Dr. Kathryn Macaulay, MD, MSCP, director of the Menopause Program at UC San Diego Health, reveals everything you need to know about symptoms, hormone health, and the latest developments in awareness and education related to the condition.
Menopause may be having a moment. But are you still confused? Are you suffering from brain fog, hot flashes, weight gain (or any of the many other perimenopause symptoms) and need help?
Well, it’s all here! I interviewed Dr. Kathryn Macaulay, MD, MSCP and director of the Menopause Program at UC San Diego Health, to help break down and demystify the many changes women deal with in perimenopause.
Dr Macaulay also gives the latest details about the now-debunked 2002 WHI (Women’s Health Initiative) Study, what it got wrong – which led to the halt of HRT being prescribed – and how menopause care is finally get the attention it deserves.
She does give a lot of expert detail about the study, particularly about the use of progesterone in the WHI study (I had to watch the video a few times to truly absorb it!) so I’ve pasted the transcript below this post. It’s definitely worth knowing, so check it out!
I really hope the interview helps you better understand your symptoms and what you need to help them. Perimenopause can be such a confusing and distressing time. There’s still a long way to go in every women getting the individualized hormone and menopause care she needs in midlife, but knowledge is power and it’s so important to advocate for our health when we go in the doctor’s office.
Take what you learn from here and get the help you need and deserve! Contact me any time via here to let me know what midlife challenges are so I can know what expert interviews can help.
INTERVIEW KEY TAKEAWAYS:
- The shift in menopause education and awareness over the last four years.
- Understanding the Women’s Health Initiative (WHI) study and its implications for HRT.
- The importance of individualized care in hormone therapy.
- Common and lesser-known symptoms of perimenopause.
- The role of lifestyle changes and diet in managing menopause symptoms.
These timestamps can help you jump to topics if needed:
00:00 Introduction begins the program. 00:30 Moreover, changes in menopause education are discussed. 02:00 However, the WHI study is explained. 05:00 Additionally, individualized hormone therapy is covered. 08:00 Furthermore, common symptoms of perimenopause are presented. 10:30 Moreover, lesser-known symptoms are discussed. 12:00 Also, lifestyle and diet tips are provided. 15:00 Finally, Q&A on HRT is answered.
What’s your biggest challenge with perimenopause or menopause? Drop it in the comments so I know what you need help or advice on for future expert interviews.
Medical Disclaimer: The information provided in this interview and podcast is for general informational and educational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.
OTHER RESOURCES:
Subscribe to the YouTube channel Taking the Mystery out of 50 for weekly insights on menopause and women’s health.
https://www.youtube.com/@takingthemysteryoutof50
Join the private Facebook group ‘Managing Midlife and Menopause Together Community‘ to connect and submit your questions for upcoming interviews.
Follow on Instagram: /takingthemysteryoutof50
Other articles with Dr. Macaulay on this website:
Still Confused About Perimenopause? You’re Not Alone.
What to discuss with your OB-GYN in Midlife.
Should all Women have an OB-GYN annual physical?
The groundbreaking menopause NY Times article Dr. Macaulay mentions.
INTERVIEW TRANSCRIPT
Madeleine
So hi Dr. McCauley, thank you so much for joining us. We first connected about four years ago when I interviewed you for an article about perimenopause, pretty comprehensive article. looking back on it, I realized that we actually didn’t delve into HRT too much probably for various reasons because the subject was a bit different back then. So we’re gonna talk about perimenopause again and update. information on what’s happened in the menopause industry, education and awareness. Obviously, I know it’s changed in the last four years, but you’re the expert. you actually teach it, you’re the director of the menopause program at UC San Diego Health, and at OBGYN. So I would love to hear from you really what’s happened in the last, say, four years or just recently, with in menopause education.
Kathryn Macaulay
Sure, yeah, great. And thanks so much for having me. I’m happy to come anytime and talk about menopause. It’s one of my favorite topics. So I’m glad to be here. But yeah, a lot has happened in the last, three, four years for sure. I was giving a lecture this morning and one of my slides is menopause is in the mainstream. Why now?
Because menopause went dark for so long after, you know, in the wake of the WHI study in 2002, but the last few years we’ve seen a real shift. And I think it there’s a variety of factors that kind of came together. One would be, you know, the popularity of here we are podcasts, social media, internet, social media influencers, some of whom are physicians who took an interest in menopause and became very, kind of vocal about it, as well as certain celebrities going through menopause at the same time or around the same time.
And realizing kind of like a gap in care and the challenges with getting the care they needed and and being vocal about that as well, and kind of publicizing that. there’s also been interest from investors in the menopause demographic and some financial publications from probably more than five, six years ago showing how lucrative potentially this market is, of an untapped market. So we saw also with COVID an increase in telehealth and then with menopause becoming more out there, more providers, more telehealth platforms providing specifically menopause care.
