Speaker 1: The content of this podcast is provided for general informational
purposes only and is not intended as nor should it
be considered a substitute for professional medical advice. Hello, this
is Karen Nicol, family nurse practitioner, and you are listening
to Itchy and BITCHI a podcast that provides answers to
your many unanswered health questions. As I mentioned in the
last two episodes, after nine years of hosting Itchy and Bitchy,
it is time for the podcast to grow and evolve
with new hosts in a slightly different format. And remember
that growth and change is a good thing. My dear friends,
Stephen Miller and Keith Millica will be the future hosts
of Itchy and Bitchy. As hosts, they will have a
comprehensive approach to wellness with a focus on connection human health,
animal health, and environmental health. To provide a transition period
for you, for me, and for Stephen and Keith, we
have a series of four episodes plans. This is the
third of the four episodes during which I will be
interviewing both Stephen and Keith. Doctor Stephen Miller is an
acute care nurse practitioner known for his expertise in diagnosing
and treating cardiovascular disease, and Doctor Keith Nillica is a
veterinarian and Board certified veterinary dermatologist who has been in
practice for thirty years. To learn more details about them
and their expertise, make sure to listen to the episode's
date at April fourth and April eleventh, twenty twenty six.
We are going to surprise talk about hormones today, specifically
about estradile, which is the most potent form of estrogen
in a woman's body. Menopause occurs when the ovary stops
secreting estradile or when the ovaries have been surgically removed. Recently,
the black box warning on HRT was removed, and this
is a big deal. I've talked about black box warnings before,
but as a refresher, this is a bold, black bordered
warning that is placed at the top of a medications labeling.
It alerts healthcare providers and patients to serious, life threatening
or permanently disabling adverse risks. The FDA announced the removal
of the black box warning from most menopausal hormone therapy
products on November tenth, twenty twenty five. This serious warning
was placed on HRT in two thousand and two when
the Women's Health Initiative Study WHI study, which by the way,
was a poorly designed study with misinterpreted data that led
practitioners to stop prescribing HRT for their patients. So now,
twenty four years later, the FDA finally took the step
to right this wrong. But it took twenty four years.
I've said it before, this culture is very tolerant of
women's suffering. Probably in light of recent studies touting all
the benefits of starting HRT early in menopause, the FDA
determined that the WHI study warnings of risks like breast
cancer and cardiovascara disease were overstated. The new and improved
labels highlight the benefits for women under sixty and within
ten years of menopause. Well hello. As soon as the
black box warning was removed, all of a sudden, practitioners
felt more comfortable with prescribing HRT. This after women were
frequently told by their practitioners that it's just part of life,
something you'll have to get through.
Speaker 2: Buck up.
Speaker 1: This surge in prescribing led to shortages of estra dial
patches in the pharmacy. Keith, what are your thoughts on
comments on the history I just shared and the consequences
of how HRT has been handled for the last quarter
of a century.
Speaker 2: All right, so I'm you go. I'm Keith Milica, doctor Milica.
Just a veterinarian, so real, no pony in this race.
But I was listening to one of my favorite news
episode podcasts and the story came to light, and I
just thought, what is going on in the medical world.
A black box warning is basically a death nail for
a drug. So and a lot of drugs that actually
have pretty good efficacy and even a few side effects
can get a black box warning for a variety of reasons.
Oftentimes because there's a serious concern in side effects. It
dramatically communicates to the providers that this can kill your patients,
and so they stopped using the drug for twenty four years.
This drug had a black box warning. So they reviewed
the literature, which is good. Always progress, and we're going
to do some menta analysis.
Speaker 3: Reading is good.
Speaker 2: How big was the review of this study? It was big.
We talked before on the last interview that in dogs,
a lot of our studies are like twelve dogs, dogs.
This was like thousands of patients, right, So they decide
that it's actually pretty good for you. Hrt is is
maybe a good thing. But then now that it's a
good thing, women can't get it, and if you can
get it, it's three times the cost. And it's like,
what the freak is going on here? So I'm not
a big conspiracy theorist, but if I was, this would
fit the bill.
Speaker 4: So there, I'll give just the slightest Yeah, so this
is this.
Speaker 3: Is steven step which I appreciate.
Speaker 4: From there, again from the male perspective, but from the
gay mail perspective, so it could be different. But the
daughters with daughters, yes, so a little pushback in that.
So they come up with a statement basically saying they
do a comprehensive review of the scientific data. Right, And
so the issue came down to divergent outcomes and looking
at divergency between estrogen alone versus estrogen plus progestion. Truly,
I think that is deserving of some adjudication. I'm not
sure twenty four years of adjudication, but so that's one
point that I think needs to be considered. The other
point is that reviewing and looking at the timing hypothesis,
which we really didn't deal with before. So the timing
of treatment either in pre sixty year old women and
favorable risk benefit profile. Again, I'm not sure twenty four
years was. That's a really long time, but certainly I
think that's worthy of mention.
