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Maggie McKay (Host): When it comes to menopause, hormones play a huge part. But how much do you know about hormone replacement? Joining us is Dr. Lori Warren, owner of Spa-V and double board-certified in both Gynecology and Urogynecology. She's going to discuss the power of bioidentical hormone replacement therapy and how it can improve the health and wellbeing of menopausal women everywhere.

Host: This is Top Docs Podcast. I'm Maggie McKay. Welcome, Dr. Warren. Thank you so much for making the time to be with us. Could you please introduce yourself?

Lori Warren, M.D. (Guest): Absolutely. Thank you for having me, and it's an honor to be here. So, I am a gynecologist. I've practiced for 31 years with a group in Louisville called Women First. And then, I most recently have spent my time at a med spa that I started about seven years ago called Spa-V. And so, I have, as you mentioned, board-certification in both OB-GYN and also urogynecology and have been taking care of women my whole life. We specialize in cosmetic gynecology at Spa-V as well as vaginal rejuvenation. And we also have been offering people hormonal optimization, and that's what we're going to talk about today.

Host: Can you tell us about the features of menopause and perimenopause? Because I think it can be somewhat of a mystery if you're not a doctor.

Guest: Yeah, absolutely. So, it affects all of us. As women, we can't get away from it because we all have menopause and perimenopause. And the difference is this, perimenopause is that time leading up to when you have your last period. And women can be affected with several different symptoms. There's symptoms of hot flashes, mood swings, insomnia. And they vary from women to women, how severe they might feel these symptoms. But the hallmark of perimenopause is that women's periods change. And they may all of a sudden miss a period or their periods can become a lot heavier. Leading up to the period, they may have more PMS symptoms sometimes and also night sweats or hot flashes during the day. And those can be variations. And then, the difference with menopause is that menopause is just one day, meaning menopause happens exactly 12 months after your last period, that's the day of menopause. And then after that, you're post-menopausal. So, it's really just a definition that we use. So, it's a series of symptoms and declining ovarian hormones for women. And eventually, they get to where their hormones are completely very low, their ovaries are no longer working, and that's when they become post-menopausal.

Host: I'm already learning so much from you, Dr. Warren. I had no idea menopause was one day. I've never heard that. That is amazing. What are some health issues related to hormone deficiency?

Guest: That can really, again, vary from individual women. But on the whole 70-80%, the hallmark really is hot flashes. So, these vasomotor symptoms with the hormonal deficiency occurs and hot flashes can be a huge problem for women. You know that feeling if-- for those women who are listening that maybe have never had a hot flash, because I'm sure that I have women of all ages and I treat women of all ages. So, that feeling when you get super embarrassed and you can't control it, and your face gets so red and you just feel like you want to crawl in a hole. That's almost the discomfort that women get when they have a hot flash. And it can last for three to five minutes. And it's a change with vasodilation and vasoconstriction that women have. And they really can't control it. Once they're in it, they want to put themselves in a freezer or they want to get a fan. A lot of clients who tell me they have a fan at their desk at work because they never know when a hot flash is going to come on. And I've had women that say they're in a board meeting and all of a sudden they'll have a hot flash and they're having a silk top on and they've completely sweated through their clothes. So, it can be a real issue, those hot flashes for women.

Another thing a lot of women tell me is they start having mood swings. And for no apparent reason, they just snap at their kids or they snap at their husband. They just feel crabby. They're, "I'm just not myself." So, that can be a problem that women have when they go through menopause.

Insomnia is another huge complaint. And you can imagine this vicious cycle that if you're having hot flashes, you're not sleeping, it can affect your sexual function and also women get depressed during this time. So, it's a huge, huge problem. Not to mention some of the other health issues that we'll get into with thinning of their bones, their libido may change, I kind of mentioned that and also weight management. How many women have come to me in that early menopausal period and said what is going on in my midsection? I never had to worry about this muffin top before. And they feel that all of a sudden distributing fat right in their midline. And that's another huge issue that women have when they get to this age, that we can certainly talk about.

