Your Checkup: Health Education Podcast

86: Menopausal Hormone Replacement Therapy Explained for Patients

• Ed Delesky, MD and Nicole Aruffo, RN • Season 2 • Episode 31

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Clear guidance on benefits, risks, and how the FDA’s label changes shift conversations in the exam room about HRT
Nikki's Corner
• Philly’s first Michelin stars and what the tiers mean
• Flying taxis in Dubai 
• A cold case solved by college criminology students

Learning 
• What HRT is, routes of therapy, and who benefits
• Reframing WHI-era fears with age and timing data
• FDA label changes and clinical implications
• Contraindications and safer use considerations
• Women’s health bias and the cost of not listening
• Practical steps for shared decisions with clinicians

References

  1. The 2022 Hormone Therapy Position Statement of the North American Menopause Society. Menopause (New York, N.Y.). 2022;29(7):767-794. doi:10.1097/GME.0000000000002028.
  2. Management of Menopausal Symptoms: A Review. Crandall CJ, Mehta JM, Manson JE. JAMA. 2023;329(5):405-420. doi:10.1001/jama.2022.24140.
  3. Hormone Therapy for Postmenopausal Women. Pinkerton JV. The New England Journal of Medicine. 2020;382(5):446-455. doi:10.1056/NEJMcp1714787.
  4. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Women: US Preventive Services Task Force Recommendation Statement. Grossman DC, Curry SJ, Owens DK, et al. JAMA. 2017;318(22):2224-2233. doi:10.1001/jama.2017.18261.
  5. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. Gartlehner G, Patel SV, Reddy S, et al. JAMA. 2022;328(17):1747-1765. doi:10.1001/jama.2022.18324.
  6. Hormone Therapy in the Postmenopausal Years: Considering Benefits and Risks in Clinical Practice. Genazzani AR, Monteleone P, Giannini A, Simoncini T. Human Reproduction Update. 2021;27(6):1115-1150. doi:10.1093/humupd/dmab026.
  7. Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Flores VA, Pal L, Manson JE. Endocrine Reviews. 2021;42(6):720-752. doi:10.1210/endrev/bnab011.
  8. The Women’s Health Initiative Randomized Trials and Clinical Practice: A Review. Manson JE, Crandall CJ, Rossouw JE, et al. JAMA. 2024;331(20):1748-1760. doi:10.1001/jama.2024.6542.
  9. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: US Preventive Services Task Force Recommendation Statement. Mangione CM, Barry MJ, Nic

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Production and Content: Edward Delesky, MD & Nicole Aruffo, RN
Artwork: Olivia Pawlowski

SPEAKER_01:

Hi, welcome to your checkup. We are the Patient Education Podcast, where we bring conversations from the doctor's office to your ears. On this podcast, we try to bring medicine closer to its patients. I'm Ed Delesky, a family medicine doctor in the Philadelphia area.

SPEAKER_00:

And I'm Cola Rufel. I'm a nurse.

SPEAKER_01:

And we are so excited that you were able to join us here again today. We've got a lot of plates in the air, a lot of juggling balls in the air right now. Dinner is cooking, and we are doing an episode. We're having, I know you seem like you're thrilled to do this right now. Fresh off a shower, hair up in a towel. Obviously, this is a that's the reason this is an audio podcast. We can just that's a little redundant, isn't it? Audio podcast. But we're having uh boigas tonight, a turkey burger. I'm so excited. You're excited.

SPEAKER_00:

I saw you're making some fries in there too.

SPEAKER_01:

Yeah, I finally learned or just figured out how to make a thin cut fry. Um, that wasn't always the case. I usually made wedge fries, which was just an exercise of laziness because I didn't figure out that I just flip it another way and then chop, chop, chop. And we're having a vegetable. You got some broccoli in there? I got some broccoli in there. So that's what we got going on. Um, you know, by the time we're recording this, it's been a couple days. I've had uh, it was a busy week at work. I saw some really cool things. Um uh this one guy was sleepwalking, and so that was an interesting one. I haven't heard that a lot. Um, our neighbors are moving some stuff into the basement as we speak. So there's a little bit of rumbling that Nikki was concerned about here. And let's see, we've got a return of some of our television shows tonight, our programs.

SPEAKER_00:

Uh yeah, Southern Charm is back. I feel like they're gonna make Page the entire storyline. And I honestly love that for her because she's not even on Bravo anymore and they're all still talking about her.

SPEAKER_01:

Oh, she's like very niche. She's left the universe entirely.

SPEAKER_00:

Well, yeah, she didn't do Summer House this year.

