risk. 5:16 And when they took the preparation in the WHI, which is Premarin, they actually had a decreased breast cancer risk that hung on through the whole study.
Finding Menopause Expertise and Second Opinions 5:25 From the original report at five or six years after starting, now to 20 years later, they have a lower breast cancer risk and lower breast cancer mortality. 5:35 So the risks to them are a slightly higher risk of stroke and possibly a higher risk of blood clots. 5:41 Those are the women that tend to also have worse hot flashes that last longer. 5:47 So for those women, they can really pretty much safely stay on into their 60s as long as they don't develop another problem, 5:55 such as high blood pressure, which puts them at a higher risk for stroke, or actually get a blood clot, then we just have to stop hormones. 6:02 In that group, that was one of the groups that should not be on them forever because between ages 70 and 80, women that were taking hormones in the Women's 6:11 Health Initiative and who had a hysterectomy and who were taking estrogen only had a higher mortality. 6:17 It was one of the few groups that had a higher mortality risk. 6:21 So after age 70, that really becomes more risky for that patient and we try to get them off. 6:27 So again, we'll go through the usual maneuvers, try cutting back on the hormones. 6:30 How bad are your symptoms? 6:32 Let's try substituting other meds. 6:35 And if nothing works, then for some women they will just stay on. 6:39 So it sounds like for most people something can be worked out in terms of tapering, gradually discontinuing, and then ultimately stopping. 6:48 But many people still do have hot flashes after they discontinue, which is the major symptom. 6:55 If people are having vaginal symptoms, what is the recommendation at that point? 7:00 But they're no longer on oral meds.
What SWAN Reveals About Menopause Timing 7:03 Yeah, if a woman can withdraw from body-wide estrogen but still has vaginal symptoms, giving topical vaginal estrogen is a pretty safe bet. 7:12 There's very good data on some of the newer preparations, the tablets. 7:16 So we're getting data on the tablets and the inserts. 7:20 The ring has very good data using what we call mass spectrometry, very accurate estrogen measurements. 7:26 And the measurements of estrogen in the bloodstream on women using those methods is very, very little increase. 7:33 It's not even known if that's biologically significant. 7:36 When you look at the long-term outcomes of those women, they seem to be very benign. 7:41 There are no increased problems. 7:42 So the risks of things like breast cancer, blood clots, stroke don't seem to apply at all when we're talking about vaginal estrogen. 7:50 But they're very effective, the preparations in reversing the vaginal symptoms. 7:54 So it's a win-win for that group. 7:58 Yes, and that's particularly important because hot flashes for most women, but not all, will go away. 8:03 Vaginal symptoms never go away. 8:06 In fact, they can get worse as people are older and older. 8:10 More years, 10 years, 20 years out from having natural estrogen or or estrogen replacement, and those tissues just seem to get thinner and more fragile, 8:21 and urinary symptoms, sexual symptoms, and so on. 8:25 So, well, that's great. 8:26 Thank you. 8:27 If you obviously have tremendous experience and tremendous knowledge of the literature, The typical OB-GYN who has, what, 8:36 10 minutes to see a woman might not have as much knowledge and background as you do. 8:42 What would you tell someone who says, my doc isn't listening to me, I'm not happy with what she or he has been telling me about managing this tapering 8:53 of my hormone replacement? 8:54 What would you tell that patient? 8:57 Many women can seek second opinions. 9:00 There are some great sources of information online. 9:03 Reproductive endocrinologists do have training in menopause, but many of them now are focusing practice on infertility. 9:10 So finding a reproductive endocrinologist who will also see menopause patients is important. 9:16 If you're just go to the reproductive endocrinologist, don't assume that they're able to treat you. 9:24 There's also the North American Menopause Society. 9:26 That's menopause.org. 9:29 And at that website, they will give you a list of menopause practitioners. 9:36 What that means is that these are people who read a book of guidelines on menopausal management, a pretty extensive clinician's guide, 9:48 and had to take a test. 9:49 And from that, they got a certification. 9:52 So that is a group that tends to be knowledgeable with the most up-to-date information on menopause and has taken the trouble to make steps. 10:00 And that includes OBGYNs, reproductive endocrinologists, it includes family medicine physicians, nurse practitioners, PAs, 10:08 and others who have taken a special interest. 10:11 So that is available on the web, and there's a heat map that can show you geographically where to find someone near you. 10:17 I'll put that information in the show notes below this link. 10:20 So that's great. 10:21 Thank you so much. 10:23 I want to just step back now and talk more about the meaning of menopause in a broader scope for women's health and some of the some newer information, 10:33 some older information that has come out. 10:36 that puts an emphasis on the timeline of menopause to really take stock of your cardiovascular and other risk factors and try to do the best that you can 10:48 to have a nice healthy life expectancy. 10:51 Maybe you could tell us a little bit more about some of that research. 10:55 Sure. 10:56 So in the SWAN study, which is the study of women's health across the nation, we began with about 3,000 women. 11:02 from five different racial and ethnic groups. 11:04 So we had white women, black women, Hispanic women. 11:08 Most of the Hispanic women were either Puerto Rican, Dominican, Cuban, or Central and South American. 11:13 So Mexican women are not well represented in SWAN. 11:16 Fortunately, we tried. 11:18 We also have Chinese American women and Japanese American women. 11:22 And those groups were at different sites around the country. 11:26 We are what we call community based. 11:28 So these women are a lot like you and me. 11:30 They're free ranging and did not have any particular medical problems at the beginning of the study. 11:35 So we did an observational study that's now been going on for 25 years. 11:40 Women were begun recruitment around age 45 to 55. And we have followed them every year for the first 12 years and then every couple of years after that. 11:50 So this gave us a very good picture of what the transition to menopause looks like in terms of symptoms. 11:56 in terms of biological markers. 11:59 And one of the most striking findings is that women will go through predictable patterns. 12:04 So while menopause seems sort of unpredictably unpredictable, some things happen that are milestones that a woman can pretty readily recognize. 12:13 So if you are having regular menstrual periods and you're not taking hormones like birth control and using an IVD that's going to mask your cycle,