Host: It's probably a good thing we don't know all these things are coming at us when we're in our 20s, but it's just a fact of life. So when it comes to hormone replacement, what are some of the controversies associated with it?

Guest: One of the things that I was going to mention about the controversies of hormones is that women are scared and they're scared about breast cancer primarily. In actuality, I'm just curious, do you know what the biggest cause of death for women are after 50? I'm just kind of doing this as a hypothetical question to get our audience to kind of think about, "Is it breast cancer?"

Host: I'm thinking heart issues.

Guest: You're exactly right. So, women actually have a much higher risk of heart disease dying, things that are going to kill us women is heart disease over breast cancer. But breast cancer is certainly a concern for all of us, and I would encourage everyone to get their mammogram every year after age 40, because that really does save lives. Because it makes sense, the earlier you find a breast, The earlier you're going to be able to be treated and then the chance that that cancer's not going to metastasize or ultimately cause your death. I have many, many, many breast cancer survivors that I've taken care of over the years. And it's really amazing how well they do especially if that breast cancer is caught early.

But as far as the controversies go, I just want to take back, I think historically it's important to think about what hormones have done because a lot of us have forgotten, but estrogen was started to be given to women in the 1950s. That would be a little before my mother's time because she wasn't menopausal in the 1950s. But possibly my grandmother's time, would've been given hormones in the 1950s. And then, what they found after a decade or so into the 1970s is that women started developing a higher risk of uterine cancer because of the estrogen, because that estrogen was unopposed. That can affect the lining of the uterus. If you have a uterus, it's extremely important to have both estrogen and progesterone, because that progesterone is going to protect that uterine lining. But early on, we didn't know that.

So, women were given estrogen only, there was an increase in actually uterine cancer. So then, they brought in progesterone and they did it back then in a form of a synthetic progesterone that was a progestin called medroxyprogesterone acetate, the Provera. And that Provera may have been one of the culprits in the Women's Health Initiative. So, the biggest study, randomized controlled study, that we have is called the Women's Health Initiative. So, women were doing well in the 1950s and even '70s once they realized that they needed to have progesterone. And a lot of women had improved bone health, heart health and seem to feel better because they didn't have all those symptoms I was just telling you about, where they were feeling like they wanted to strangle somebody in the store or get road rage or be really angry that so many women going through menopause that aren't taking hormones may feel.

And so, the NIH wanted to start studying the hormones and what was the true risk of hormones and what was the true help for cardiac disease. Because we suspected, even when I started in practice in 1991, I did my residency at Tufts in Boston and then came to Louisville, Kentucky and practiced in a private group for many years, and we felt early in the '90s that we were really doing a disservice to women if we didn't offer them hormones. But what we learned through the Women's Health Initiative is that maybe it was the type of hormone that we were giving women and that could have been an issue.

So, the Women's Health Initiative, I feel like I really should go through that if that's okay and kind of explain that study because I think a lot of healthcare providers still harken back to that study as kind of the gold standard. But in fact, there were some major flaws in that study because it wasn't the typical woman going through menopause. Actually, they designed the study to have older women, most of the women were over 60 that were in this study, and 21% of them were over 70 in this study. Well, those women, part of the criteria was that they shouldn't be having any menopausal symptoms because they didn't want the placebo patients to drop out of the study. So, they wanted all the women to actually not have all those symptoms that women can suffer from. So, that I think was a big problem. And in that group of women that they picked that were older to begin with, sometimes on the average 13 years passed when they went through menopause, they also were sicker women, 30 to 40% of them were smokers, they had diabetes, high incidence of obesity and also hypertension. So, this was to begin with an unhealthy, less healthy group of women than maybe the typical 48 to 52-year-old going through menopause. So, the average age of menopause is 51.4. But women for four years before then, or several years before, can start feeling symptoms, that's that perimenopausal time that's so important to women where they actually may need to think about some hormonal treatment even though they're still having their periods.