Investors also investing in those platforms. So kind of different business models for improving access of for care. and then I always think a turning point was an article in the New York Times from February 2023, written by the journalist Susan Dominus, entitled Women Have Been Misled About Menopause. and that was a great article about what happened around the time of the WHI and after the study
Madeleine
Mm-hmm.
Kathryn Macaulay
ended prematurely and sort of the downstream effects of that over the years. She interviewed many people for it. It’s just a very thorough article. Some really top experts are interviewed in that. article as well. So it’s a great read. that went viral. There were, thousands of comments in the comments section with a lot of women sharing, their experience and a lot of them, feeling kind of dismissed or just having trouble getting care and different stories being shared about that. So I think that kind of started to really get menopause out and the discussion started again.
Yeah. All those so that article was so just so great that she was invited to be the keynote speaker at the Menipaw Society annual meeting later that year. So it was really exciting to hear her talk about the feedback she got from that. so yeah, yeah. It’s a really
Madeleine
Interesting. I’ll I’ll link that article actually to at the on the bottom in the show notes.
Kathryn Macaulay
it’s a good one.
Madeleine
talking can we just quickly go back to that WHI study? Could you break that down for people listening? I mean, I know it’s been in the news a lot, but it’s still to come from you, from an expert. That would be great. The flaws and everything to do with that.
Kathryn Macaulay
Yeah, yeah. I think it’s just Yeah. I mean, the flaws were it I don’t really like to talk about that way. I and I again
Madeleine
Hm.
Kathryn Macaulay
I just was talking about this this morning in the other presentation I give. I have a slide on this, sort of what do we learn from it? you know, it wasn’t a study that was ever designed to look at the risks and benefits of treating symptomatic women in their early menopause or their Perimenopause or fifties. It was a primary prevention study looking at a very specific dose of oral, a type of oral estrogen with a type of progestin. so it was kind of narrow in a way. It wasn’t looking at all the different formulations we have and it wasn’t looking at younger women. I think, we learned some things about what not to do with hormone therapy. And I think that’s really important.
I mean, we saw what happens if you initiate hormone therapy to a woman, particularly who’s far out from menopause, more than 10 years, that there Risks. We saw again what risks there are with oral estrogen, which we already knew, but kind of confirmed that in terms of risk of blood clots and stroke and those risks go up, the older you are. So we learned some of what not to do. And then we also very interestingly saw the role of the type of progesterone they used in that study, madroxy, progesterone, acetate, and its potential that it may be a driver for the increased breast cancer risk. And the women who were in the combination who had their uterus and had to take a progestin along with the estrogen.
Madeleine
Yeah.
Kathryn Macaulay
Because the other arm of that WHI study was women who had hysterectomies and took the estrogen alone. And they found a decreased risk of breast cancer over time in their post-intervention follow-up studies at 13 and 18 years. So that changed our view of looking at progesterone and breast cancer and the type of progesterone. So I think that there were things we learned from that study. it was also the first randomized controlled trial of hormone therapy that showed a reduction in vertebral and hip fractures with hormone therapy. So we knew that estrogen already had positive effect on bone density, but this was actually, looking at the fracture risk reduction. So that’s a positive for hormone therapy.
Madeleine
Yeah.
Kathryn Macaulay
So there are some things we learned from that. it just really got taken out of context for unfortunately the women who were, going through menopause at that time who were still good candidates to use hormone therapy, and got kind of just lumped into this no, it’s too risky group.
Madeleine
Yeah. Thank you. A couple of things I was thinking as you were saying that. So can you just go over what kind we’re gonna delve into HRT detail later, but was it just oral HRT that they were taking and was it just synthetic? Because that’s different. That makes a difference, doesn’t it?
Kathryn Macaulay
Yeah, it was yeah. It was the more popular hormone therapy that women took at the time.
Madeleine
Okay.
Kathryn Macaulay
The brand name was Prem Pro Conjugated Equine Estrogen with Madroxy progesterone acetate. That’s a combination pill if they had a uterus. if they had hysterectomies, then they just took the conjugated equine estrogen alone. it was one dose, point six two five, two point five for the combo and then point six two five for the estrogen alone. So that’s why I was saying it was a very you know just one fixed dose. It wasn’t sort of looking at HRT all sorts of formulations and dosages.
Madeleine
So we now even know that oral HRT has got side effects that other ones don’t anyway, don’t we? Like the transdermal patches and the other gels. That because it’s absorbed through the liver.
Kathryn Macaulay
Right. Right.
Kathryn Macaulay
it’s pass and and it’s metabolism is through the liver, right? So
Madeleine
Right.