SPEAKER_01:

I guess, yeah, that makes a good point. Um I guess she's just still in the zeitgeist, as it were, huh?

SPEAKER_00:

Mm-hmm.

SPEAKER_01:

Yeah. Um, I was able to walk to work to um a coffee shop. I know, it's a total of 180. I'm sorry. I like but this is how today? No, I wasn't there today, but um yesterday, yeah. I was able to like during my lunch break, you know. I actually had a lunch break and was able to take a walk outside and that's nice. Walk to a little coffee shop. It was nice. What's up? It was good. They also had a lavender latte.

SPEAKER_00:

You love a lavender latte.

SPEAKER_01:

I do. It's tasty. Like every time I walk into a place, I kind of freeze up a little bit. And I'm like, oh here I go. I'm just gonna get a I'm just gonna get a drip coffee and we're gonna call it a day. But no, no, I like a lavender latte. And you know, there's nothing wrong with that. Okay. So why don't we introduce our newest segment that's gonna be a little more formal? You know, we actually didn't talk about this because I wanted we wanted to leave this for this segment. What do you want to call it?

SPEAKER_00:

Oh well, I haven't formally workshopped a name, but basically it's going to be uh Nikki's current events that Eddie probably has no idea are going on in the world.

SPEAKER_01:

I think Nikki's corner is funny.

SPEAKER_00:

Yeah, that's a little bit of a you know shorter, shorter title, which I guess would be easier for brevity's sake.

SPEAKER_01:

Brevity is the soul of wit.

SPEAKER_00:

Yeah.

SPEAKER_01:

All right, so what do you got for me?

SPEAKER_00:

Well, I have a couple things.

SPEAKER_01:

Okay.

SPEAKER_00:

I have three actually.

SPEAKER_01:

Wow.

SPEAKER_00:

Um one, the first one is most recent and most topical because we live in Philly and on Tuesday, I think it was Tuesday night, um, three Philadelphia restaurants were awarded Michelin stars. Uh, I think for the first time ever.

SPEAKER_01:

Wow. What uh did you know this? Restaurant in Philadelphia for the first time ever, or just like in Philadelphia. I've oh, like a Michelin star in Philadelphia. There are three restaurants. So I've been a guy who didn't know anything about Michelin stars, and Karthik like said he like I went to a Michelin star restaurant in New York, and Mike, you know, for all you listeners, the guy in the basement.

SPEAKER_00:

Yeah. Sometimes he leaves his basement and maybe goes to restaurants with Michelin stars, apparently.

SPEAKER_01:

Perhaps. Um, I didn't realize this was a big deal. And no, I here you got me. I didn't know. Um, should I try to guess what the restaurants are? Do I know them?

SPEAKER_00:

Um you I didn't know two of them. I did know of one of them, and now I'm kicking myself that we've have not been there yet because it's gonna be so hard to get a reservation. Um, two of them are in Rittenhouse and one is over in Old City. So all fairly close to us.

SPEAKER_01:

Is one park?

SPEAKER_00:

No. Oh no, Steven Star with the Michelin star.

SPEAKER_01:

That was good. I know. I know I like that. It's so funny.

SPEAKER_00:

So, okay, so three restaurants formally got a star, and then there are other rankings in the whole Michelin universe, I guess. So there are the stars ranking from one, two, and three. Each restaurant got one star. So one star is high quality cooking that will be worth a stop. So it's wait, hold on. So the star rankings, all the restaurants got one star.

SPEAKER_01:

Which is a good thing.

SPEAKER_00:

Which is great. So one star is quote, high quality cooking that's worth a stop. Two stars, they quote as excellent cooking worth a detour. And then three stars, which is the highest award, seems pretty rare. Um, is quote, exceptional cuisine worth a special journey.

SPEAKER_01:

Wow.

SPEAKER_00:

So, like, you know, you're making a trip out of going to this restaurant. So I'll tell you what they are, but then I'll explain the other umbrellas. So the lowest one is well, not I don't want to say lowest. One of them is um Entry first. Bib Gourmand, I think is how you say it. Um, so this is what I was reading, kind of um the umbrella of more like simpler restaurants that don't have all like the fancy to-dos. Like there's not a wine cellar, there's not a smalier there, but the food is still really good. And then Michelin recommended. Um the kind of description for that is a broad selection of dining options that may not have a star but still offer good cooking. So maybe something that like may have been in the running.

SPEAKER_01:

So that's a bib gourmand.

SPEAKER_00:

Plus or minus. No, that's a Michelin recommended.

SPEAKER_01:

Oh, okay.