Then when they looked at that, I think that we have to think about the risk because what happened is in 2002, the media got ahold of this study and it became a huge news flash that hormones increased breast cancer. So, everyone started going off. And I was in practice, so it was very alarming to me because I certainly didn't want to give hormones to women if it was increasing the risk of breast cancer. I think if you really delve into what that risk really was, it's so interesting. The relative risk was a 25-27% increase in breast cancer, which sounds huge, right? But the absolute risk really wasn't teased out at that point and the absolute risk, and these are the women that were in the combination Prempro. Prempro is Premarin combined with Provera, so Premarin and Provera, and that was the Prempro that they were on. And the absolute risk that I wanted to get back to was there was instead of four out of a thousand women with breast cancer compared to the placebo group, there was five out of a thousand.

The absolute risk, if you think about it, if someone asked me, gosh, you know, these hormones, even those hormones, which I don't think are as good as the biodentical that we're going to talk about, your risk may be increased instead of four out of a thousand chances, five out of a thousand. So, it's interesting to note that that risk really was not that huge, but yet it completely changed the way we took care of women in 2002 from that one study.

The other interesting thing that I think women should know about, and I tried to explain this to my patients, you know, there's a lot of fear of hormones and I try to explain that the Premarin-only arm, that was the women who had had a hysterectomy, and they only put them on the estrogen. And the type of estrogen they put them on was conjugated equine estrogen. It actually comes from horse urine, which some women are mortified to hear about. But these women that were on the Premarin-only arm actually had a slight protective effect from breast cancer. And that never really came out in the media, that estrogen actually may protect. And it didn't come to huge statistical significance, but the difference was the same in reduced risk of one in a thousand women. When you looked at the absolute risk, those women on Premarin-only had this slight protective effect.

So, I think it's important to know maybe where some of the controversy and fear came from, and it came from this one study. Since then, ACOG has said that it should be used just for vasomotor symptoms. So, ACOG, if people don't know, that's the American College of OB-GYN that most OB-GYNs belong to. And we certainly listen to them. They have a lot of position statements and practice bulletins that sort of monitor what's going on in the OB-GYN world. They're also a very conservative group and they said, "You know, at this point, maybe we should re-look at it, look at maybe the type of hormones that we give women, and something that's more biodentical and also the mode of delivery." It may be safer to do something transdermal. So, transdermal is a patch or a pellet or a cream or even a vaginal ring that women can use through the skin compared to something oral. The medication used in the Women's Health Initiative was actually Premarin. And that was an oral delivery system of estrogen to women. And it may be safer to actually do something through the skin. So, all my patients, for years, if they want to be on hormones, I've tried to get them on some type of transdermal estrogen rather than an oral estrogen because we feel that it could be safer than going through the liver and possibly affecting some of the clotting factors. So, that's something we always talk to women about.

But very interesting, the NAMS position statement came out, NAMS is the North American Menopause Society, and they had a position statement in 2017 that kind of was much more liberal. It said maybe use different hormones for women or bioidentical hormones for women compared to the hormones that were used in that Women's Health Initiative study. And maybe you don't have to be as concerned about the lowest dose for the shortest amount of time, but individualize the therapy for your patient and give her hormones to help her health and her wellbeing and basically quality of life. Because one thing I didn't mention that I think is interesting is that we're all just living a lot longer. So us women, the last a hundred years, we've basically doubled our lifespan from where it was a hundred years ago. So, we're going to be spending a third to a half of our lives in menopause. So, this is a crucial issue for all women when you think about that women who choose not to be on hormones, which some women are not candidates for, it's not their fault. They just are too concerned about the possible risks of hormones or haven't been able to tolerate hormonal therapy. They're going to spend many years of their life in a hormonal deficit state. We can also certainly look at that. But I think a lot of OB-GYNs also think that there's a cutoff point, that if you're on hormones, you need to stop maybe by age 65. And what NAMS said is, no, we don't really need to. If someone's healthy and doing well and they started on hormones when they were going through menopause, you don't necessarily just have to stop them at age 65 and beyond.