Kathryn Macaulay
with oral and the transdermal skips that. So with transdermal you don’t have that stimulation of pro coagulant, pro clotting like proteins and such.
Madeleine
Sure.
Kathryn Macaulay
so we have a good body of observational evidence to support transdermal estrogen, particularly at like average to low dose not having an increase in blood clot risk
Madeleine
Okay. So we should say another significant change obviously. It was in November last year when the FDA removed the black box warning, as they say, on HRT. Can you tell us a bit more about that?
Kathryn Macaulay
Sure. So that was a welcome, in my opinion, a welcome change because it was frustrating. I mean, the black box warning was put on all estrogen and progesterone containing products and cited specifically the risks from that initial 2002 WHI study. So for instance, putting those risks that blood clot, breast cancer, stroke, heart attack on vaginal estrogen, which is just locally absorbed and isn’t even absorbed and is not associated with any of those risks.
Madeleine
Hmm.
Kathryn Macaulay
So that was very frustrating because women would really need to start an estrogen and come in with a lot of symptoms of what we call genito urinary syndrome of menopause and need a vaginal estrogen. And then I’d prescribe it and have them come back in three months, see how they’re doing. And it turns out, you know, I didn’t start it because I read the package insert and I got scared. So then I got into the habit of taking that extra time to explain that part. It didn’t really reflect what the product well.
Madeleine
Yeah. I should say around the time that I spoke last spoke to you about four years ago, so I was 51 then, I was perimenopausal. And I asked my doctor, not at UC I’m a with a different provider, if we could talk about my HRT options. And I clear as day I remember her look she was typing and she just turned around, she looked at me in the eye and just said, You don’t want do that, you could get breast cancer or blood clots. Now, this was four years ago, and I knew then that the WHI study had been debunked. And I was staggered. I did know people who were on HRT, and I was shocked and I was really disappointed because I knew it was case close. There was no way I was going to get hormones. And I spoke to a friend who was also with them, and they were like, Yeah, you won’t get them there. So how has that changed for doctors, would you say, and how you teach and since then?
Kathryn Macaulay
Just to clarify, I wasn’t scared about the black box warning. I was frustrated with it. The patients were.
Madeleine
Right.
Kathryn Macaulay
So I had to take the extra time to explain that then with future prescriptions so that patients wouldn’t come back and then we lost three months in our treatment plan.
Madeleine
How has itt changed? Because I know you teach residents.
Kathryn Macaulay
Well, it’s not changed how I teach or anything like I already understood, the safety of using hormones in women in their fifties because there was a sub-analysis of the WHI study that looked at the risks based on age and for cardiovascular risk. That was published at least a few years after the initial WHI study. and they saw that there wasn’t an increased risk in adverse cardiovascular outcomes in the women in the fifty to fifty nine year old age group. So when they broke it down, because they had women age fifty all the way to seventy nine enrolled in that study.
So the initial results were all the results together, but then they did a later looked at it by age. so I already knew, in that age group within 10 years menopause that it should be safe to use. And we, have our transdermals that we use now more often for the estrogen component To minimize, thrombosis risk as well.
So I don’t think my teaching has changed that much. I’ve been teaching this over the years and because there was such a need. patients still were referred to be by their primary care doctors over the years being taken off hormones and wanting to start. So I had to give the blessing to a lot of hormone therapy prescriptions over the years when other people didn’t want to prescribe it.
So Personally, the black box warning, I’m seeing it more that the patients feel more reassured by that. And I think other providers, other than, primary care providers that I’ve talked to, nurse practitioners, you know, APPs, different people are interested in menopause I think it’s because gives a lot of people more comfort that there’s not this big warning on it.
Madeleine
Yeah. Actually that’s a good point. I wanted to ask you because I was speaking to a friend yesterday, telling her that I was gonna interview you, and she was like, please ask this because there are nurse practitioners and PAs who are setting up their own businesses and making good money. and so for example, she went to a nurse practitioner, she was prescribed testosterone only. and her husband actually at the same time. And she later went to an OBGYN because she was starting to feel a bit uncomfortable about it. And she was tested, and the OBGYN said, your testosterone levels are off the chart and it could be thickening your blood. So what do you say to women who go to those kind of side businesses or they can be a menopause certified practitioner, can’t they?
Kathryn Macaulay
Yes. There’s a lot of those practices and I would say to them I understand why. I have lots of patients who were waiting for the appointment with me and I completely get I’m seeing as many people as I can, but there’s only so much I can, do and so yeah, I tell them I understand, the need for getting help sooner and usually that’s a long wait.
