Transcript
00:01
Nicole
Hi, everybody, and welcome to the Woman-Centered Health Podcast. Today we are speaking with Dr. Stephanie Fabian, a professor and chair of the Department of Medicine at Mayo Clinic in Jacksonville, Florida. The penny. Bill George, director of the Mayo Clinic Center for Women’s Health and the medical director of the North American Menopause Society about hormone therapy for menopause symptoms. We also want to let our listeners know that we are undergoing some strategic changes to improve our listener experience and streamline our processes. We will no longer be offering our traditional show notes and will instead include takeaways resources and transcripts directly on our website. However, we would still love and appreciate your support and you can find ways to support us by going to our website www.womancenteredhealth.com and clicking the Support US tab. My little guy also wants you to support us. Also, if you missed our big news, nurses can now earn ce for listening to the WCH podcast. 

00:56
Nicole
Just check out myceq.com or download the Cehq app or you can visit our website to learn more. 

01:04
Stephanie
So hi Dr. Fabian. Thank you so much for being a guest on our podcast today. The first question we always ask our guests is if you can share with our listeners some details about your background. 

01:15
Dr. Fabian
Sure, and thanks for having me. I’m really happy to be here today. I am an internist, which may be unusual in terms of caring for women in midlife and being a hormone person, but I’m an internist. I’ve practiced Women’s Health since about 2005, and have great interest in terms of research on menopause hormone therapy, the effects of aging, and the relationship to hormones. Sexual health is another area of interest and expertise. I am the Chair of Medicine for the Department of Medicine at Me At Clinic in Jacksonville, Florida, and have been in that role for a couple of years. That’s also been very fun and challenging. 

01:58
Stephanie
The other question we always ask all of our guests is what informs your perspective. In other words, why do you do what you do and what is most valuable to you? 

02:08
Dr. Fabian
Got into Women’s health shortly after the results of the Women’s Health Initiative study were published. What I found is a lot of my patients just weren’t able to get the information that they needed and weren’t able to get hormone therapy in general. What spurred my interest really started with that, but then grew into such an interesting field to try to figure out some of the research questions around hormone therapy, the risk, the benefits, who should have it, what is it good for, what does the loss of estrogen mean for women around midlife? The topic is fascinating, but it’s also so incredibly rewarding to work with patients who are in that transition phase. It’s interesting, it’s stimulating, and I love my patients, that’s why I’m in it. 

03:00
Nicole
I always love the response to that question. So, as we said, today, we’re going to talk about hormone therapy for menopause symptoms. So let’s jump right in. Can you start out by explaining to our listeners what is the North American Menopause Society, or NAMS and what it is goals of NAMS? 

03:19
Dr. Fabian
NAMS is the North American Menopause Society, and our mission is to promote the health and quality of life of all women during midlife and beyond through an understanding of menopause and healthy aging. Our vision is really to serve as the definitive independent and evidence-based resource on midlife, women’s health, menopause, and healthy aging. We’re healthcare professionals, researchers, the media, and the public. One of our primary areas of focus is making sure that healthcare professionals have the information that they need to be able to care for women in midlife using evidence-based information. 

03:56
Stephanie
What are the gaps that you feel existed in menopause and symptom management? 

04:03
Dr. Fabian
Well, I think one of the biggest gaps right now is that women just aren’t getting treated. After the publication of the Women’s Health Initiative trial results in 2002, the use of menopausal hormone therapy plummeted significantly from about 40% of post-menopausal women using it to about 4%. So by orders of magnitude decrease. It really hasn’t changed substantially in the years since then. Despite the fact that we have a better understanding in those subsequent years about the risk-benefit profile related to hormone therapy use in women. Specifically, we’ve come to find out that the benefits typically outweigh the risks for the majority of women who are within ten years of menopause onset and are in their 50s. Most women actually are candidates for hormone therapy, but women are still suffering from a lot of symptoms. Not to say that all women need to be on hormone therapy, they don’t, or that there aren’t other options out there, but women are undertreated. 

05:05
Nicole
During our phone conversation, you shared that there is this movement from calling it hormone replacement therapy to just hormone therapy. Can you share more about this movement and why it is happening? 

