When I started in OBGYN practice in 1987, we offered HRT for symptom control and protection from heart disease, dementia and hip fracture. The WHI study created a panic and seemed to confirm the increasing murmurs, particularly among breast surgeons, that estrogen causes breast cancer- not sure if this was as nefarious as Dr Makary indicates in his book.
My patients and I discussed the relative risks and benefits of HRT and agreed that the WHI told us what we instinctively already knew: There is no "one size fits all" solution. For some women, any risk of cancer was a deal breaker. For many more, the benefits of symptom control and maintenance of bone density was worth the risks we discussed.
What I then witnessed was a generation of adult medicine and OBGYNs who had no training in treatment of menopausal symptoms and many who refused to prescribe HRT. The alternatives such as antidepressants and gabapentin had their own risks and were less effective than estrogen.
Currently, I hear some "menopause specialists" state essentially that all women should take estrogen and other hormones. It feels as though the pendulum has swung completely back.
As for the Black Box, the worst in my mind is for vaginal estrogen cream. The risk of using it is practically zero (sensitivity to vehicle ?) but I have absolutely seen a pea sized amount 3 -5 times weekly applied near the urethra prevent life threatening urinary sepsis.
I feel exactly the same way on everything you stated here! I started IM practice in 1992 and my experience was identical to yours. I learned how to prescribe HRT and have always done so. It was pretty clear that the "evils" and risks of HRT were being overblown and that each woman had her own risks for those particular issues and her own goals/values on what needed to be treated. It was a straight-forward discussion and straight forward treatment.
I did not fully recognize how limited the next generation(s) of physicians were in the use of HRT. Younger physicians definitely had a fear and had been told it was just bad all around. Women who had been on HRT and doing well were often pulled off due to this fear-mongering.
The recent surge of "menopause experts" has been interesting. I think bringing public awareness back to menopause in general is good and having HRT as an option remains a good thing. We may eventually find out (hopefully via a well-designed RCT) that treatment in peri- or early menopause is beneficial in re: bone health, etc.
But these "experts" who are now on a crusade to right the wrongs that have been done to women and who tout HRT as the new fountain of youth for all things related to aging: better skin! No joint pain! Stronger! Live longer! No evidence for that and my experience does not bear that out.
I agree with the pendulum swings we've lived and practiced through. The generation before ours just handed women HRT without discussion because "you need this". These newer experts want to treat everyone with this new fountain of youth.
As usual, the truth is in the middle.
Bottom line: menopause is natural and an inevitable part of life. It is not to be feared. You don't need tests to "diagnose". Keep an open mind - if you have bothersome symptoms, HRT may be the most effective option to relieve. If you feel better overall, you may want to take for some period of time. But it does have risks - I've had numerous ladies develop DVT, PE while taking. Not everyone should take it.
I feel exactly the same about topical (vaginal) estrogen. For a wide variety of very common symptoms and issues, it is first line therapy and carries little (to no) risk. Labeling that under the umbrella of systemic HRT is ludicrous.
So nice to finally hear from somebody my "vintage" with same experience. Thank you!
Also absolute risk always is low from an individual perspective. But from population perspective this could be huge , in the realm of tens of thousands. So population/societal perspective is also important when you look at risks.
WH2 would be helpful, but good luck getting participants willing to test if they will get cancer! :)
To those commenting on different types of hormones, we agree. It's just that there is very little empirical data to discuss regarding the different compounds. It's why a WHI 2 would be very helpful.
I am lucky to have had a bright gyn doctor who told me about all the positive studies from the Scandinavian countries and recommended I start hrt , BTW the gynecologist never agreed or endorsed the WHI findings .
I appreciate the topic and your historical use of HRT. I was disappointed in this podcast because the type of estrogen (WHI) is no longer used and the age of the women and types of HRT being prescribed now are different. I think the black box should be removed IMO. And I like the idea of a WHI part deux, with Vinay, Jay and Marty at the helm.
Agree with the fact that today's women patients ( are well informed with lots of questions and concerns) and predominantly women gynecology physicians have better treatments- topical -and spend more time on perimenopause and menopause.
The WHI used oral Premarin and a synthetic progestin (medroxyprogesterone) Today’s HRT regimens use topical, vaginal or implanted estrogen (estradiol) and a micronized progesterone (prometrium). I am under the impression that avoiding oral estrogen reduces SE due to avoiding the first pass effect of the liver. Additionally, prometrium is not a synthetic progestin but actual progesterone. I think the newer forms of HRT are more effective in my practice.