Cardiovascular Health and Takeaway Advice 12:23 most women will notice a skip. 12:24 They'll skip the cycle. 12:26 And now that we have smartwatches and fancy devices to measure our cycles more carefully, a more than seven-day difference in the menstrual cycle length, 12:34 meaning the beginning of one period to the beginning of the next, perils that entry into the transition. 12:41 The median age that that happens is about age 47, but it can be much earlier. 12:47 An earlier entry into the transition usually means that it's going to be longer and probably more symptomatic and bothersome. 12:55 So I know when a patient comes in my office and she's 37 and she's reporting these symptoms already, she's probably going to have a rough time. 13:03 She's probably going to wind up needing some treatment. 13:06 But, you know, let's see how it goes and how the discussion goes. 13:09 By age 49, women begin to skip for longer and longer periods of time. 13:13 So that 60 days or more of amenorrhea marks the entry into the late transition. 13:20 And from that point, it's 95% likely that within the next four years, That woman is going to have her final menstrual period. 13:28 Could be earlier, could be a little bit later. 13:30 But for the most part, final menstrual period four years later. 13:33 And that's right at around age 51, 52 in the population. 13:38 So most, that's the median age at menopause. 13:41 And it's unlikely that women have menopause after age 54. That's a late menopause. 13:47 That's beyond the 95% sort of limit of age. 13:51 And a late menopause carries some issues with it, but in general, it's a marker of good health. 13:57 While we tracked women in swine, we looked at their tendency for diabetes. 14:01 We looked at heart markers. 14:03 We looked at their cholesterol levels. 14:05 We looked at the thickness of the arteries in the neck using ultrasound. 14:09 It's a marker of atherosclerosis or hardening of the arteries. 14:14 And what we found is that that late transition seems to be the flashpoint where pretty much everything takes a turn for the worse, 14:23 even in the healthiest women. 14:25 So that is when the most mischief happens. 14:28 Hot flashes get worse. 14:30 The thickness of the carotid arteries increases at the most rapid pace. 14:34 Bone loss begins to occur rapidly, and we'll do that for the next five to seven years, and then it levels off again. 14:41 So that's where we really want to watch what's happening with the women. 14:46 That's when women will notice that their waistline starts to expand. 14:49 It's almost universal. 14:50 There's an increase in sub mid-body fat. 14:54 And there's a small decrease in lean body mass. 14:56 And that levels off again when the transition is done. 15:01 So some of these things are attributable to age. 15:04 Some are attributable just to hormones like estrogen, but it's overly simplistic to think that everything is hormone related. 15:11 There may be an interaction also hormones and with symptoms or symptom susceptibility. 15:17 That's great. 15:18 That's great information. 15:19 Thank you. 15:20 Those are kind of the main messages that I wanted folks to be able to get from you today. 15:26 And I think I like to end my videos with a kind of to do what's the take home message from all of this. 15:34 And based on what you have told us today, I think my take home message would be to stay linked in with your primary care doc during this time and be watching 15:48 your blood glucose levels, your cholesterol levels, your blood pressure, your weight, and exercise of course underlies prevention of many of these other 15:59 conditions that do seem to increase as women go through their menopausal transition. 16:05 Is there anything else that you would like to add that is a take-home message for people today? 16:10 Well, I think that's your last part is the most important. 16:13 It's really, it's the simple stuff. 16:16 And I also think that women at this time of life tend to neglect that sometimes. 16:19 But the American Heart Association used to have what they called Life's Simple Seven. 16:24 And now they made it Life's Simple Eight. 16:26 So they went up eight to include sleep, I think. 16:28 But it's just all the things that you're saying, you know, check, have your cholesterol checked. 16:33 This is when it changes. 16:35 This is when high blood pressure may, become evident if it runs in your family. 16:39 This seems to be the point in life where women will express that problem even if they haven't had it before. 16:46 So it's good to stay connected. 16:48 And also, I think an important aspect is to treat symptoms. 16:51 Don't suffer in silence. 16:53 Hormones are not as dangerous as they have been portrayed. 16:58 Many women can very safely take them. 17:00 And it can make this ride a whole lot easier. 17:04 Hormone treatment is going to make any of those other outcomes change, but it'll certainly help you sleep and make it easier to stick to a healthy regimen. 17:13 Great. 17:13 Well, thank you. 17:14 I think this was very comprehensive and easy to understand, hopefully. 17:19 And as I always say at the end of my videos, if you have things that you would like me to cover, please put it in the comments and I'll do the best I can. 17:29 Otherwise, please take some of Dr. 17:32 Santoro's great advice to heart, and I hope you're having a long, healthy lifespan. 17:37 Thank you so much. 17:39 Thank you, Pat. 17:40 Thanks for listening to the Women's Health Span Voices podcast. 17:44 If today's episode spoke to you, follow the show and share it with a friend ready to take charge of her health and please leave a review. 17:53 It helps more women find us.
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