5 Things Doctors Told My Patients That Aren't True (Menopause & HRT)

Dr. Victoria Andarcia, MD: Hi, and welcome to Conversations with Dr. Victoria Andarcia Today's episode is the craziest things I've heard in clinic this month. I wanted to do something a little bit different and take you into conversations that I'm having in the exam room when I'm in clinic. Every single one of these sentences has been something I've heard a patient actually say to me in the last month. It's not exaggerations. They're actual things I've heard. And sometimes these women have been. told these things by other doctors. So I just want to go one by one and just start busting some of these myths or things that women are hearing in actual doctors' offices because it's not true. And it's unfortunate that we're still having to have conversations like this. So we're gonna go through it. I'm gonna tell you why it's wrong, what's actually been shown in the research. You don't have to take my word for it. This is stuff that you can look up. One of my favorite books that goes into this in detail is The Menopause Moment by Dr. Kelly Casperson. So you can also read that if you want more information. myth number one. This patient was told by her gynecologist, that vaginal estrogen doesn't really do anything. That was horrifying to me to hear that, but she never took vaginal estrogen, she was complaining of vaginal dryness, and then she was told that by her provider. What does the vaginal estrogen actually do? So when estrogen drops during menopause, the tissue, the vagina, vulva, lower urinary tract, it changes, it thins, it loses elasticity. Less blood flow. And that's actually what we're calling genital urinary syndrome of menopause, or for the sake of this conversation, GSM. And it's the reason for dryness, pain with intercourse, that raw, irritated feeling that women often get. And I've heard it multiple times described as feeling shards of glass. When you start using the vaginal estrogen, it's not masking that. situation, it's actually reversing it. It restores the thickness of the lining, improves blood flow, and restores a healthy pH so that you can have protective bacteria there. The other important part of using this estrogen is that it prevents UTIs, especially as you get older. When that pH, when the tissue thins and the pH is shifting, the urethra vaginal canal becomes most much more susceptible to bacteria that can cause urinary tract infections. This is why so many postmenopausal women start to get recurrent UTIs. I used to see this in the hospital all the time when I was an internist. Women would come in over and over and over again with recurrent UTIs. A lot of them were on on antibiotics to keep it at bay. Not ideal, right? Not good for your gut microbiome. And When you're using the vaginal es estrogen, it's one of the most effective things that we can do to prevent that cycle. I want to be clear about why this matters. We've all many women, not everyone, but most women have had a UTI. When you're younger, yeah, it's annoying, it burns, and you have to take antibiotics. But in an elderly woman, a UTI can cause confusion, delirium, falls, hospitalizations, and that can trigger a downward spiral in your health. Sometimes we're to the point where you cannot get back to the baseline you were in before that hospitalization, if that's what it comes down to. And just with this hormone cream, your risk of ending up in a hospital with recurrent UTIs or like a really bad sepsis from a UTI goes down considerably. And then what about the safety of using this vaginal hormone cream? Because this is another misconception. Because when people hear estrogen, they think about, you know, general hormone therapy and Some of the fears around that, which we will talk about later in this episode. But the vaginal estrogen is different. It's low dose and it's working locally on the tissue. Very little of it reaches a bloodstream. Does some of it reach the bloodstream? Yes, but very little. And it is considered safe for the vast majority of women, including many breast cancer survivors, in coordination with their oncologist, of course. So it's really not in the same category as systemic hormone therapy. Now the next question someone might be thinking is, well, why isn't a lubricant enough? The lubricant is addressing the friction situation in the moment, but it doesn't do anything to help the tissue recover in general. So the vaginal estrogen is treating the tissue. That's the difference. Now, on to the next one, method number two. Joint pain is just part of getting older. Hormones won't help that. Heard this one before. So a woman comes in with achy joint, hands, knees, shoulders, and she's been told or has already decided that it's part of aging, early arthritis, and nothing can be done except taking ibuprofen. However, estrogen exists, well, estrogen receptors exist throughout your whole body, but we're talking about the joints here. So in the cartilage and the synovium, which is a lining that lubricates your joint, and in the surrounding connective tissue. So estrogen is not just a reproductive hormone, it has anti-inflammatory effects actually. And that includes her joints. So when estrogen drops during perimenopause and menopause, a