SPEAKER_00:

So I'm gonna go through them.

SPEAKER_01:

So this is not the guy selling tires.

SPEAKER_00:

No.

SPEAKER_01:

Okay.

SPEAKER_00:

It's not. Ha ha. That was actually the bib gourmand gourmand, I think is how you say it. Um, so this is the like more simpler, um, maybe also more affordable kind of restaurants, but still have really good food. Um, also a lot of these are like very close to us, which I love for us. Wow. Um Diesengolf. Okay, which is like around us-ish. El Chinon. I actually don't know how to say that. Fiorella. Oh, I know. No kidding. Actually, both um, both of Mark Vetri's restaurants, the other ones are rec in the recommended.

SPEAKER_01:

Um, watch out, Steven. Vetri is coming for you.

SPEAKER_00:

Yeah, which he has um a new pasta cookbook.

SPEAKER_01:

Oh.

SPEAKER_00:

That he just put out. Really? Yeah. Interesting. Be interesting. Hmm. You should write that down. Write that down. Write that down, write that down. Okay, so Fiorella, Fourth Street Delhi, Angelo's, Di Alessandro's, Del Rossi's, which I think Del Rossi's is that sandwich place. I have to go back and look, but I think they have a hoagie with uh like fried pickles in it.

unknown:

Oh.

SPEAKER_00:

I feel like I sent that to you on Instagram, and I think that's where it is. Um, Pizzeria Badia.

SPEAKER_01:

Oh, yep. Which is up. Wait, really?

SPEAKER_00:

Fishtown-ish, Northern Liberty.

SPEAKER_01:

We've been that's been on our list.

SPEAKER_00:

Yeah. Uh Royal Sushi and Izakaya, and then Sally.

SPEAKER_01:

I've heard of Royal Sushi. Yeah. Izakaya is different. Or is it Royal Sushi Izikaya?

SPEAKER_00:

It says Royal Sushi and Izakaya.

SPEAKER_01:

Are they the same thing?

SPEAKER_00:

I don't know.

SPEAKER_01:

Okay. Wow.

SPEAKER_00:

And then, so that's in the first one. Then for Michelin, recommended um Ambra, Hiroki, Elada, Laurel, Forsythia, High Street, Kaleia.

SPEAKER_01:

Kaleia. Good for them. That's awesome.

SPEAKER_00:

Honeysuckle, Laser Wolf.

SPEAKER_01:

Oh, you've been to Laser Wolf?

SPEAKER_00:

I have been. Uh, Mish Mish or Mish Mish. Um, Little Water and River Twice, which they're both owned by the same couple. And I have heard, so Sam, my old co-worker, talked about River Twice all the time, and she said that it was like a life-changing experience. Really? Yeah. I she said it was really good. They have um their whole thing is they have like a daily like things on their menu that change daily.

SPEAKER_01:

Oh. The the vast majority of these things I have not heard. Yeah. And they're right here.

SPEAKER_00:

Um, I think River Twice is more in like South Philly. Okay. If I'm not mistaken, but don't quote me on that.

SPEAKER_01:

Sure.

SPEAKER_00:

Then we have Southwark, Vernick, Food and Drink, My Loop, which I've never been, which I've always found interesting. And I always think so. When my brother Eric was little, he was obsessed with soup and he always called it loop, and he would be like, I want loop. And so that's what I think of.

SPEAKER_01:

Really?

SPEAKER_00:

I'm like, this is a restaurant for toddlers.

SPEAKER_01:

That's Michelin recommended.

SPEAKER_00:

I'm sure it's great. Uh, Pietra Mala, Saraya, Zahav, Roxanne, Veg, and then Vetri Cucina.

SPEAKER_01:

Veg?

SPEAKER_00:

Mm-hmm. Yeah.

SPEAKER_01:

What was the one before veg?

SPEAKER_00:

Roxanne.

SPEAKER_01:

Roxanne.

SPEAKER_00:

Roxanne. So those are all of the ones that are really good but didn't get a star. And now we'll get into the stars.

SPEAKER_01:

Wow.

SPEAKER_00:

So the first one, this is the one that I'm upset we haven't been to yet because now it's gonna be really hard to get a reservation. Uh-huh. Do you want to take a guess?

SPEAKER_01:

Um we've been planning to go.

SPEAKER_00:

Um, I don't know if we've been planning to go. I've been wanting to go.

SPEAKER_01:

Is it is it here in Center City?

SPEAKER_00:

Um, it's over in Randhouse.

SPEAKER_01:

I don't know.