Those are some of the controversies that's come out and it's really this scare factor. I've spent my whole career really unraveling from the Women's Health Initiative and trying to really figure out, "Are our hormones more benefits than risks?" And that's always the question. Any therapy, as a physician, that we give women, do the benefits outweigh the risks or are the risks too high?

Host: And Dr. Warren, what are bioidentical hormone therapies?

Guest: So, bioidentical is the hormones that your own ovaries make. So, the hormones that are estradiol and estriol. There's another hormone that our ovaries make called estrone, that's a weaker estrogen that we usually don't replace because that could be an estrogen that wouldn't be as healthy. But estradiol, 17 beta-estradiol is the most potent estrogen that we have in our body. And so, we're replacing with biodentical therapy those same chemical structure that our own ovaries would make. And that's why the name biodentical came up, because the estrogen molecule wasn't changed or it's not horse urine, which isn't necessarily terrible, but it is something that, you know, many women have done well with, but they may have slighter risk with the oral estrogens that we try to stay away from now.

The big concern was the type of progesterone. So, there's a micronized progesterone that's bioidentical. And you want to try to stick with that, in my opinion, because of what came out of the Women's Health Initiative, that it really was the combination of the Premarin with this synthetic progestin, which is the Provera, that they did have that slight increased risk of breast cancer. So when I replace people, I think that it makes sense what I would want would be hormones more similar to just like what I used to make. And that's what biodentical is. And then, there's also testosterone, DHEA. Some doctors are also keen to replace thyroid. Thyroid aberrations in women are much higher than we might have thought before. That's another bioidentical hormone, that there's different forms of thyroid treatment that women can be on and there's a natural thyroid or bioidentical thyroid that they can pick, potentially with their provider.

Host: And what's the difference between using BHRT, what it can make for your state of mind and for controlling symptoms like weight gain and low sex drive, and maybe even reducing disease risk, is that right?

Guest: Yes, exactly. I'm really glad you asked me about that because we're learning every day how important hormones are to us, especially as we age. So, I think you asked me lots of things in that, but I'll try to break it down and just talk about them. I made some notes before I came in because I think it's so important to explain some of the advantages of what is going on with our health and where estrogen can help. But certainly brain, you asked about that.

So, one of the things that I definitely noticed when my hormones started declining was word-finding. I would be somewhere and it would be someone I knew very well, and all of a sudden I was like, "Oh my gosh, what's their name? I can't remember." And even with my patients, I was having sometimes a difficult time until I saw their chart and saw their name. And it might have been someone I had taken care of for years, and I definitely knew them, but I had to see their name to click that in. So, there is a time where our memory can be affected by going through menopause, and estrogen can help that. There's many studies that show that estrogen is neuroprotective for our brain. We're not sure that it can treat Alzheimer's, but it may help prevent Alzheimer's disease, which is something I think we all worry about as we age because we are living so long, we don't want to have dementia. So, brain health is really, I think, important and hormones can help us with our brain health and memory, and also with our moods. You mentioned moods. You know, our brain is responsible for a lot of what we think and feel. And we've found that hormone replacement therapy can help with some of that mood lability that we have, not just when we're going through menopause, but even as we get a little further into our years as well.

I mentioned that heart disease was something that we are really concerned about with women. Because if you look at that as far as leading reasons for death, heart disease is really the most common cause of death after age 50. One in two women are going to die of heart disease diagnosis, whereas one in 25 die of breast cancer. So, breast cancer is still a huge thing that we need to think about. But I think that women would be surprised because when they're surveyed, they usually think that breast cancer's number one, and that heart disease is way down the line. So, I think it's really important. But estrogen has been shown to decrease our risk of heart disease by a huge percent, and also decrease the risk of a sudden heart attack. And it may prolong the life of women who already have coronary artery disease. So, I think estrogen can be huge and there's ongoing studies looking at that. And I think the controversy still goes back to the type of hormone that you give women, I think bioidenticals are safer. And also, the way that you give it, the transdermal versus the oral estrogens are safer in my mind with all the literature that's come out in the last 20 years since the Women's Health Initiative.