When I started in OBGYN practice in 1987, we offered HRT for symptom control and protection from heart disease, dementia and hip fracture. The WHI study created a panic and seemed to confirm the increasing murmurs, particularly among breast surgeons, that estrogen causes breast cancer- not sure if this was as nefarious as Dr Makary indicates in his book.
My patients and I discussed the relative risks and benefits of HRT and agreed that the WHI told us what we instinctively already knew: There is no "one size fits all" solution. For some women, any risk of cancer was a deal breaker. For many more, the benefits of symptom control and maintenance of bone density was worth the risks we discussed.
What I then witnessed was a generation of adult medicine and OBGYNs who had no training in treatment of menopausal symptoms and many who refused to prescribe HRT. The alternatives such as antidepressants and gabapentin had their own risks and were less effective than estrogen.
Currently, I hear some "menopause specialists" state essentially that all women should take estrogen and other hormones. It feels as though the pendulum has swung completely back.
As for the Black Box, the worst in my mind is for vaginal estrogen cream. The risk of using it is practically zero (sensitivity to vehicle ?) but I have absolutely seen a pea sized amount 3 -5 times weekly applied near the urethra prevent life threatening urinary sepsis.
I feel exactly the same way on everything you stated here! I started IM practice in 1992 and my experience was identical to yours. I learned how to prescribe HRT and have always done so. It was pretty clear that the "evils" and risks of HRT were being overblown and that each woman had her own risks for those particular issues and her own goals/values on what needed to be treated. It was a straight-forward discussion and straight forward treatment.
I did not fully recognize how limited the next generation(s) of physicians were in the use of HRT. Younger physicians definitely had a fear and had been told it was just bad all around. Women who had been on HRT and doing well were often pulled off due to this fear-mongering.
The recent surge of "menopause experts" has been interesting. I think bringing public awareness back to menopause in general is good and having HRT as an option remains a good thing. We may eventually find out (hopefully via a well-designed RCT) that treatment in peri- or early menopause is beneficial in re: bone health, etc.
But these "experts" who are now on a crusade to right the wrongs that have been done to women and who tout HRT as the new fountain of youth for all things related to aging: better skin! No joint pain! Stronger! Live longer! No evidence for that and my experience does not bear that out.
I agree with the pendulum swings we've lived and practiced through. The generation before ours just handed women HRT without discussion because "you need this". These newer experts want to treat everyone with this new fountain of youth.
As usual, the truth is in the middle.
Bottom line: menopause is natural and an inevitable part of life. It is not to be feared. You don't need tests to "diagnose". Keep an open mind - if you have bothersome symptoms, HRT may be the most effective option to relieve. If you feel better overall, you may want to take for some period of time. But it does have risks - I've had numerous ladies develop DVT, PE while taking. Not everyone should take it.
I feel exactly the same about topical (vaginal) estrogen. For a wide variety of very common symptoms and issues, it is first line therapy and carries little (to no) risk. Labeling that under the umbrella of systemic HRT is ludicrous.
So nice to finally hear from somebody my "vintage" with same experience. Thank you!
Great work Doctors!
Also absolute risk always is low from an individual perspective. But from population perspective this could be huge , in the realm of tens of thousands. So population/societal perspective is also important when you look at risks.
WH2 would be helpful, but good luck getting participants willing to test if they will get cancer! :)
To those commenting on different types of hormones, we agree. It's just that there is very little empirical data to discuss regarding the different compounds. It's why a WHI 2 would be very helpful.
I am lucky to have had a bright gyn doctor who told me about all the positive studies from the Scandinavian countries and recommended I start hrt , BTW the gynecologist never agreed or endorsed the WHI findings .
Disappointed that the topic of what type of estrogen used was basically at the last few minutes of the podcast.
I appreciate the topic and your historical use of HRT. I was disappointed in this podcast because the type of estrogen (WHI) is no longer used and the age of the women and types of HRT being prescribed now are different. I think the black box should be removed IMO. And I like the idea of a WHI part deux, with Vinay, Jay and Marty at the helm.
Agree with the fact that today's women patients ( are well informed with lots of questions and concerns) and predominantly women gynecology physicians have better treatments- topical -and spend more time on perimenopause and menopause.
The WHI used oral Premarin and a synthetic progestin (medroxyprogesterone) Today’s HRT regimens use topical, vaginal or implanted estrogen (estradiol) and a micronized progesterone (prometrium). I am under the impression that avoiding oral estrogen reduces SE due to avoiding the first pass effect of the liver. Additionally, prometrium is not a synthetic progestin but actual progesterone. I think the newer forms of HRT are more effective in my practice.
Great discussion, thanks