SPEAKER_00:

I think let me just double check before I sound dumb. Yeah, it's in Rent House.

SPEAKER_01:

What is it?

SPEAKER_00:

Friday, Saturday, Sunday.

SPEAKER_01:

Friday, Saturday, Sunday.

SPEAKER_00:

Yeah.

SPEAKER_01:

That's a Michelin star. Wow.

SPEAKER_00:

So there's that one. Um the next one is Her Place Supper Club.

SPEAKER_01:

Ah.

SPEAKER_00:

Have you? I feel like I've heard of this one. Yeah. Really?

SPEAKER_01:

Yeah.

SPEAKER_00:

Have you been there? No. Oh. I'm just gonna say, what's her name? Right. And then um the last one is Is this like a French place? I feel like I want to say this wrong. Provenance? Provenance.

SPEAKER_01:

I haven't heard of this place.

SPEAKER_00:

Oh, Korean and French influences.

SPEAKER_01:

Wow. So, yeah. That's kind of crazy. The vast majority of this list I had no idea. And we have a lot of work to do, it seems.

SPEAKER_00:

We do. Wow. Oh my gosh. I love that Fiorella's on a list in that. That's fun. We like that place. I love that place.

SPEAKER_01:

That was good. Excellent.

SPEAKER_00:

Yeah. So that's my first one. Did you know that that had happened in Philly? I had no idea. Really?

SPEAKER_01:

Yeah.

SPEAKER_00:

Wow.

SPEAKER_01:

So thank you for culturing me today.

SPEAKER_00:

You're welcome. And then I have two other ones that are smaller. Well, one's like shhm medium size, and then one's just like a little cool thing that happened.

SPEAKER_01:

Let's hear it.

SPEAKER_00:

So the medium one is. Um wait, hold on. Let me go back to my thing. Okay, so we're getting flying taxis next year.

SPEAKER_01:

Flying taxis.

SPEAKER_00:

Yeah. Um, yeah. In I think it was early 2026, Joby Aviation, which is a US aviation company, um has been working for the last 16 years and it's set to launch 200 mile per hour flying taxis in Dubai.

SPEAKER_01:

In Dubai.

SPEAKER_00:

So that's where they're, you know, they're like ahead of everything over there. So they gotta we can't do this here. No. That'd be crazy.

SPEAKER_01:

I kind of thought you meant in our backyard. Okay.

SPEAKER_00:

No, we as in the the earth.

SPEAKER_01:

The earth, the people of earth.

SPEAKER_00:

So allegedly, it will work like any other ride hailing app except for instead of a car, you're getting a battery-powered aircraft that will swoop in and fly you.

SPEAKER_01:

Wow.

SPEAKER_00:

It's battery powered.

SPEAKER_01:

This is fraught with peril. Yeah, I feel. Is it operated by a person? Does it seem?

SPEAKER_00:

Um, yeah. So um this article I was reading, they it was one of the test pilots named Peter Wilson. He said it's an absolutely awesome aircraft to fly. The flight is smooth and handling qualities are exceptional. I'm not sure exactly what a handling quality is, but it sounds exceptional. It says Wilson has previously test flown F-35 flighter flighter fighter jets. And the simple controls on the air taxi are, quote, super safe. They ensure the pilot has a quote low workload while also still being able to do the things they want to do, which I don't know what that means. And I don't know how I feel about that because, like, if you're flying me, I feel like that's that's what you're doing.

SPEAKER_01:

Right. You know? Right.

SPEAKER_00:

I don't know. So the aircrafts will have six propellers to be used in case of an emergency, I guess in case the battery fails.

SPEAKER_01:

Right. Gotta charge those things, gotta charge those puppies up.

SPEAKER_00:

And according to Joby Aviation, the ride will be in an SUV-sized flying taxi that will cost the equivalent of an Uber black. What? The most expensive option offered on the ride hailing app.

SPEAKER_01:

Stop.

SPEAKER_00:

That's what it says. Um, technically, it's not a door-to-door service. So the hailing aircraft, say hail one more time in this article. I mean, geez. So the aircraft, I guess we'll be using either Uber or Joby's own app, and the aircraft will pick you up and drop off up to four passengers at a time at a specialized takeoff and landing points known as Verdi Ports. So there are four planned for Dubai. Um, and then once they land, customers will be transported to their final destination by car.

SPEAKER_01:

Wow.

SPEAKER_00:

Yeah. There's no traffic, speeds go up to 200 miles per hour. The company says a 45-minute journey will be cut down to 10 minutes.

SPEAKER_01:

Oh my gosh. Wow. Yeah.