Speaker 2: So sub dividing the population into are you a thirty
year old person, a sixty year old person, a ninety
year old person? Is that what you're talking about?
Speaker 4: Yes, okay, you mean in the study or yes. So
in the retrospective review of this analysis comparing the Women's
Health Initiative with more recent evidence, the timing hypothesis evolved, right,
because before then it was just estrogen for everyone.
Speaker 1: Well, but in the WHI study, this is one of
the faulty pieces of the design, is that they started
women who had never been on HRT. They started them
on premarin anywhere from age sixty eight to seventy three.
And we don't typically do new starts of HRT on
a seventy three year old woman, not typically, right, So
it was a bad setup.
Speaker 4: It's a bad setup, and I totally agree with that,
thank you.
Speaker 2: The twenty four years is a long time.
Speaker 4: So almost a quarter of a century women have had
to deal with being taken hormones away and with the
fear of cardiovascular implications. So then there was the third
panel point, which was that they need an expert panel
deliberation and a sixty day public comment, And I get
it because there are a lot of different bodies of
expertise that needed to weigh in on this. And then
fourthly acknowledging that warnings were based on incomplete data. And
this is the point with the Women's Health Initiative. It
was incomplete data set, so they were looking at putative
harm and secondary outcomes, and they weren't looking at primary outcomes.
In this we're talking about WAWHI yes, and so they
were inappropriately extrapolated those outcomes. I think that's a really
key thing that I think if I were a listener,
I would want to know about clinical trials across the board.
Is inappropriate extrapolation of data across populations really becomes a
big deal, And it doesn't matter if it's hormone or whatever.
But in this situation, we're talking about HRT. So that
was my little bit of pushback in that there were
some valid points, but twenty four years is a really long.
Speaker 1: Time, WHI was on conjugated horse estrogen, and they did
do some of the study on prim pro which has
conjugated estrogens and progestin, and a lot of providers mistakenly
is progestin and progesterone synonymously, and progestin is a synthetic
version of our progesterone and has a bunch of risk factors,
especially clotting. Our own natural, bioidentical progesterone does not have
the same risks that progestin holds. So I just want
to make it clear to our listeners that progestin is
a very different thing, and don't let anybody tell you otherwise,
because there are a lot of providers who still don't
know the difference, believe it or not, a lot of
GYNs who don't know the difference between a progestine and progesterone.
Speaker 2: And hormones are complex. I mean, they really are a
very complex, metabolic, interactive kind of system. I want to
go back to my outrage. There you go, Okay, so
sixty days I've worked for pharmaceutical companies, and in sixty
days they could easily have ramped up production knowing that
the FDA was probably going to open up and release
this black box nightmare limitation warning. And so what is
up with not being able to get these patches? Right?
The patch is one of the leading ideal fewest side
effects type therapies. And I want to ask you about
side effects in a second, But why why didn't the
pharmaceutical companies ramp up? And look what's up with that? Well, Karrot,
you're supposed to have the answers here.
Speaker 1: Well, yes I do, but they're usually not angry capitalisms.
It's capitalists answers. Well, I think we don't think ahead
in these things. I think they didn't expect. I'm sure
that practitioners would start writing them like it's handing out
candy on the street corner.
Speaker 2: I mean, so along those lines that now the prescription
rate for esters and patches is skyrocketing because it's now safer,
we understand the limitations, and so women now have access
if they can find the product.
Speaker 4: And I think too, I think for the audience, I
think it's important to state that the transdermal patches are
preferred over oral formulations right here.
Speaker 2: Yes, you're the expert care, and so tell us what's
what with the modality of administration?
Speaker 1: So there are multiple benefits of topical estra dial over oral.
Number one, when you use a topical estradl whether it's
a patch or a cream or a gel or intravaginal estradl,
it does not have a first pass through the liver.
And during that first pass what would happen And this
is what happens with oral estrogen. When it passes through
the livers, we produce more fibrinogen. And when we have
higher levels of fibrinogen in our blood, we have increased
risk for clot. So by doing it transdermally on the
skin in the vagina, then we reduce significantly reduce clot
risk because we do not increase fibrinogen levels with topical estradioline.
Speaker 2: What topicals are you talking about? So you have a patch, creamream.
Speaker 1: Gels, intravaginal like if you did a vaginal cream, that
would be compounded.
Speaker 3: We have vaginal rings that.
Speaker 1: Have estradile and like a slow release yeaw, you even
started vaginally and it releases for three months. And so
anything that is not directly going into the digestive system.