05:16
Dr. Fabian
Yes. In general, we don’t call it replacement because we’re not actually trying to replace what the ovaries used to make. We are just trying to treat symptoms. The concept that we’re trying to give back everything that those overs used to make is inaccurate. The term replacement would only be really used in the case of, for example, a woman who had both ovaries removed in her 30s was a non-cancerous condition. We hope that doesn’t happen very much anymore, but when it does, we would be trying to replace what the ovaries made at that point because that woman would have had normal ovarian function up until about the age of 52. In that scenario, we would call it a replacement. It is for a 55-year-old who has been through menopause. We’re not trying to replace what her ovaries were giving her. 

06:08
Stephanie
NAMS recently released a new position statement on hormone therapy, which we will be sure to include the link for on our web page. Can you share with us what fueled the updated position and what changes were made from the 2017 position statement? 

06:25
Dr. Fabian
Yeah, well, as you mentioned, the last one was published in 2017, and so it needed to be updated. It was five years old, so no substantial changes in the overall recommendations were made, but there were new data added where appropriate. We’re starting to learn more about some of the nuanced aspects of hormone therapy. And we updated all of the sections. Actually, we sort of started over. The overall recommendations haven’t changed, though. Again, as I stated before, for the majority of women who are within ten years of menopause onset and under the age of 60 and are having bothers, some symptoms and benefits outweigh the risk. 

07:05
Nicole
Thank you. In the position statement, it says, quote, personalization with shared decision making remains key with periodic reevaluation to determine an individual woman’s benefit-risk profile. And, quote, can you share with our listeners how they can frame or ask questions to personalize and create shared decision-making around hormone therapy? 

07:29
Dr. Fabian
Yeah, that’s a great question, and this is absolutely key. What I do in the office when I see patients and we have discussions about hormone therapy, really comes down to what symptoms are they having, and what are they trying to fix. What problem are we trying to treat here? What’s the patient’s knowledge about this? What is her understanding of risk and benefits? What is her family history? What is her personal medical history? Are there any reasons that she absolutely could not take hormone therapy? A detailed discussion about risks and benefits in her particular situation. Taking into account whether she has high blood pressure or a history of blood clots, a family history of breast cancer, et cetera, all of those things need to factor into the discussion, as well as what we know about what more monthly people and you do for me in terms of symptoms, very effective in terms of symptoms, what will it do for my bone? 

08:23
Dr. Fabian
It will absolutely protect bones while you’re on it. The other big ones are what are the heart risks in my particular situation, what are the breast cancer risks in my particular situation, and what do we know about brain health as it relates to hormones? All of that is a tailored discussion based on the patient’s history, family history, and understanding of where she is in terms of her knowledge about hormone therapy. 

08:50
Stephanie
As you’re talking through all those topics, especially the risk and benefit, the personalization of it, where can clinicians go to understand their patient’s risk and benefit if that makes sense? 

09:07
Dr. Fabian
Well, that’s what the hormone therapy physician statement is for it’s really to help people understand what the risks and benefits of hormone therapy are. And, putting that in the context of your patient in front of you is more nuanced than that because there are all shades of gray and there is a breast cancer risks, but not a lot. There’s no black and white in decision-making. That’s the art of medicine is where you really get into what’s bothering the patient, whether the risks or benefits. This is true with any decision-making regarding medicine. Right. It’s an informed discussion about what this is going to do for you and what are the risks. 

09:46
Stephanie
In our clinical experience with Nicole and me, we have found that some providers are really reluctant to prescribe hormone therapy. Why do you feel that is the case overall and what advice do you have for those reluctant providers? 

10:02
Dr. Fabian
Well, I think typically when I see a provider who’s reluctant to prescribe it, I think it’s a lack of comfort and understanding about hormone therapy. For the most part, that stems from just unfamiliarity with it and how to use it. That’s what Nam aims to do is really to help providers better understand what the options are and how to use them. I do think the results of the Women’s Health Initiative study that were published back in 2002 colored People’s View of Hormone Therapy, and that’s despite multiple publications after that subsequent year that went on to better define the population that was talking about. The initial results were reported as one group of 50 to 79-year-olds and did not distinguish based on age or decade of life. We had a better understanding of the specific risks related to women in their 50s versus 60s versus 70s, it became much clear. 

11:03
Dr. Fabian
I think providers at that time had already stopped listening and the message really didn’t get out there very well. That clarified the issue. I think we had a provider education issue as well. 

11:16
Nicole
I want to circle back to where we’re talking about risk and benefit and talking with patients. We have an episode where we talk about health literacy and numeracy. I’m just wondering if you have found any way of framing those conversations around numbers like what is your risk of this that has worked well in your practice? 