SPEAKER_00:

That's what they say. And it will generally operate at around 1500 to 3,000 feet.

SPEAKER_01:

I guess that's below most airplanes.

SPEAKER_00:

They've been working on this for 16 years to quote optimize this aircraft to be incredibly quiet. It says it's dramatically quieter than a helicopter, and instead of the wop wop of a helicopter, it's more of a whoosh. That's what they say.

SPEAKER_01:

That's so interesting.

SPEAKER_00:

So Dubai is going to be the first to try it, and then they predict that the American cities will not be far behind. Um, and I guess it doesn't name which cities. I feel like they're probably not chosen yet. But there are it looks like going to be five cities that will be like the test or like the pilot cities for wow for this to happen.

SPEAKER_01:

This seems like a big game changer for for travel. And hopefully it works out that it's all safe and whatnot. But that's I mean, this is really cool. I had no idea. Once again, you got me.

SPEAKER_00:

Yeah. I guess in June Trump signed three executive orders at the White House said in a statement would quote accelerate domestic drone production. The statement added that, quote, create a pilot program testing flying cars, including air taxis.

SPEAKER_01:

Wow.

SPEAKER_00:

So I guess that's what he's doing in there.

SPEAKER_01:

Flying cars. I think we're here.

SPEAKER_00:

You can't have health insurance, but you can have a flying car.

SPEAKER_01:

Right.

SPEAKER_00:

Yeah, you can have people who are homeless and hungry, but we can have a can't have your food stamps, but you can get in a flying taxi.

SPEAKER_01:

Exactly. Okay.

SPEAKER_00:

Probably gonna cut some of that out.

SPEAKER_01:

No, I think we're gonna leave it. Did you know that one of our previous three episodes was listed as explicit in Apple Podcast?

SPEAKER_00:

For what? I'm not sure.

SPEAKER_01:

Probably.

SPEAKER_00:

Okay, so that's my second one. And then my third one is a cool little ditty. Okay. This I just kind of found while I was perusing for some research. So don't feel bad if you didn't didn't know that this happened. But earlier this month, a group of college students in Texas solved a cold case murder from 1991.

SPEAKER_01:

Wow.

SPEAKER_00:

Yeah. So there was a group of criminology students at where did they go?

SPEAKER_01:

That's some chilling news.

SPEAKER_00:

University of Texas at Arlington. So their criminal part of their um curriculum for criminology and criminal justice has a class where it partnered with the Arlington police and then it gave them access to all of like the police files and the including the cold case files.

SPEAKER_01:

Huh.

SPEAKER_00:

So a group was investigating um was investigating the death of 25-year-old Cynthia Gonzalez in 1991. And they um, oh, it doesn't say the date, but earlier this month, the Arlington Police Department um said the U.S. Marshals arrested Janie Perkins, who is now 63. Oh yeah, on November 6th for one count of capital murder in connection with the investigation of the death of 25-year-old Cynthia Gonzalez from 1991. So Gonzalez, who was killed. Um, I guess so the police that were originally working with her in September of 1999, or not working with her, working on her case in September of 1991, she was found um, she was reported missing, found dead. She also was working as a quote adult entertainer. So I guess that kind of factored into it, and then the case went cold. But it turns out that Gonzales and then the woman who was arrested this year, Perkins, wow, shared a romantic partner, and that romantic partner broke up with Perkins to go be with Gonzales and classic case of a scorned woman. Wow. And I guess the students had figured it out because she was mentioned multiple times throughout like the files, I guess. Like this woman, and like people had like I guess witnesses had mentioned her name, and then they looked more into it and they were like, Oh yeah.

SPEAKER_01:

Oh my god.

SPEAKER_00:

She done it.

SPEAKER_01:

She done it.

SPEAKER_00:

She done it. So yeah, that's my cool little thing that happened.

SPEAKER_01:

You got me all three for three. I had no idea that any of these happened.

SPEAKER_00:

I'm good. You're welcome.

SPEAKER_01:

Yeah. I feel way more cultured now. And I think the audience loved that segment. I think you got to pump these out.

SPEAKER_00:

Really?

SPEAKER_01:

Yeah. This is gonna be great. I think this is like a huge too long.

SPEAKER_00:

Is that gonna be boring?

SPEAKER_01:

It's not gonna be boring. No, you're just three different segments. You could probably have a whole podcast about this. Oh my god. You know, like five current events that are happening that people need to know about.

SPEAKER_00:

Oh my god, we can't get sued.