Speaker 2: Then Doctor Miller side effects.
Speaker 4: The biggest scary thing is the increased risk for benus thrombosis.
And then the historical fear was moderate cardiovascular risk associated
with oral formulations. But then there's also with that transdermal avoiding.
The hepatic first pass is the issue related to elevated lipids,
so you don't have to worry about hyperdruglis rhodemia when
you do the transdermal formulation. So there are differences, and
I do think historically when we go back to the
Women's Health Initiative, that evidence was poorly understood, you know,
and so there has been some really positive things to
come out of this period of time that we've waited,
not twenty four years.
Speaker 5: It don't so would you he's watching me glare out
of it, would you say oral is more risky and
bad and topical trans epidermal is better.
Speaker 2: Fewer side effects absolutely well.
Speaker 1: First of all, if you're using something like a patch
or the vaginal estradyle ring, or even creams or gels,
but especially a patch or the vaginal ring, it's a
slow even release, so you're going to have fewer breakthrough
symptoms like hot flashes and night sweats because you get
a more steady estradile state that's going into your bloodstream
and then into your tissues. So that's a big advantage too,
because we have a natural fall off of levels when
we use something orally, because it has to go through
our digestive system, it breaks down a lot of it.
And as a matter of fact, because of that, we
also have to use much higher doses, so we get
the same effect after we lose a bunch of in
our gut. For instance, if I were compounding of estradile
cream and someone was on a tablet or you know,
some form of oral estrogen, we would cut that dose
in half when we convert it to a transdermal form.
Speaker 2: How often do they have to put on the cream
or a patch.
Speaker 1: Well, the cream, the cream or gel is usually once
or twice a day. The patch is once or twice
a week. We have patches that are twice weekly that
are quite small, which is nice. The once weekly is
easier for people. But that thing at the highest dose
is about as big as this coaster that's on the table.
Speaker 3: Next to me. Four it's a big it's a big thing.
You know.
Speaker 1: Typically people like the twice weekly dosing because it's a
much much smaller patch and it's clear that once weekly
is usually a flesh colored and that's fine if you're
a white person because it's that color. Yeah, but maybe
not so much again capitalism or a person of color.
Speaker 2: So what I've heard that the availability of the patches
is very difficult now because of the demand, and I
think they come in different milligram doses, and then I've
heard of people cutting them in half. It just desperation
to what do you think about that?
Speaker 1: Yes, you can cut patches in half. Absolutely, you might
have a little more difficulty getting it to stay in place.
But personally, I cut my patch in half.
Speaker 2: So you would go up a milligram dose and then
cut Yeah.
Speaker 1: So for instance, I'm getting super personal, but I have
a prescription for a zero point zero five milligram patch
and I cut it in half, so I have a
zero point zero two five zero point zero two five
milligram patch is the lowest dose we have, and then
it goes up to point one.
Speaker 2: And this I assume at least my patient's veterinary side.
I would want them to consult me and talk to
the provider about exactly what you're doing.
Speaker 3: Oh, yes, yes, don't just.
Speaker 2: Go willy nilly cutting your.
Speaker 1: Patches willy nilly whatever. But I often would tell my
patients that if they were having financial difficulty getting their patch,
you know, so I would say, let's if they were
on a point oh five, let's do a point one,
we'll cut it in half. So we're going to take
a little break right now and calm our nurse, and
we'll be right back with lots more information. So stay
with me, welcome back. We're going to continue this discussion,
and it's good. It's gonna be good.
Speaker 2: So the other thing, Doctor Miller and Karen that y'all
were talking to me, I'm just the ignorant veterinarian sever
about these things. Ever, they were running through the benefits
of HRT and in veterinary medicine. If we see five
percent improvement, that's pretty good, Like we like that, and
anything above five percent ten percent, we're doing really good.
Like that's a treatment that we're going to focus on
that can help our patients. So what kind of improvements
do you see with HRT now?
Speaker 3: Well, as a person who.
Speaker 1: Is an expert in that area, my goal always is
to have them one hundred percent relieved of their symptoms.
A lot of that involves some really good listening and
knowing how to dose different products. In a way to
try to make that happen. I would say, though I
typically could get people to feel eighty to ninety, is
it better, which is big, But that was also because
I worked hard to do that. I mean, I learned
a lot over the years. I studied. Over the years,
I listened to patients and people's symptoms and what makes
them better, what makes them worse, Rather than worrying just
about labs, far more successful. When you start treating labs,
you're in trouble. You're in trouble. You got to listen
to people. When it comes to hormones, treat the patient,
not the paper. It's exactly, especially with hormones, because the
range of normal is huge, and where you feel great
is not where the person next to you feels great.
