S4 Ep190: Ready, Set…. Start!, Stop! Switch! Hormone Therapy with Risa Kagan MD

At my monthly Ask Me Anything Webinars, I always get questions about hormone therapy- when to start, when to stop, if the dose should be changed as women get older, and what to do if someone continues to have symptoms or continues to bleed… In this episode, Dr. Risa Kagan and I answer submitted questions. We start by briefly running through the established indications for starting menopausal hormone therapy (MHT), and then Dr. Kagan and I discuss the “what ifs” of hormone therapy. Do you have to wait for 12 months without a period before starting MHT? If someone is taking birth control pills for control of perimenopause symptoms, at what point should they go off? And can they immediately transition to MHT or do they need to take a break and make sure they are no longer making estrogen? A woman with severe hot flashes is having all day, all night hot flashes- how long is it going to take to get some relief? Does it matter if it is oral or transdermal as far as the onset of action? What are the chances of getting 100% relief? If someone has started MHT but is still having flashes, how long should they wait before adjusting it? What is the best starting dose if someone has severe flashes? High or low? A woman wrote in that she has been using a 0.75 patch, but continues to have severe flashes. She got a serum level, and it is 10. Her doctor is reluctant to increase her dose. What would you tell her? A woman has tried four different protocols and has nuisance bleeding with all. She had an ultrasound and biopsy, and it was all normal. She wants to continue MHT, but is tired of the bleeding. She wants to know which protocol is the least likely to cause bleeding An internist told a woman that after 5 years, it is time to go off her MHT. What about if she is primarily taking it for hot flashes- how likely is it that her hot flashes will return? What about if she is primarily on it for bone health (known osteopenia) and joint pain-? What about if she is primarily taking it for sexual benefits? (Libido, lubrication, orgasm)? What about if she is primarily taking it because she is worried about dementia A woman decided to go off HT since she was only taking it for hot flashes and is now 10 years out. Her manicurist told her that she should taper; otherwise, her flashes will come back. Her gyne says, stop. What does Dr. Kagan say? A 60 year old woman started estrogen when she had a hysterectomy and ovary removal. She was told by her internist that there is no way she will still be having hot flashes in her 60s, and therefore no reason to continue her estrogen. Is that correct? What is the likelihood that she will still be having hot flashes in her 60s or 70s? The next question is from a woman who increased her oral estradiol to 2 mg to get rid of her flashes, but is still taking her original Prometrium dose 100 mg. Is that enough to protect the lining of her uterus? When do you increase it? A question from a Substack reader- “I used estradiol gel for 8 years at the start of menopause. I decided to stop it and did so for 3 years; however, my hot flashes (sleep, mood, etc) were relentless and violent. I decided to start again after a 3-years hiatus and at the age of 65. I feel so much better. Is this a problem having stopped and then started again a few years later?” How can you tell the effectiveness of the HRT you're taking (other than no more hot flashes?) I still feel lack of motivation, low libido, joint aches and I'm so much slower running (1 min+/mile). (What this really comes down to, is what are realistic expectations for what HT will do?) How long can a postmenopausal woman stay on testosterone, estrogen and Progesterone? Let’s say a woman has been using a.05 estradiol patch but her skin is really irritated and has decided to try the spray instead. What is the equivalent dose? A woman with a hysterectomy who is taking estrogen alone has been taking a 1 mg estradiol pill. She has decided to switch to conjugated equine estrogen since she would like breast protection. Is that correct thinking? If she is going to make the switch, what is the equivalent dose? A 51 year old is no longer having hot flashes but wants to continue her transdermal estrogen since she has low bone mass and is worried about progression to osteoporosis. What is the minimum dose of estradiol to ensure that she is getting maximum bone protection? Many questions came in about initiating hormone therapy after age 65... Dr. Risa Kagan is a Clinical Professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, and a consulting gynecologist with Sutter Health. Other episodes with Dr.