SPEAKER_01:

No, I don't want to get sued for all the things we don't have related to this show. Wow. Well, thank you. You're welcome. A lot of effort into that. I really appreciate that.

SPEAKER_00:

I take my job very seriously, you know.

SPEAKER_01:

You do.

SPEAKER_00:

All right. Well, now that I've done all the talking.

SPEAKER_01:

You bet.

SPEAKER_00:

So what are we talking about today, Ed?

SPEAKER_01:

I don't like the way that sounds. So what are we gonna talk about today, Nick?

SPEAKER_00:

Today, to come off of the heels of last week's episode talking about menopause, we today are going to talk about hormone replacement therapy.

SPEAKER_01:

Yes.

SPEAKER_00:

And, you know, things are happening, so we're gonna talk about it.

SPEAKER_01:

Things are happening. We alluded to it last week and we wanted to follow it up. So, the most recently in the news last week, the FDA requested labeling changes related to the safety information to clarify the benefit and risk considerations for menopausal hormonal therapies. So if you're listening to this, just tuning in, having no idea what this is, uh, the idea is that we will help better clarify, or we will kind of put it into words the complex weavings of time that have been happening about HRT. So, what is hormone replacement therapy before we dive in too quickly? Hormone replacement therapy, also called menopausal hormone therapy, is a treatment that uses estrogen and sometimes another hormone called progesterone to relieve symptoms of menopause. HRT can be taken as pills, patches, gels, sprays. And women who've had their uterus removed, otherwise from a surgery called hysterectomy, can take estrogen alone if prescribed. And those who have a uterus take both estrogen and progesterone to protect the lining of the uterus from things like endometrial cancer. So that is the background of it. Um, HRT is extremely effective and it can help a myriad of people with a myriad of symptoms. Hot flashes, or otherwise called vasomotor symptoms of menopause, if you ever see a commercial on television or night sweats, happen in 75 to 80 percent of women going through menopause. So extremely common and they can be extremely bothersome. This is the symptom that people on HRT often reach out for help for. It is the most effective treatment option for these symptoms, but there was so much controversy shrouding the prescribing pattern based on risks from old studies that we'll talk about today. What HRT can also help is with vaginal dryness and discomfort, especially some local vaginal estrogens, can help with dryness, pain during sex, and urinary symptoms. And there's also a fair amount of evidence that HRT, while not the primary reason to be prescribed for this, do have some positive benefits on bone health and they reduce the risk of fractures. So there were, after talking about all of the benefits and being the most effective treatments for vasomotor symptoms of menopause or hot flashes, which can also affect women's mood because they can't sleep as well, all compounding into their decreased function or limited function. So there ended up being certain risks that the general population was concerned about based on older research. And this leads into what now may be considered common misconceptions. Like HRT is unsafe for everyone. That is not the case. So it was decades ago in the early 2000s now, to say decades ago, sorry for the people out there who are triggered by that. There was a large study with the Women's Health Initiative initially raised concerns about HRT and its related health risks, or reportedly at the time. Later research that looked back showed that the risks that were demonstrated, and these risks we'll talk about soon, were dependent on age, timing, and health status. So what they found is that for most women, looking at it again, most women under 60 or within 10 years of menopause, HRT is considered safe and effective for symptom relief. And I think this has been known for a long time now, but just recently the FDA has made a significant move. The risks that the FDA addressed and removed black box labeling for include removing statements from the drug information about cardiovascular disease, breast cancer, and probable dementia. And these things lived on the medication in a giant black box. That's what a black box warning is for anyone prescribing the medicine, anyone taking it to say, highlight bold underline, do not miss this. These medicines can cause this. So naturally, previously, prior to the women's health initiative in the early 2000s, many people were on HRT to help alleviate their symptoms. And then this information came out, and it wasn't stratified by age, and it wasn't stratified by underlying risk or health status. The women's health initiative did not stratify by age. The average age of the patient in the women's health initiative was in their early 60s when, as we talked about last week, the average age of menopause is 51 in the United States. So realistically, that leaves about 10 to 12 years of symptom burden that are being had that is being unaddressed. But it was only until later did they go back and relook at the data dependent on age. And that's when they found that those risks that I previously mentioned breast cancer, heart disease, concerns about dementia, did not bear themselves out as they once did in this production of the data and the research. So all of that is the backing of why the FDA made the changes to this and why it's such a big deal. But basically, what I just to go back to it, they looked at women at all ages and took them as having the same risk. When, yeah, maybe someone who's 70, 75, 79, and in some specific situations more towards 60 shouldn't be taking this. And maybe it should be weaned off at that point. But for women who are within 10 years of menopause and less than age 60, which is now the information that's being put out there to clinicians, this if you don't have any contraindications or any reasons that you shouldn't take it, you could probably think about it now, which is a big change.