I’m trying to expand our program at UCSD to have more providers. so and we do, we have now a total of 10 providers and it’s growing. So there’s more people to see within UCSD. It’s not just me. So for a while it kind of was, but that’s really changed. But
So I just feel that. especially for patients who have insurance. the visits at least should be the lab work should be covered by insurance. testosterone is off label used for postmenopausal women with with low sexual desire. so it depends. Sure insurance doesn’t always cover it. for different reasons, I don’t always understand why, so they may have to pay for that out of pocket, but it’s actually not always that costly because what lasts a man a one month supply would last a woman almost a year. So, if you look at it monthly, it breaks down to a better, cost usually.
So I feel disappointed that, some of these practitioners charge a lot of money for these initial consults and repeat visits and and then, especially to be you have your testosterone off the charts, we have no idea. What that’s going to do. We know what the adverse side effects are of having a superphysiologic testosterone as a woman. Long-term risks, I don’t know what you’re doing with your body, So that’s not really sustainable as a woman.
You didn’t live in that testosterone range when you were 30. Now you’re, 50s or 60s or, you know, with these sky-high levels. what on earth are we doing with the body? So it’s kind of an experiment that they’re doing then, with those superphysiologic levels, but I’ve seen some. unfortunate side effects for women who were overdosed on the testosterone, voice changes, hair loss, things like that.
I understand why they would seek out that care. But yeah if they could see a certified menopause practitioner, that would be good. But I would say that a lot of people have been getting certified by the menopause. society, it seems like it’s that membership has really grown. we have doctors who are not even women’s health specialists who they take care of an entirely different patient population and suddenly they’re menopause certified, and out seeing patients and charging large sums of money.
Madeleine
It’s big business, like you say. Yeah. Hmm.
Kathryn Macaulay
So that’s concerning to me because I don’t think it’s necessarily so simple that you can just decide to switch I think there’s a lot of nuance to what we do.
Madeleine
Does telehealth fall into that bucket? The ones that are specific?
Kathryn Macaulay
Some of them are good. And again, I appreciate their role being out there trying to help with appointments and access for women and if they take insurance too, which I think is great. but they vary in quality. So I think that bears looking at. It would be interesting if someone could do something where they can maybe look at, the quality of the different types of providers and and how in align they are with, recommended, care and guidelines. It would be interesting to see.
Madeleine
That gives me a good idea. Okay, I could look into that, yeah.
So could you talk a bit about the menopause program at UC San Diego Hill?
Kathryn Macaulay
Yeah, so I started the program as a junior faculty member in two thousand four. we really had a strong need in our department for somebody to take over menopause because what had been sort of a more straightforward thing, we were kind of prescribing hormones and not really worrying about it and thinking there were at the time a lot of benefits we thought and it had become a much more complicated discussion after the WHI in terms of helping people understand really what are their risks.
So the emphasis became on providing more individualized care with hormone therapy, not just a one size fits all approach. and so it took more time. And so, there were providers who maybe didn’t wanna go that path and take the time for that and so maybe or had other, things that they were busy with. Maybe they did more OB, more surgery, So I was interested in the area for a long time. And so I started the program that way. And it was good because I got a lot of referrals. Yeah, yeah. I got a lot of referrals.
Madeleine
Okay. so you actually started the program?
Kathryn Macaulay
Yes. They had a menopause program at UCSD back in the nineteen eighties, when they had some different people there running the department who were interested in it. so it’s interesting. They they had already had a menopause program. It just but not at the time anymore when I started training there. So it was good.
I got initially a lot of internal referrals from like primary care doctors in particular and from my own colleagues. Some of these were women who abruptly stopped their hormone therapy after the WHI. And we know from studies, fifty percent of women have return of symptoms after stopping and so they were just desperate to get back on. So I like I said, I gave the blessing to a lot of hormony prescriptions during that time.
Madeleine
Right. Yes, it’s interesting you say it because I’m reading a book called Estrogen Matters at the moment. And I was really surprised to find out that prior to the two thousand and two study, it was very common to get HRT, to prescribe it and get it. I thought it was quite a new thing, but prior to that study when it kind of screeched to a halt, it was very popular to treat menopause symptoms.
Kathryn Macaulay
Yes. I was in my residency training during that time and there was a lot of observational data that was showing cardiovascular disease prevention benefits, osteoporosis, dementia. long term health benefits but so the WHI was designed to be a randomized control trial to test that hypothesis that hormone therapy reduces risk of heart disease. What we saw in the observational studies.
Madeleine
Okay. So I do hear and read a lot of women who are still frustrated. I’ve now got on HRT, I moved providers and I was asked immediately, do you want to look into your HRT options? I was like, yes, fantastic. But I read all the time women so frustrated about being gaslit about their symptoms that are probably menopause symptoms. not knowing where to turn, but just being really frustrated and angry about this.
Do you know, outside of UCSD, do OBGYNs, what kind of menopause training do they get? Do they go to conferences? Do they get this ten minutes that you know that you hear about?