few things can happen. Your inflammatory markers can go up, cartilage won't get maintained as well, and the joint lining doesn't stay lubricated. So this is a huge woman why women will start to describe joint pain or stiffness in their 40s and 50s that seems to have come out of nowhere. Well, it didn't come out of nowhere. It's often hormonal. So one of the questions in the menopause rating scale that we use to assess your menopausal symptoms in the clinic includes, are you having joint pain? Because in a lot of these patients, when you're restoring their hormones, that achiness can come down because you're driving one of the actual drivers, which is a loss of hormones. Now I'm not saying that hormones will fix every joint issue, but I'm saying that it can make it better. For the vast majority of women. And the other thing is just getting older is not an answer to all these things. Right. Sometimes there's an actual underlying reason that we should be addressing. Okay, that one was short, but real. Number three, feeling tired all the time is just part of getting older. this one is the most frustrating one because so many women have just quietly accepted that exhaustion is their new normal. Even though we have so much to do and we really shouldn't be stopped by feeling tired, but these women stop expecting to feel good. So we're gonna chat about hormones, what they do, and how that impacts energy levels. So we're gonna talk about progesterone first. Progesterone, it ha I call it like the calming hormone. It has a little bit of a sedative effect. It interacts with GABA receptors in the brain in a similar way that anti-anxiety medications do. So this is just like a little bit of a side note. But when women come in and perimenopause, a lot of times the first kind of symptom is mood changes, irritability, and anxiety. That's to do with the drop in progesterone. But progesterone also helps us sleep. So when progesterone drops, your sleep quality goes down. Women will fall asleep fine, but often, of course, we've heard you're waking up at 3 a.m. and you can't get back to sleep, or you're sleeping your eight hours, but you're still exhausted. So that, number one, impacts your energy. Obviously, if you're not sleeping well, you're not gonna have energy, but that can be your progesterone dropping. Two, estrogen plays a role in your mitochondria and how it functions. So if we go back to, I guess, middle school, we remember that the mitochondria is the powerhouse. inside the cell. So Talking about that, right? Estrogen helps with creating energy, but also another part that can disrupt your sleep at night is having night sweats, hot flashes. And again, that can disrupt your sleep. Number two. no, number three. Sorry. Testosterone. I talk about this all the time in my clinic. I think every woman needs to be on testosterone. And a lot of times they are coming to me on hormone therapy. And that includes progesterone and estrogen, but not testosterone. But testosterone is really important because it is not just a libido hormone, which it's currently being used for by some providers. Yes, it can help with that, but it's so much more. When I start women on testosterone, I can see that their motivation goes up, their mental clarity goes up, their energy, like their physical energy goes up. And so when it starts to decline, some women will say they're not just like physically tired, but the one thing that I hear is in many different w forms and ways that they say it, but it's just like they're unmotivated. I don't feel like going to the gym. I don't feel like doing this thing. I'm I know I have this long to do list, but I just can't get myself to do any of it. And then you're feeling a little foggy and you're feeling a little flat. And then when you start testosterone, I just hear, I feel like myself again. So that's a missing piece. And like I said, a lot of women are on estrogen and progesterone now, but I don't know that A lot of providers are comfortable with testosterone, maybe, or they don't know how to dose a testosterone, that it's just the missing piece. So when a woman tells me that she's tired, just because she's getting older, we have to ask a few questions. How are you sleeping? Let's look at your hormone levels. Because a lot of times correcting the hormonal deficiency can help. Not always, not 100% of the time, but in most cases, addressing the hormonal deficiency can help. And just one more thing. Fatigue isn't a character flaw or an inevitability. It's a signal that is worth investigating because, like I said, a lot of times hormones can help, but sometimes there's other things going on causing the fatigue. We shouldn't accept that as just part of normal aging. Okay. This is a big one. I've talked about this on the podcast before, but I'm having this conversation weekly in the clinic, so it's worth bringing it up again. Hormones cause cancer. And it's a big one, right? We know about the WHI, the Women's Hormone Initiative study, and it's a little bit more nuanced than like people think, right? So the Women's Health Initiative was a big study. If you don't know about it, it was released in 2002. That's when that headline came out saying hormones increase risk of breast cancer. with on women in