11:39
Dr. Fabian
Yes, for sure. Especially with regard to breast cancer risk, we use that and it’s less than one in 1000 women will develop breast cancer after about five years of therapy, related to hormone therapy specifically. When you look at the big picture, about three and 1000 women will develop breast cancer anyway, and it takes it to just under 4000. So the risk is small. If you agree with it some lifestyle things, it’s somewhere between the risk of one and two glasses of wine daily. It’s about the same as being inactive. It’s about the same as being overweight or obese. There is a lot of putting it in the context of what people do and their normal lives sometimes helps people understand the numbers better, but the absolute risk is low. 

12:26
Nicole
What communication tips do you have for clinicians so that patients do not feel like their symptoms of menopause are being dismissed or minimized? 

12:34
Dr. Fabian
I think this is just like any other issue in medicine. When you talk about communication, listening to your patient and menopause discussions are no different. I think first understanding that the burden of menopause symptoms can be quite significant and that we are having a better understanding of how these symptoms actually affect women in terms of their daily activities, their ability to work, their relationships, et cetera. And it’s not unsubstantial. So these symptoms have consequences. We used to pat women on the head and tell them that their symptoms will last a year or two and then be gone. But we know that’s not true. The mean duration of menopause symptoms is seven to nine years for hot flashes. About a third of women will hot flash moderately to severely for a decade or more. It’s important to understand that the burden may be significant and the symptoms may not be short in duration. 

13:30
Dr. Fabian
In fact, they probably won’t be. Toughing it out is probably not the best option for most women who have significant symptoms. Just putting that in context with your patient, I think to understand that she wouldn’t be in your office if banning herself and toughing it out or working. I think if she’s there to talk to you about it, that is a significant problem and it needs to be dealt with. 

13:54
Nicole
Thank you. I really appreciate you saying that. I’ve actually had some friends recently who are struggling with symptoms of menopause and they’ve been to multiple providers and are basically getting told welcome to menopause, honey. And that’s it. 

14:09
Dr. Fabian
I hate to hear that. It makes me so sad because again, honestly, if that woman is in your office, she’s already had it, right? The symptoms are already bothersome enough to go see you as a provider. I understand that there are human options available and very safe and effective ones. We can do something about these symptoms and we need to help women. 

14:28
Nicole
Which is then I always followed up. I live in a rural area, so your access to more specialized can be difficult. That’s also been a conversation I’ve been having with my friends where do you go and how far are you willing to travel? 

14:44
Dr. Fabian
Yeah, it’s a wake-up call. 

14:47
Stephanie
Yeah. As someone who has not gone through that yet, when you say that seven and nine years, it’s like, oh great, yeah. 

15:00
Dr. Fabian
The bottom line is if you’re a patient and your provider is dismissing any of your symptoms, not a pause or not you should probably find another provider. Right? Exactly. 

15:12
Stephanie
I hope that I would see got a provider who wouldn’t dismiss it, but I would hate to have to experience that as a patient. 

15:20
Dr. Fabian,
Well. That’s where the North American menopause society comes in, too. We have a located provider tab on menopause.org where you can find a practitioner in your local area who is certified by the North American Menopause Society as having some knowledge of menopause. Providers actually have to take a test to prove that they have the knowledge to be able to deal with these issues. 

15:43
Nicole
Can you actually share more about that for our listeners who may be interested in that certification? What does that look like? Yeah, that would be great to share. 

15:52
Dr. Fabian
It’s a certification exam and it’s based on general knowledge about menopause. We have multiple resources, including a Menopause practice guide that helps practitioners understand the content that they need to master to be able to pass that test. Attending our annual meeting and getting CME credits, we have a Menopause 101 course that we have every year at the meeting. Now it’s been so successful because it really helps people jump into this space who haven’t been there before. So it’s very helpful. It’s also something that can be done online so those sessions are recorded and available. If practitioners are interested in getting into the field, it’s an incredibly rewarding field. We do offer the certification and we do offer some of the knowledge-based educational activities that would be needed to pass the test. 

16:45
Nicole
Is this good for nurse practitioners, PA, and physicians? 

16:50
Dr. Fabian
Yes, pharmacists, nurses, nurse practitioners, physician assistants, anybody can take the test. She is a medical professional. 

