Maggie McKay (Host): Menopause is a fact of life for women, another stage of life. But there is a lot of misinformation about it. So today, we'll erase the myths about hormone replacement and women's health with Dr. Deborah Wilson, founder of Deborah Wilson MD and Associates.

Welcome to Top Docs. I'm your host, Maggie McKay. Great to meet you, Dr. Wilson. Let's dive right in. What is menopause and why does it happen? And what are the symptoms?

Deborah Wilson, MD: There are many terms around menopause, such as perimenopause and postmenopause. And frankly, they're not particularly useful. It's more useful to get down into the physiology of it. So for years after a woman starts her period and has cycles and around 50, her ovaries no longer make hormones. So, during what we call the reproductive years, her ovaries are making estrogen, three different kinds of estrogen actually, testosterone, and progesterone. But around 50, the ovaries run out. They run out of follicles, follicles are what form eggs or what produce eggs. So, they run out and she no longer has estrogen or testosterone or progesterone around and that causes a number of symptoms.

The most common are hot flashes, night sweats, vaginal dryness, insomnia, irritability, that sort of thing. And some women breeze through it, they really don't get affected much at all, which is amazing to me, frankly. And some women really suffer with the hot flashes and they can't sleep at night and they're grumpy during the day and their relationship, at least their sexual relationship with their partner becomes a big challenge because without hormones, there's really no sex drive. And also, there's significant vaginal dryness, so pain on intercourse. This is what we deal with every single day.

Host: And what is hormone replacement?

Deborah Wilson, MD: Well, hormone replacement is replacing the hormones that your ovaries made. So if we come in and replace estrogen and testosterone and progesterone, sometimes that's a different conversation. But then, those symptoms go away, then she doesn't have any hot flashes or night sweats anymore. And she all of a sudden develops a bit of a sex drive, it's never going to be the same as it was when she was 22, but still, and the vaginal dryness disappears. So, a sexual relationship with her partner is more comfortable and pleasurable. So, we can come in with hormone replacement and there are lots of different options when it comes to hormone replacement.

Host: And there's been a lot of discussion through the years, decades actually, whether hormone replacement is safe. Is it?

Deborah Wilson, MD: Oh, yes. This is a conversation. I might as well put it on replay because I have this conversation all the time. So, unfortunately, and really unfortunately, I mean, in the '90s, we recognized that hormones were great for a woman's well-being and for her heart and, obviously, for sexual function and energy and all that sort of thing. So, I was practicing in the '90s. I've been practicing for 37 years. And then, all of a sudden there was the Women's Health Initiative Study, which was in the early 2000s. And unfortunately, it was a very badly designed study, and I won't go into the details, but just let it be said that it was a badly designed study. And they even stopped it early, because they were so concerned about the negative effects of hormones. And it just had reverberations throughout the media and throughout the medical world. And so, all these women went off their hormones because they were afraid of getting breast cancer. And they were afraid of having a stroke or heart attack. You know, unfortunately, the study was done on oral Premarin, which is pregnant mare's urine, which is a whole other conversation. It's very cruel to horses. So, the study was done on oral hormones. It was done in women who were in their 60 to begin with, which is that's not a good idea to start hormones that late, generally speaking. But the impact of this study was just stunning. And all these women were off their hormones, and there was a lot of suffering as a result of that. That actually persisted for a number of years.

But over the last few years, there have been multiple studies looking at do hormones actually cause breast cancer or cause a predisposition for breast cancer? Do hormones actually cause stroke and heart attack? And what we've seen is that as long as the hormones are not given orally, like swallowing something, and it's not Premarin, it's more bioidentical estrogen, actually, it doesn't increase the risk for breast cancer. I mean, breast cancer is everywhere. One in seven women gets breast cancer, and there are probably multiple factors involved in that, and that's another conversation. And as long as you don't give it orally, it doesn't pass through the liver, it doesn't increase fibrinogen, which is a clotting factor, and so it doesn't increase the risk for stroke and heart attack. And fortunately, over the last year or so, this has been pretty well-publicized in the mainstream media. So, we're seeing women finally be comfortable with addressing the symptoms that they suffer with.

You know, I'm not saying it's safe for everyone. It's not safe. Hormone replacement is not safe for everyone. And, you know, if a woman has had breast cancer and is estrogen receptor positive, it's not a good idea to take estrogen, obviously. If she has a genetic clotting defect, a mutation that predisposes to blood clots, then it's probably not a good idea. That's a little controversial too. But all these things, I mean, I could talk for five hours and I talk for, you know, 10 hours a day, because I only see menopausal women at this point.