hormones. So almost overnight women and doctors stopped getting hormones. But what they looked at was two different groups. You had women on estrogen alone because they have had a hysterectomy, no uterus. And then you had the women who were on estrogen and a progestin, which is a synthetic progesterone. And they had a uterus, right? Because if you're on Estrogen, you need to be on progesterone if you have a uterus. And what they found was a slight increase, like very slight, still an increased risk. And we don't want anybody to have an increased risk, but a slight increased risk in the women who were in the estrogen and progressin group, not the estrogen alone. Estrogen estrogen was not the problem. It was the progestins. Progestines bind to androgen receptors. Androgens are protective against breast cancer. So it might have something to do with that. Not a hundred percent sure, but I'm guessing from what I've read that that's what happened. But anyways. Again, women who had a hysterectomy and were on estrogen alone did not have that same risk. And in a long-term follow-up over 20 years, the estrogen alone group showed a significantly lower rate of breast cancer than the women on no hormones at all, including colon cancer. And interestingly, they also had a lower breast cancer mortality risk if they were on the estrogen, because it's inevitable, right? Breast cancer unfortunately is common. Whether you're on hormone therapy or not, you can get breast cancer. But the women who were on estrogen had better survival rates. so again, just to summarize, the synthetic progesterone, not the estrogen, seems to be what was driving that added risk. I don't use synthetic progesterone in my clinic. I just use bioidentical. That hasn't been studied, but because it's bioidentical, the consensus is that it should not and is not acting in the same way as that progesterone. so yeah, that's hormones cause cancer is a blanket statement. That's not what the data showed. It's the type of hormone that was used, specifically the progestin. But there's one caveat, and this is what I tell women in my clinic all the time. I already said it, but I'm just gonna say it one more time. If you have a breast tumor and you don't know about it, and you start and it's hormone sensitive breast tumor that's growing silently, starting hormone therapy can accelerate. a growth, which is why it's important to get your screening mammograms, your screening ultrasounds, whatever it is that you do to d do your screening. But that's different than hormones cause cancer. I hope you see the difference there. But anyways. like I said about the testosterone, there's some research being done by multiple providers. One of them is Dr. Rebecca Glazer. I think that's how you say her last name. But anyways, that it's showing that testosterone can be protective to the breast tissue, not harmful. She's done long stu like long perspective studies on this. She was following women who are given subcutaneous testosterone, meaning pellets. or testosterone combined with aromatase inhibitors, like anastrazol slash armodex over a 10-year period. And the data that she has showed that women had a meaningfully lower incidence of invasive breast cancer compared to the population that was not on that. And she's even done this on women with a history of breast cancer, treating them with testosterone and anastrozole together, because test anastrazole prevents the conversion of testosterone to estrogen. And there was also not an increased recurrence in this population. And this patient population had a significant improvement in their quality of life, energy, mood, sexual functions, which is important if you've been through breast cancer. Anyways, that is still an evolving area of research. not your mainstream standard of care everywhere, but it's interesting because it's starting to come out and we're starting to understand this. So the goal of this is just to say, do your research. It's out there, you just have to look for it. Don't be scared. What I want you to walk away with is that estrogen, progestins, bioidentical progesterone, and testosterone all behave differently in your body, and we can't lump them all together under the hormones cause cancer, because that does a disservice to women. And this is a conversation to have with a doctor who actually is hormone-trained, because assuming that your doctor knows anything about hormones just because you're a doctor is incorrect. Weak bones are just part of getting older. No, no. And actually, if I can tell you like two things that I'm terrified of happening as I get older is having osteoporosis, which is weak bones, and having a cognitive decline or dementia. And the thing is, like those you don't really feel those happening until it's too late, right? You can't feel your bones getting weaker. It just one day you fall, you do something, a movement, and then all of a s you have a like compression fracture of like T12 or whatever, one of your spinal bones. Bones. And by then, you've like missed the window of opportunity to make things better or prevent them from happening. So let's get down into the physiology. Your bones are a living tissue and they're constantly being broken down and rebuilt, right? You want to break down bad