Kathryn Macaulay
Yeah, I mean I think it’s variable. We have many certified menopause providers now that I see in San Diego. I’ve got colleagues at other institutions. Kaiser’s starting a menopause program. yeah, I think it’s it’s gonna be variable. there’s plenty of providers, yeah. In
Madeleine
Okay. It’s growing?
Kathryn Macaulay
Yes. it’s just taken time and a lot of the priors didn’t maybe they didn’t get educated during their training. So that’s I think where we’re trying to catch up a bit. really trying to get the providers like this generation, my residents graduating, in a week, and they just rotated with me. They each got six weeks with me or something at least, and so they’re all gonna leave with a good foundation.
Madeleine
Okay, great. So we’ve gone over the positive news about developments in menopause education and for help for women who are going through it. So now can we break it down, go back to perimenopause, because that is still confusing for so many women, especially for a certain age. I’m fifty-five, so I’ve gone through all that stuff, but it was very confusing at the time. and a lot of women are going through it now. So obviously. so firstly, can you please sum up how you may know your in perimenopause?
Kathryn Macaulay
Yeah, that can be tricky for some, but I think if you’re in the right age range, I mean typically, we see that menopause can happen between like forty, fifty-eight. so perimenopause symptoms can happen even when you’re still cycling. so hot flashes would be one thing to look for, change in your cycle length, particularly a more than seven-day shift in your cycle length. You start to see that happening. night sweats, those are like nocturnal hot flashes. Mood changes. what gets hard is weight gain happens in your forties. It doesn’t always signal perimenopause. I mean, people are getting older and women do start to notice that But that can also be more rapid. So women can feel like it’s faster over perimenopause.
Fatigue is another hard one to know. It’s a problem because symptoms can present in a cluster, and it’s sometimes hard to tease out. Is it from another medication? Is it from something else?
Sleep disturbances certainly.
Madeleine
Would you do a a blood test? If someone came into you saying, I think I’m going through this, is that the first thing?
Kathryn Macaulay
It’s just not that helpful if especially if they’re having regular cycles. And even if they’re starting to have irregular cycles, it might be worth it – if they’re having irregular cycles to check thyroid levels, TSH, maybe prolactin.
It’s more useful in someone who doesn’t have menstrual cycles to go by. If maybe they had an ablation of their uterine lining and they’re not having periods, then I would do it, but I think the menstrual cycle tells you a lot about what’s happening hormonally. And blood tests just don’t really always reflect it.
When you’re in perimenopause, your blood test can fluctuate, your FSH can go high, it can shift around. So it could look like you’re in menopause, but then you have a period again and then it’s different at another time. So it’s challenging. I think you just have to look at the whole picture with the symptoms, the age of the patient, and what symptoms they’re having.
Madeleine
Sure. you’ve mentioned a lot of the more well known symptoms like insomnia, brain fog, hot flashes. What are some of the lesser known ones that you would say women could maybe attribute to perimenopause?
Kathryn Macaulay
Yeah, so joint pain, there’s there’s so many different symptoms that have been associated with menopause.
Madeleine
Yeah. Could you talk about joint pain a bit actually? only because I had it and I had no idea. I was having x rays and all kinds of things. What exactly I know the estrogen well, you can go more into it why we get joint pain and what kind of joint pain? Do you mean like when you sit down and your knees hurt or what is it?
Kathryn Macaulay
Well, it’s not just one thing. So I think there’s just a variety of musculoskeletal complaints that women can have. some authors who published a paper about this suggested even calling it musculoskeletal syndrome of menopause, which that’s not an official thing. But they were talking about just the variety of different changes in the musculoskeletal system that can happen during menopause.
So what’s hard to show is okay, is it estrogen or is it not? Is it just that developing osteoarthritis or but you can get muscle pain, joint pain… frozen shoulder is more common.
Women in a certain age group fifty, around ages 40 to 60, women can start to have bone loss. Bone loss can even start to happen before the last menstrual period like a up to a year before that so yes, some people maybe wouldn’t be aware that some of those things are happening. Some of those things you wouldn’t necessarily feel, but and then skin changes too.
I think skin changes are more really not so much with the fluctuation. More of the symptoms in perimenopause, I think, are driven by the fluctuating hormones. whereas, when you’re fully menopausal and estrogen is depleted now and low, I think that’s when you start to see some of the other things like the skin changes. that other challenge too is the variability between women and what they experience.
I have some patients who don’t really have many symptoms. I saw one yesterday and she was so happy. So she’s already been skipping her period for months now and she’s fifty-one and just feels good. So I think that’s a good indication she might not be a person who’s gonna experience a lot of symptoms. I think the fluctuating hormones can be tricky for like mood, sleep. That’s another one.
Madeleine
What about migraines? Because I had hormonal migraines for about ten years. Debilitating. Absolutely awful.