Another thing that you may have asked about, but I think it's really important to bring to women is that I would have these women come in, this is really profound because now with my med spa, we do some aesthetics for skin and also for the vagina as well, because the vagina is profoundly affected by the lack of hormones. So, we can talk about that as well. But I would have a patient come in one year and say, "Yeah, I think I'm going through menopause. I've skipped a few periods. I don't really have a lot of symptoms. I don't want to start on hormones yet. But I just know it's coming." Then, the next year she would come in and I would look at her face and I would say, "You stopped your periods, haven't you?" I could tell that they were losing their collagen.

Host: Wow.

Guest: I know, I could tell, I wouldn't even have to ask her on the chart. I would say, "You've stopped your periods," because I could see in one year the changes in that patient's face. We lose 50% of our collagen if we're not on hormones the first five years after menopause. So, you know, the wrinkles, the dryness, sometimes itchy skin can be affected by this amazing hormone called estrogen. As you can tell, I'm a big proponent for it. But again, safety first, we always individualize it for each of our patient, to take a good medical history, find out if she has any contraindications to being on hormones. And it's quite frankly not for everybody. And there's other things that we can do now in the aesthetic world to help if you can't be on hormones and do different types, all kinds of different therapies, which is fabulous.

But, as a urogynecologist, a big part of my job, especially when I was doing all the prolapse surgeries for women, was taking care of urinary problems, urinary leakage, prolapse, weakening of that vaginal pelvic floor, that women would have. And that really starts to change in those menopausal years. So, women who have had babies, vaginal births, that's sometimes the first insult to the pelvic floor. But then when we start losing our collagen in menopause, that can become more of an issue. And certainly, stress incontinence, increased risk of urinary tract infections can be related to the lack of estrogen and also vaginal infections as well. So, I think that those skin issues are important.

But I think the biggest vaginal skin issue that I see is women will come in and say, "Okay, I stopped my periods, and why does it hurt now for me to have sex?" The medical term for that is dyspareunia. And dyspareunia is a huge issue for women, whether they've had vaginal births or not once they go through menopause, because that vaginal skin changes, it becomes thinner and we have this word for it, it's called atrophic. So, that sounds bad, doesn't it? But it just means that the skin is thin and it's not elastic. We lose our collagen, but we also use our elastin. So, you can use a vaginal lubricant, but that's not going to change the cellular structure.

So, women come in and say, "Why does it feel like I'm getting these cuts every time I have intercourse?" And it's because the vagina's not stretching anymore. And it just feels completely different for many, many women who go through menopause. And that's one of the things that we address at my spa now, is not just hormonal wellness, but also vaginal rejuvenation. There's different devices that can help non-hormonally, even thicken the skin, make it more tolerable to have intercourse and hopefully enjoy intercourse as time goes on, because that's a big change. And if we live a third of our life in menopause, women aren't ready to just say goodbye to their relationship as far as their intimate relationship is concerned.

Host: Right. Well, it's good to know there's so many options. And what an eyeopener. It's such useful information, Dr. Warren, thank you, about all the latest hormone therapy. Thank you for being here. And if someone would like to make an appointment with you or find out more, where would they go?

Guest: Thank you. So, I'm at Spa-V, it's a med spa in Louisville, Kentucky. It's right in the heart of St. Matthews on Chenoweth Lane. And you can call us at 502-425-5258. Make a phone call. Kelly's there and she can talk to you about all the things that we do there. And then, our website, I'd love for you to check out our website, it's called Spa-V.com. It's interesting, you know, I started Spa-V for the vagina, a vaginal spa, which was kind of unique. But then, that V is sort of segueing into vitality. So, it's Spa-V for vagina health, vaginal health for women, and also vitality. We have a lot of male patients who come in and have different services. Testosterone is a huge issue now for both men and women, and that's something that our clients are looking into as well if they're a candidate for testosterone therapy.

Maggie McKay: Wow. That is so fascinating. Thank you so much, Dr. Warren. Again, that's Dr. Lori Warren. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Top Docs Podcast. I'm Maggie McKay. Thank you for listening.