bone, rebuild it so that it gets stronger, and that's called remodeling. Estrogen's job is that in that process, it keeps the cells that break. The bone down and check. When estrogen drops in menopause, that break comes off. So the bone breaking down will outpace the rebuilding. And this is why the most rapid bone loss a woman will ever experience happens in the first several years after menopause. It does not happen gradually. Happens, I think I read somewhere it was within the first five years. but anyways. The other thing to note about this is that insurance does not cover DEXA scans. DEXA scan is a bone scan that measures if you have osteoporosis or osteopenia until your sixties. If you've had menopause early in your forties, by the time you're doing a DEXA scan in your sixties, it is too late. Too late. I think everyone should have a DEXA scan in perimenopause. And then if you want to wait until your sixties or whatever after, maybe. But sixties is too late. okay. So one other thing that I want to say I've seen in the clinic is I have women in their sixties who are on hormone therapy with pellets. I have seen their bone density improve. So I had a patient who went from osteoporosis to osteopenia after one year of pellet therapy. And I have one whose primary care doctor called her and said You are defying all odds because as you get older, your bone density is improving, which is not normally the case, right? But hormones can help prevent that. so then moving on. I don't want to just give people a false impression that like all you have to do is take hormones and then your bones are going to be. miraculously like healed or like you'll never get any weak bone problems because the bone doesn't only respond to hormone therapy, it responds to mechanical load. So long story short, I'm telling you to exercise because every time that you have your strong muscles contracting and pulling on the bone, or every time you're doing resistance training, it is signaling to the bone we need to stay strong. Right, because of the friction and the force. Muscle mass declines with the loss of estrogen and testosterone. Right. So it's not only that your bones are getting weaker because the signals are not there to keep it rebuilding and keep it strong, but if you're also losing muscle mass. Then your bone doesn't stand a chance. So how do I protect my bones? It's never just one thing. It's hormones plus strength training. Strength training, not just like walking, because a lot of my patients will be like, Well, I walk 30 minutes a day. That's great. I'm glad that my patients are out there walking. But you need to actually like do resistance training so that we can age better and be stronger. Do not wait for your DEXA scan to tell you that there's a problem and that you have to do osteoporosis. I am not a huge fan of the medications that we have to treat osteoporosis. I've seen many women on it. They're still having fractures. Just so I don't stir the pot too much, I'm just gonna say maybe you book a discovery call and we can talk about it. But in general, let's just quick summary. Vaginal estrogen is really important, it prevents dryness. And yes, that can help improve your sexual health, but it's more than that. We we want to prevent these UTIs, especially as you're getting older, because recurrent UTIs are not fun, you can get septic. You can end up in the hospital and that will significantly decrease your quality of life. And it's an easy fix. It's just twice a week. number two, joint pain is just part of getting older. Hormones won't help that. We talked about why that's not exactly true. Number three, feeling tired all the time is just part of getting older. That's the most frustrating one. Do not accept symptoms as just part of getting older. We can always feel better. No matter where you are, what your baseline is, even if it's a great baseline, you can always feel better. Number four, hormones cause cancer. This is a big one. It's a big conversation, and I don't know that we can just do it in a couple minutes. I tried my best to summarize this. Again, my go-to book for anyone who's on the fence about hormones is The Menopause Moment by Kelly Casperson. And then lastly, we talked about weak bones are just part of getting older. We can prevent that. And the reason that I find weak bones so terrifying is because if you fall and you break a hip, quality of the life significantly goes down. I think at two years the mortality is like 30%. Two years after hip fracture, that's huge. Also, I think about a one-fourth of people who fall and have a hip fracture. Cannot return to that baseline that they were before that hip fracture, meaning they're either walking with an assistive device or they're in a nursing home. That's just not in my life plan. So a broken bone is a lot more than just a broken bone in this situation. And that's about it. So those are the top things I've heard in my clinic this month. If there's anything crazy next month, I will definitely share that with you. And Just one more thing. If you've been told these things by a doctor, by your mother, by the internet, there are resources you can reach out to me. I'm happy to share them so that you can learn more. And that's it. Thank you for listening.