Kathryn Macaulay
Yeah, that those can get those can sometimes get worse during perimenopause. Again, especially if they are hormonally triggered, like menstrual cyclical, that might get sort of destabilized. typically though, for women with migraines, especially with menstrual migraines, when they reach menopause, they get better So there’s a good percentage of women that might find that that actually improves after menopause.
Madeleine
Yeah, that’s where I’m at now. I have them for ten years. My stepmum was the same and a friend. They had debilitating hormones for ten years, hit my menopause, and never had them again. So there’s always hope. However, HRT, I’ll ask about that later, but I know estrogen can be a trigger for migraines.
Kathryn Macaulay
Yeah. So yes, it can be. So I’m usually we have some caution. We can still use it in women with migraines, but it is something to be aware of that, you know, we might start with a low dose.
Madeleine
And does perimenopause affect your cholesterol levels and vitamin deficiencies?
Kathryn Macaulay
Yeah. For lipids, yes. there can be lipid changes that happen and they can start to happen quickly with changes in LDL, the bad cholesterol can increase, HDL can decrease. So there are changes seen there. hot flashes are felt to be like a marker of inflammation possibly, and have been associated with, worse bone health, cardiovascular outcomes, so it’s interesting. There’s a whole cardiometabolic component there.
Madeleine
And the brain fog, this is one I’ve had. and I was normalizing it for a long time. I would constantly lose my train of thought, which is really embarrassing. It’s ’cause I would always think, gosh, if I don’t sound interested enough in what I’m saying, how can anyone else be? But I would insert weird wrong words into sentences and honestly I went on HRT and it stopped almost straight away. Do you find that is common?
Kathryn Macaulay
It depends. The studies that have been done have shown a neutral effect. The better clinical trials have shown a neutral effect on HRT and cognition. That’s been looked at. Meaning like doesn’t really hurt it, make it worse or better. But anecdotally in my practice, yeah, especially again, the symptoms come as often multiple symptoms woven together and So maybe they have poor sleep and they’ve also got, fatigue and they’ve got brain fog and then they start HRT and their sleep gets better and then other things improve too.
So sometimes it’s hard to tease out what’s driving what when there’s multiple symptoms. But if the patient’s a candidate for hormone therapy and they want to try it and see if the brain fog improves. It’s not really one thing, brain fog. it’s a common complaint for sure, but it’s can be, a variety of different cognitive complaints from yeah, word finding, easy distractability, forgetfulness, difficult to concentrate, things like that.
Madeleine
Yes, it definitely helped me and I’m on a low dose because of migraines. So I’m just so happy about that because that was that was alarming to be honest. I was definitely researching early onset dementia a few years ago I hadn’t really heard about brain fog so much then. And it was alarming.
Kathryn Macaulay
Yes. And that that’s a great point. I do try to reassure my patients that early onset dementia is rare. these cognitive complaints seem to be worse during perimenopause, and then they tend to get better with post-menopause once the hormonal shifts are over and you’re fully in menopause. So that’s been demonstrated too in studies. so there’s there’s hope for that.
Madeleine
Okay. Can you talk a bit more about weight gain in perimenopause? What do you suggest to women? Beause it does come on differently and it seems like your your appetite increases and then it all goes round the middle. And what can you say in preparation for this? ‘Cause you can’t believe it till it happens.
Kathryn Macaulay
Yes. Well in preparation for it, I do tell women, if they’re premenopausal and they’re just asking, what should I do for menopause? certainly if their weight is not optimized before becoming perimenopausal or into menopause, I’ll come up with suggestions for them to try to get back to their healthy weight if they’re not there before menopause. And then there have been some studies looking at very, consistent exercise and stopping some of the weight gain. adhering to a Mediterranean type diet seems to be a more favorable diet, probably for everybody, but for menopausal women.
There’s some interesting work coming out looking at GLP1 agonists. It’s unfortunate hormone therapy doesn’t really seem to move the needle a lot With weight, again it tends to be more neutral in terms of not causing weight gain, but not always really resulting in big dramatic weight loss. but if someone’s really symptomatic, it might help if they’re really tired and not sleeping well and having a lot of maybe hot flushes during the day too, that are, making it harder to exercise and things like that and be mindful of diet, then yeah, indirectly hormone therapy may help. But I think There’s some studies coming out looking at GLP one agonist and menopausal women and showing good results and in combination with HRT even more weight loss.
Madeleine
Interesting. How about hair loss? What do you say to that? Why does it happen and what what do you suggest for it.
Kathryn Macaulay
Hair loss is difficult too. I’ll refer to dermatology if there’s patchy hair loss, if I’m concerned about certain types of alopecia that I don’t treat. usually making sure you’ve done a good work up thyroid function, check iron levels, things like that is important. They can certainly see if they’re gonna be using hormone therapy anyway. They can see if some of that shedding, I do hear a lot of women feel it it gets better. that they’re not shedding quite so much.