Host: So, is it fair to say that just that one study is why we thought estrogen caused breast cancer strokes and heart attacks?

Deborah Wilson, MD: Yes, it really is. It's that one study. It was a big one. Yeah.

Host: Amazing. And what are the advantages of hormone replacement?

Deborah Wilson, MD: Oh, lots of advantages. Number one, probably the most compelling advantage is bones, bone strength. As people get older; men too, actually, you know, because they lose testosterone-- as women get older, bones tend to deteriorate, but they do not deteriorate as much if there's estrogen around, because estrogen preserves bone mass. And there's really no more powerful-- we're not going to call estrogen a drug, it's hormone replacement, it's what your body made for years. But there's nothing more powerful than estrogen in terms of maintaining bone mass and preventing osteoporosis.

You know, osteoporosis is bad. It causes breaks, spinal fractures, and hip fractures. And frankly, you know, if a woman at the age of, say, 76 has a hip fracture, her health in the future is challenged. You know, we call it a downward spiral. So, it preserves bone mass. And we're also seeing that if hormones are started around the time of menopause, that it's very positive as far as the cardiovascular system, it has cardiovascular benefits. And then thirdly, every brain cell has an estrogen receptor. So, I mean there's a study done looking at women on hormones and off hormones, they're all postmenopausal, the women on the hormones do better on IQ tests. In fact, if you take a group of women who are not on hormones, you test them, and then you give them hormones and test them again six months later, they do better on IQ tests. I mean, it increases memory and just cognitive function generally speaking.

So, those are the benefits. And then, you know, we can go on. I mean, there are sexual benefits there. It's good for your skin. It's good for energy if you add testosterone to estrogen. Testosterone, I mean, if you give testosterone to birds, they sing more. So, testosterone is a mood elevator and it increases energy level and increases the ability to build muscle. And obviously, it's great for sexual function. It's great for sexual desire.

Host: And you mentioned it's not for everybody. So, who is a candidate for hormone replacement and who is not?

Deborah Wilson, MD: So, the recommendation at this point is if hormones are going to be given to a woman, it should be done within 10 years of the advent of menopause or ovarian failure. So, we really would prefer to start hormones early in the game. So, you know, if a woman comes to me and she's 75 and wants to start hormones, it's not a great idea for a number of reasons.

But most women are candidates as long as we start it early enough. But as I said, if a woman has been diagnosed with breast cancer, it's not a good idea to give her hormones, especially if the breast cancer is estrogen receptor positive. If she was on estrogen before and developed breast cancer, it doesn't necessarily mean that the estrogen caused the breast cancer, although, you know, conventional wisdom all over the place has doctors telling patients that. That's not really true. So, most women are candidates. There are genetic mutations that cause a predisposition to clotting, like factor V Leiden. There are families where you see a lot of blood clots, a lot of pulmonary emboli and, you know, other blood clots. So, you know, in those patients, generally speaking, it's not a great idea to use estrogen. We can use testosterone, but testosterone alone, you know, it has its advantages, and there there are some positives, but it doesn't really do the job.

Host: And if a woman is not a candidate, what can be done to mitigate the symptoms of menopause?

Deborah Wilson, MD: Well, you have to separate them out, so you have to look at each symptom and address it. There is a new drug on the market that helps with hot flashes. There are actually a few drugs. Actually, some of the antidepressants like Prozac help with hot flashes. So, we can treat the hot flashes if that's a big problem. Almost any woman, no matter what her contraindications are to taking hormones, can use vaginal estrogen, like a vaginal estrogen suppository or a cream, and that will increase elasticity of the vagina if she's having pain with intercourse. So, you have to separate out the symptoms and treat accordingly.

Host: I'm still back on the birds singing more are on testosterone. I just love that.

Deborah Wilson, MD: It's true.

Host: And also, the brain, every cell has an estrogen receptor. That's so wild.

Deborah Wilson, MD: Yeah.

Host: Amazing. So, thank you so much. This has been so educational and helpful. Thank you for sharing your expertise, doctor.

Deborah Wilson, MD: You are welcome.

Host: Again, that's Dr. Deborah Wilson. And if you'd like to find out more, please visit drwilsongyn.com. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is Top Docs. I'm Maggie McKay. Thanks for listening.