SPEAKER_00:

Yeah, that's huge.

SPEAKER_01:

Huge. I mentioned a list of reasons that someone might not be able to take the medicine. And I just wanted to read them off here um uh briefly in a quick list. Um, this is from an article from the American Academy of Family Physician. So these are reasons that someone can't take hormone replacement therapy. Um, it's not a good idea if you have unexplained vaginal bleeding. If you can eventually explain it, you could probably rethink about it. A history of stroke, probably not a good idea. An active estrogen sensitive cancer, so brast or endometrial cancer, or a history of Estrogen-sensitive cancer is a reason to have pause or what they call a relative contraindication. So it's not an automatic no, but it's something to really, really think about. A history of venous thromboembolism, otherwise stated a blood clot in the legs or the lungs or somewhere else. Um, you should exercise some pause with a personal or strong family history of thromboembolic disorders. That's a pulmonary embolism, and a history of coronary artery disease, that is plaque forming around the arteries of your heart. And active liver disease is probably a reason to think twice. That's the list. So this is huge because I mean, in training, we didn't we didn't talk about this at all because of these black box warnings, and it was not something that we used every day. Plenty of medicines we use every day, but these ones were put to the side.

SPEAKER_00:

And it's because everyone hates women, they all want us to suffer.

SPEAKER_01:

There's probably a not insignificant part that it took so long for this like inertia to build up to make these changes. But I also think there was a lot of that this happens, right? There's like this happens every day where just because I was talking to a patient yesterday, just because their old doctor did something somehow, they go to a new doctor, because I'm seeing a ton of new patients from like other practices, and they go to a new doctor, and everything is just done the same way because there is probably a good reason that it was done that way. And that's why speculation is important. Because when you look at this data from the Women's Health Initiative from a different lens, and you do not consider that a woman aged 50 is the same as a woman aged 60 or 70, and that they have different risks at different points in their life, that there could be years of benefit because hot flashes can last routinely on average, not average, but like the longer cases can go up to seven years. So if we're talking that you can safely take HRT for the first 10 years after menopause, you can get coverage for these. I just think this is very groundbreaking. I think people should feel empowered to ask. Truthfully, I I was doing a lot more reading about it to try to prepare for this episode and get ready for people coming in because I think this is very important and to have open and honest conversations about it. Do you have any thoughts? I I think this is like this is fascinating that this is happening like this.

SPEAKER_00:

I also think that like not to like sound like a feminist. No, go for it. And like that person, but it's like through like a woman's life, like there are so many changes. It's like, okay, like you go through puberty, you get your period. That's a sucky thing. Like, you just have to deal with it. This is just something that like happens to your body, you have to deal with it. And then if you have kids, okay, you know, have to go through pregnancy, and then you have to go through birth, and then you have to go through postpartum. And all of those parts, like, some part of that sucks.

SPEAKER_01:

Right.

SPEAKER_00:

But it's like, okay, this is just like a part of what happens to your body. This is just like what you're going, going through, and like deal with it. And then it's like, all right, you're done having kids, you chill for a sec, and now it's time for something else to happen to your body. Now it's menopause, and this is just the list of sucky things that happen to your body, and you just have to deal with it. Yeah. But like maybe you just like don't or don't have to deal with it as badly.

SPEAKER_01:

Right. Maybe they're like the most effective option is now back on the table for uh probably most people, not even some.

SPEAKER_00:

Yeah.

SPEAKER_01:

No, and you you're right. I think, and that's why women's health as a whole branch is so important and why it deserves separate time and attention because of the exact reasons that you just mentioned. Like there are some routine exams that I'm seeing where like women have to have two separate doctors, and sometimes if they're not seeing someone from family medicine who does women's health care just to be a woman and stay up on routine normal health care for like a pap smear. Or I'm seeing their gynecologists ordered their mammograms. I'm like, I that's great. Everyone should pitch in and help, but like you're a woman, so you have to have two doctors at baseline. Like, that doesn't that's inconvenient. Or it's necessary. I don't know. The gynecologists are super valuable. They are. You know, we need every everyone to jump in because with all the so many people and far two clinicians to take care of people. A little soapboxy, but you know, as we round out the episode here, if anyone has any questions, please feel free to reach out to us. This is something we're learning more about here. We are certainly not experts, but we definitely noticed this news. We wanted to kind of use our mouthpiece here to or even like explain.