Madeleine
Interesting. Another one on the list!
Kathryn Macaulay
Yeah, another exactly.
Madeleine
So going into HRT, what are the most important changes that have occurred in HRT?
Kathryn Macaulay
Any changes with HRT other than the black box warning going off? That’s probably the most recent
Madeleine
Okay. sure.
Kathryn Macaulay
And then, I think we’ve covered a lot of it with the transdermal kind of being the more popular version now. Ssometimes the option to use an IUD for the progesterone part if women don’t tolerate the oral progesterone well. A lot of women do like the oral progesterone, at least in my practice, anecdotally again, but It has a side effect of drowsiness. So some women prefer to take it at bedtime and see if that helps with sleep.
Madeleine
Are all hormone therapies now bio identical? Not synthetic, like the ones they used in the WHI study.
Kathryn Macaulay
No. The other hormones are still available. So there are a variety of products.
Madeleine
They are? Okay, interesting.
Kathryn Macaulay
Bioidentical was kind of more of a marketing term. It’s not really a medical term. It just refers to the hormone you’re taking. It’s really more biosimilar, like you’re taking estradiol that chemically structurally is similar to the estradiol your ovary produces, as opposed to taking, say, conjugated equine estrogen, which is not like a human estrogen, or a modified version of estradiol. And the same goes for the progesterone. But those are not the only ones available. There’s the other ones are still on the market. Sometimes people don’t tolerate, the progesterone well – the micronized biosimilar, bioidentical progesterone.
Some people get a lot of central effects. They feel like it’s too much, too sedating, not necessarily sedating, but they feel woozy sometimes dizziness, constipation, bloating. Some people don’t tolerate it well. Mood changes every now and then. So sometimes we go to the other versions, the synthetic versions, or maybe use an IUD for the progesterone part. That’s off label use, but we do have some safety data.
Madeleine
So of course now we’re dealing with the shortage of HRT. It feels like a drama every time I try and get my prescription filled, whether it’s patches or now even progesterone. So obviously when you have to move pharmacies, for example, to go from CVS to Costco to wherever to SaveOn, sometimes they have different manufacturers. So I had a situation, for example, where I was getting my progesterone from CVS, they didn’t have it at the time, so they switched it to SaveOn. And I took that, it was a different colour, different number on it. I took it and I had splitting headaches for four days. Now it was the exact same milligrams. I guess, maybe the inactive ingredient was different. .
Kathryn Macaulay
That was the progesterone that gave you a headache?
Madeleine
Yeah. I switched back.
Kathryn Macaulay
I have patients report for sure report like they notice a difference, especially with the patches. not so much progesterone. But the patches because the different manufacturers they might use a different adhesive, slightly different, and maybe it doesn’t adhere as well to one skin. depending on what you’re using. or sometimes they feel like the symptoms came back. So again, maybe it’s not a good adhesive matrix they’re using. Maybe the hormones aren’t absorbing as well through the skin.
Madeleine
Okay. How about vaginal estrogen? Is that good for preventative reasons or I know it’s good for sexual health and sexual function.
Kathryn Macaulay
Yeah, yeah. I mean, they don’t don’t really use it for preventative reasons. Other than, if one is already getting symptomatic, like dryness, then not all women need to use vaginal estrogen. So it’s not an absolute that one’s gonna have to use it. so yeah, I usually tell women, if you start to notice more dryness, if intercourse is starting to get comfortable, don’t wait too long, let me know. Be proactive about that and get started on it sooner rather than, later, when it’s really painful. At the first sign of feeling like someone might need it, like you try a lubricant, usually with over the counter lubricants, silicone based lubricants can be good. And if that’s not really helping it with comfort with intercourse, then a vaginal estrogen would be would be next. So we don’t just though automatically put, people on it. At least I don’t. Maybe some people will.
Madeleine
The only reason I ask is because of I know UTIs are really bad in older women and I’ve read that that could help, but obviously I think that may be a new way of thinking with that because a lot of older women aren’t on HRT.
Kathryn Macaulay
No, no, I mean certainly yeah. If one is prone to UTIs and now they’re menopausal, I absolutely put them on Yeah.
Madeleine
And what do you say to women maybe in their sixties who missed out in a way on HRT at the right time?