16:59
Stephanie
That’s awesome. We have some listeners for sure who we’ve noticed are not clinicians or more of the patient side. What would you like to share with these folks who may be considering hormone therapy to help manage symptoms of menopause? 

17:18
Dr. Fabian
If you’re a patient and all of us are at some point. Right. I think understanding are your symptoms menopause based? Probably the first one, and a lot of women, I think, have symptoms that they don’t recognize as being related to menopause. Just understanding that the gamut can be anywhere from sleep disturbance to mood disturbances, which are quite common, palpitations anxiety symptoms, sleep disturbances, the common hot flashes, which everybody knows about. Also vaginal, dryness, pain with sex, urinary frequency, and urgency. There are so many symptoms that actually relate to menopause and then how much are they bothering you? Seek out a practitioner who knows something about menopause management. Again, it’s not all about hormone therapy, but hormone therapy is probably the most effective treatment that we have for all of the gamuts of symptoms. For example, if someone’s just having vaginal dryness, maybe a lubricant is enough to take care of those symptoms. 

18:23
Dr. Fabian
There are many management options that don’t necessarily mean that women have to take hormone therapy. Again, the majority of women are probably candidates for hormone therapy if their symptoms bother them significantly. 

18:38
Nicole
I’m just curious, in your clinical experience, what symptoms have folks been coming in with? They’re not necessarily connecting to menopause and are seeking thinking it’s something else. 

18:50

Dr. Fabian
I think a lot of the mood symptoms people don’t really recognize as being hormonally driven and the key to some of those is that you might have had a pattern of hormonally related mood issues in the past like premenstrual syndrome, mood problems, or postpartum baby blues or postpartum depression or things like that, to where it’s really triggered by following estrogen levels. I think the mood is one of the bigger ones that people don’t recognize. Joint aches are one of the more common symptoms of metaphors that we’re starting to recognize. Not that I would recommend hormone therapy for every woman who has a joint ache, but it’s one of those that a lot of women don’t really tie in. Palpitations is another one. I see women who get cardiac workups, probably appropriately so, but then their symptoms resolve as we treat their menopause symptoms. Yeah, there are some that are a little more obscure in terms of being known as plastic menopause symptoms and I. 

19:50
Nicole
Think that’s good to know for our listeners as well who are clinicians who might be seeing these things and may not be connecting it themselves either. 

19:57
Dr. Fabian
Exactly. I see actually a lot of women diagnosed with fibromyalgia around this time because they’re coming in with sleep disturbance, a lot of fatigue, and they have joint aches that aren’t explained by a rheumatologic condition or arthritis. Actually, menopause symptoms can overlap a lot with those symptoms. 

20:17
Nicole
Yeah, that’s really fascinating. 

20:20
Stephanie
Yeah, I have noticed that seems to be a common age when women get diagnosed with fibromyalgia. 

20:27
Dr. Fabian
Yeah, I have a suspicion that many of those symptoms may just be related to menopause. 

20:35
Stephanie
Yeah, that makes sense. Like brain fog. 

20:39

Dr. Fabian
I feel like brain fog. Exactly. 

20:47
Stephanie
Would you mind talking I know this is probably in your position statement or it is in your position statement, but for maybe women who decide that hormones are not right for them and some of these symptoms like hot flashes or mood disturbances, what other go to can providers recommend for some of these things? 

21:15
Dr. Fabian
Well, again, it depends on the symptoms. If it’s a vaginal dryness symptom, we certainly have lubricants and moisturizers, but also a lot of vaginal estrogen therapy is very safe and effective and has minimal absorption. If that’s the only symptom of hot flashes, the antidepressants have some data to support their use. Also, oxybutynin is an old bladder drug that has some data to support it. Also, Gabapentin is another one that has some data to support it. For those, I always try to have people ask the question can this drug double duty? What can you get a two for it, in other words. For those women who have mood disturbance and hot flashes, maybe antidepressants would be a good option. For women who have migraine headaches or trouble sleeping, gap appending might be a good option because of the side effect of sleepiness so you can dose it at night, for example. 

22:13
Dr. Fabian
The Oxybutin women have overactive bladder symptoms and also hot flashes. Sometimes that can be a good option. Try to get a twofer out of those other drugs and really kind of tailor the use to whatever the patient’s primary symptom is. 

22:28
Stephanie
Can you tell our listeners where they can learn more about NEMS and hormone therapy? What are some good resources for them? 