SPEAKER_00:

You might have to cut this and put this back to my soapbox.

SPEAKER_01:

Sure.

SPEAKER_00:

Like I feel like with like you always hear women who after they've been diagnosed with endometriosis in particular, and how like you always hear like how hard it was to like get that diagnosis, how they were in pain for so so long, and they kept going to the doctor, and like not to sound like everything's an attack on women, but like, because I'm like not one of those people, but then it's like they said that they would go to the doctor, and no one listened to them, they just chalked it up to like being a woman, this sucks, you have to deal with it.

SPEAKER_01:

But like, really, like, no, it was real, yeah.

SPEAKER_00:

Uh yes, like how many times do you hear that?

SPEAKER_01:

You know, all the time, yeah, yeah. And those those stories get echoed loudly and rightfully so to raise awareness.

SPEAKER_00:

Yeah, it's like, oh, you're in pain while you're a woman, so get used to it. Like that sucks.

SPEAKER_01:

No, and like it's a shame that it only happens sometimes on the back end, where you hear about them on social media, you hear them about them amongst talking about friends and stuff, but it happens in those like couple quiet moments when it's just the woman and the the clinician who's taking care of them, and that person deciding whether they're going to listen to what they're saying or not. And I don't I don't know where this culture of like poo-pooing symptoms and ignoring like over-reassuring has come from or why that exists. I think it's a systemic thing. But it's absolutely there.

SPEAKER_00:

Yeah.

SPEAKER_01:

If you're listening to this and you've made it this far, thank you. We want to wrap up with some key points. So HRT or hormone replacement therapy happens to be the most effective treatment for hot flashes, night sweats, and some vaginal symptoms of menopause. And now, for many women, it is back on the table. The risks, of which there are some still, right? There's always theoretical risks, but there are risks to the burger that you ate last night. There are risks to drinking the alcohol you had that weekend, there are risks to the tobacco people smoke. There are these theoretical risks that may or may not happen to you. And you and your doctor or nurse have to sit there and decide whether the theoretical risk is worth it as opposed to the benefit you might get from the day-to-day things you experience. And that's the question. And you have to go sit there and have this conversation. And my hope for you is that you have a caring, interested primary care doctor or a person who does women's health on your side to ask these questions. And these questions aren't just related to women's health and menopausal hormone therapy. This is about any medicine or any treatment or any surgery. Do the risks that we understand exist outweigh the benefit? And it's it happens both ways: the benefit versus the risk. But for HRT, it depends on age, health, type, and timing of therapy. Lots of soapboxing tonight. Um, for most women, most healthy women under the age of 60 and within 10 years of menopause, oftentimes the benefits outweigh the risks for symptom relief. This opens up a floodgate of women who qualify. And I will say very clearly, HRT is not recommended for preventing heart disease, dementia, or other chronic conditions. So that is something that is seen out there. I see people making claims about this on the internet, and that is, those are not true. It is not the primary cause for these things or primary reason for them to be prescribed. And at the end of the day, regular checkups while you're on the medicine and what's called shared decision making, where you and your clinician go back and forth and say, is this still good for me? Is my risk the same? That's important. You should do that. So, for more information, you should talk with your healthcare clinician about your symptoms, your health history, and the options for treatment, of which there are non-hormonal ones too. But on this very important episode, we thank you for coming back. And we hope you learned something for yourself, a loved one, or a neighbor. You can find us on Instagram. You can look up our website where we have our collection of episodes or wherever you listen to podcasts. If you made it this far, you're probably interested. And I would sincerely appreciate if you left a quick review saying, like, whatever you thought about the show, be honest, but any favorable thing helps get the word out. And most importantly, stay healthy, my friends. Until next time, I'm Ed Dolesky.

SPEAKER_00:

I'm Nicole Ruth.

SPEAKER_01:

Thank you, goodbye.

SPEAKER_00:

Bye.

SPEAKER_01:

This information may provide a brief overview of diagnosis, treatment, and medications. It's not exhaustive and is a tool to help you understand potential options about your health. It doesn't cover all details about conditions, treatments, or medications for a specific person. This is not medical advice or an attempt to substitute medical advice. You should contact a healthcare provider for personalized guidance based on your unique circumstances. We explicitly disclaim any liability relating to the information given or its use. This content doesn't endorse any treatments or medications for a specific patient. Always talk to your healthcare provider for a complete information tailored to you. In short, I'm not your doctor. I am not your nurse. And make sure you go get your own checkup with your own personal doctor.

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Dr. Edward Matthew Delesky, MD

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Nicole Aruffo, RN

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