Kathryn Macaulay
Yeah, that’s tricky. I have had more women come in, sometimes a lot even in their seventies, you know, wanting to go back on. And some of it is a a misunderstanding with the black box warning coming off, they’re thinking, well, maybe I should start it now. But I think unfortunately that late, maybe not so much in the sixties. it depends on, what their symptoms are, what they’re experiencing. If they’re largely asymptomatic, I don’t know how much of a benefit they’re really gonna get other than maybe with bone health. and they can use vaginal estrogen indefinitely though, but for systemic hormones, I’d have to really just look at the individual and their overall health and what they’re experiencing and do we really feel because in your seventies, I just don’t really see that the benefits are gonna be there.
Madeleine
Really, yeah.
Kathryn Macaulay
And more than 10 years from menopause, the farther out you get there could still potentially be some risks. But we really need to look more, with transdermal estrogen and knowing it’s safer, could we be using hormone therapy starting it in older women? it’s shouldn’t have the same risk as what we saw with the oral estrogens. But you have to ask yourself what benefit if there’s early initiation is what helps to prevent heart disease, maybe. And early initiation help to prevent osteoporosis treating you when you’re symptomatic. yeah, I’m just not sure that far out how much of a one would get from it. So but it really depends on the individual. In general, I think you’ve probably missed some of the benefits there. So you it’s not like you’re gonna catch up with them at that point. Your body’s already, aged twenty years. You’re not gonna reverse things necessarily.
Madeleine
So it is good for prevention though, you would say for osteoporosis and maybe brain health. Yeah.
Kathryn Macaulay
Well it that is one of the FDA approved indications, but we’re still using hormone therapy. The guidelines and such are not still there to suggest using it for heart disease prevention again because we need more bigger trials, longer trials on that. But we have some encouraging studies, the elite trial is one that showed some benefits with early intervention looking at certain markers of vascular disease. So we have some encouraging data, but I don’t think we’re really at the point for an asymptomatic woman to just go on it for prevention. For dementia, I don’t think we know the research is mixed there. It’s mostly observational studies and some show a good benefit, some show harm, some are neutral. So I think we still need some more studies to really be taking it to prevent all these different things. But you’ll hear different things from different people.
Madeleine
It’s developing, isn’t it, as well.
Kathryn Macaulay
Yes, but I think osteoporosis is one exception where if someone’s really got a lot of risk factors for osteoporosis and they already have low bone mass and they’re a candidate for hormone therapy, I think they could certainly consider it for prevention. And I do have patients who take hormones long term, who decide they’re just they feel better on it and they want to take it.
Madeleine
Yes, how would you know when to come off?
Kathryn Macaulay
Yes, and that depends on the individual too. You know, your bone health, residual symptoms. some women will maybe stop in their sixties or seventies, and again, it’s not a one size fits all recommendation.
Madeleine
And it just feels like it’s such an evolving subject and situation, doesn’t it? Which is good, at least it is.
Kathryn Macaulay
Yeah. I mean we’ll see what updated guidelines come out, in the future we’ll see, what they say. But it is a lot happening in the space right now.
Madeleine
Okay. Well thank you. Thank you for that comprehensive look of it. So wrapping it up, is there any misinformation you would like to clear up that you note out there or how would you want to wrap it up with the listeners?
Kathryn Macaulay
How would I want to wrap it up with misinformation? Well, I think telling women that they need to start hormone therapy before to get ahead of menopause somehow, I think something I’m worried about is the younger women who are maybe approaching perimenopause but not quite there yet, feeling a little bit panicked or feeling like there’s such a strong now push for hormones that they need to be starting something and it’s really not necessary.
I mean, unless you’re starting to have symptoms that are becoming bothersome and such, that’s different. and checking blood levels when you’re on hormone therapy, trying to achieve certain levels, other than testosterone just for safety monitoring, I don’t really think levels are gonna be helpful for most cases. What we care about is how you feel.
Madeleine
If you’re in menopause, for example, you go on HRT, should you not retest once you’ve started the HRT to see if those levels have got up? if you’re from zero, for example, with estrogen, is it not worth ’cause how do you know you’re on the right dose? Is it really symptomatic still?
Kathryn Macaulay
It’s really symptomatic. Yeah. So if you’re still having hot flashes and night sweats generally, and that would be the easiest one to measure, you can go up on your dose. So I think that’s gonna matter more. It can be tricky with levels when you time the blood draw with when you put your patch on and it’s just what type of assays used and things like that. And so I feel like it can often be more confusing to people. And the bottom line is I’m gonna look at a level and I’m gonna say, Okay, well do you feel good on your estrogen? So I try not to go chasing that because I think it gets more confusing.
If I’m worried about bone health, then I’m really gonna look at bone density over time. We might start somebody on maybe not the lowest dose, start them on a better dose of estrogen that we think should be effective for preventing osteoporosis, though all the doses should have some benefit there, but I would follow the bone density more over time than chasing levels.
Madeleine
Okay, great. All right, well I think gosh, we’ve been over a lot, so thank you for your time. I know you’ve got patience and I really appreciate it.