22:38
Dr. Fabian
Menopauseorg is the North American Menopause Society website and has great resources there. We’re actually in the process of updating our website now and has also good resources for providers, including memo notes which are available to members to download for their patients, but their patient information sheets on blaming the risk of hormone therapy. We also have one on genotype urinary syndrome of menopause and there’s another on Osteoporosis coming out soon. So lots of good patient resources. We also have our position statement which gives all the information on the risks and benefits for providers so they can better explain them. Our annual meeting really is a great resource for learning more about the field in general and especially the Menopause 101 session which is on the first day of our meeting. We are always welcoming new practitioners who want to learn more about what we do. We take note of good patient resources too. 

23:40
Nicole
And for our listeners who are interested in learning more about the conference, it is October 12-15th in Atlanta, Georgia.  

23:50
Stephanie
Have you noticed a trend of more practitioners being interested in menopause and hormone therapy than traditionally? 

24:02
Dr. Fabian
I want to say I hope so. I know our membership is increasing this year and it’s higher than it’s ever been. That’s really exciting to see and we would of course like to grow our membership and open it up to new people and the younger generation with fresh ideas. It would be really great to see an influx of new providers who are willing to learn this and take it on because I think this field is growing and I think what we’re learning about in the field continues to grow and it’s just a really exciting time and Menopause is becoming more of a topic in the public domain now. This is great to see and I think women who are suffering are just more willing to discuss it and are seeking answers. I think the drive for the need for menopause practitioners has never been greater and will continue to increase because we do have an aging population and there are more women entering menopause every day than there ever have been in the past. 

25:07
Nicole
I don’t know if you call it a weird thing with this, is that anyone with a uterus goes through menopause, and yet here we are, still not really talking about the symptoms of it and managing it publicly and like, oh, it’s this growing area, which it should be, but funny that always should have been. Right. This is a conversation we should have always been having. 

25:31
Dr. Fabian
100%. You are speaking to my passion here, and I usually start a lot of my articles with this is a ubiquitous experience for 100% of women are going to go through it if they’re lucky to live long enough. Right. It’s not like it’s an odd thing that happens to just a few people. Now the global population, there are more women than men, so it happens to a lot of people, and we need to be prepared to deal with it. It’s in all populations, including people who may not identify as women, as you were alluding to, and we need to understand what that looks like and how we manage it. There’s a definite need, and I don’t think we will ever have enough practitioners to take care of this problem, but I would welcome anybody who wants to get into the field. I’m happy to discuss how to do that with them. 

26:18
Stephanie
Yeah. And I like to say everybody suffers. If the woman or the matriarch is suffering, everyone suffers, right? 

26:27
Dr. Fabian
Yeah. 100%. Yes. Women are the healthcare drivers for their families, too. It’s important to understand when women aren’t doing well, as you said, everybody suffers. The economy suffers. The whole global economy suffers. Because if women aren’t doing well and if they’re leaving the workforce for menopause. 

26:48
Nicole
Symptoms I’m just curious now you’re piquing my interest in the education of clinicians of all sorts. Is this not really something necessarily included? We have PhDs, so it’s a little different than being on a clinical track, so we kind of missed all that. Is this something that is not necessarily included and you have to seek out additional experience? Or is there a movement towards adding this into everybody’s curriculum? Can you speak to that? 

27:17
Dr. Fabian
I wish that were true, but there’s been a movement to move it out of the curriculum because the curriculum curricula are just too full. In general, we did a study on this and published it in 2018. Medepost education for residents of any type is somewhere in the range of one to 2 hours for internal medicine, family medicine, and gynecology. Most residents do not receive much of any menopause education, and the majority are coming out of their programs feeling under-prepared to manage menopause symptoms. I wish I could tell you the reverse was true. In general, these programs are so full with what they have to cover, that manipulation has gotten dropped for the most part. 

28:01
Stephanie
Dr. Fabian, I would personally like to thank you so much for your time and commitment to advancing sexual and reproductive health communication. Do you have any last thoughts you would like to add before we end? 

28:14
Dr. Fabian
No, I’d just like to thank both of you for bringing this topic up today and allowing the discussion. I think it’s been a wonderful discussion. For your listeners again, menopause.org, the North American Menopause Society is here as a resource for you, and we would love to have you join us, and I would love to have you be part of our community. So thanks again for having me. 

28:36
Stephanie
Thank you. 

28:37
Nicole
Yes, thank you.