Even with patches estradial patches, which we have several doses,
and you think, well, that's great. But if I told
the women of the world that there are seven bras
sizes and you've got to find one that fits you
as close as possible, people would be burning mattresses in the.
Speaker 3: Street or broad or broad something. They've been burning something.
Speaker 1: We accept that there are only these few doses for
women and for men to replace hormones. And that's one
of the many reasons I got into compounding, because there
are infinite number of doses with compounding.
Speaker 2: Right. And then doctor Miller, can you give us some
statistics on cardiac disease benefits?
Speaker 4: Well, I think as we were talking, the thing that
sort of was sticking out with me is sort of
the American College of Cardiology did that twenty nineteen systematic
review based some evidence on that and basically came out
with a statement that said, if your cardiovascular risk was
less than five percent, then consider transdermal therapy. If your
cardiovascular risk was five to ten percent, consider transdermal estrogen,
and those with greater than ten percent should consider no
hormonal option at all. Tell me, Kire, Yeah, not for law.
Tell me your perspective, because people of that take care
of HRT, send people for me to say yes or no.
And there have been people historically, who usually men in cardiology,
who have made commentary about no HRT based upon the
WHI data, And so I guess I would be interested
in your thoughts about that perspective.
Speaker 1: And point, well, think about what estradile does for our body.
It makes things stretchy and flexible, including arteries. So we
you know, if we have less arterial stiffness, our arteries
function better. If our heart muscle is more flexible, it
functions better. So it's not just about the flexibility, which
is a bit big deal. Our cholesterol numbers go up
when we don't have hormones, because our hormones are made
from cholesterol. So when we don't have hormones, our brain goes, oh,
what the heck, she has no hormones. She must not
have goop to make hormones. Well, let's make some more
goop and then she can make hormones. Levels naturally go up,
which increases your risk for cardiovascular disease. I mean, we
have studies now that show that estra dial is heart protective.
Speaker 4: Yeah, and so I think, but I think my point
to asking that is this whole delineation between should I
do oral or transdermal or just transdermal or not at all? Okay,
And I think again, that's what people are asking me
as a cardiovascular exp They're wanting me to say to them,
you should not do oral therapy because you have preexisting
cornary artery disease and stints. You should only do transdermal. Now,
I would be somewhat reluctant to tell any female person
that no therapy at all would be okay. Right, So
it puts me in a bit of a position number one,
number two the risk calculator for that how many people
actually on these women who need HRT are running the
risk calculator and putting it in their documentation to say, well,
I've calculated your risk based upon these variables, and for HRT,
this is where you resign.
Speaker 1: Here's what I would say about those things. Definitely, if
I had someone and I did, if I had people
who had heart disease or personal clot history or family
history of clot, I would never put them on oral estradial.
I always used topical and as a way to not
saying to protect yourself as a practitioner, but just to
monitor what risks are happening. If you're on transdermal estradile,
just draw a fibrintagen level, it's not that big a deal.
I would monitor fibrintage and levels and those people. Now, also,
it's so individual. If somebody came into you with new
diagnoses of heart disease and they're already on some kind
of hormone replacement. I would say, okay, you're on oral
form of estrogen. I know there are benefits, cardiac benefits
for women being on hormones, but we need to reduce
your clot risk, and we can do so by giving
you a transdermal version of estradile. If somebody came in
to you and they were just diagnosed with heart disease,
or you've just diagnosed them with heart disease and they're
seventy three years old and never been on hormone replacement therapy,
or they were on hormone replacement therapy from age fifty
one to fifty eight, and they said, you know, can
I do hormone replacement therapy?
Speaker 3: I heard it would be good for me. I'd be like, what.
Speaker 1: Symptoms you have and why you know, why would we
want to start that at this point based on the age,
based on and not being on hormones all this time,
we see the most benefit in terms of hormone replacement
therapy if women are on HRT, specifically estra dial in
the first five years of menopause, and now we're even
seeing that it's more beneficial to start it in perimenopause,
just before you go into menopause, not to say that
you don't get any benefit after five years, but the
really meat of it, the meat of the benefit is
in those first five years during the transition. So would
you ever, well, once they get into menopause, would you
ever use oral hormone replacement? Or we started saying that
the patches and the topicals are the way to go,
and then doctor Miller brought up oral and heart disease
and their high risks with oral. So would you, as
a practitioner, where would you put in an oral It
sounded to me like you would always use topical.
Speaker 4: So I want to chime in a bit. This plays
in to the underrepresentation of women with cardiovascular disease and
the number of studies have been done. And so you
look at the subpopulation of women who have cornery disease
and stints and they're on aspirin, they may be on plavix,
they may be on anticoagulation therapy, and what does that
subgroup analysis look like? We really don't know. And so
then risk benefit. So then the addition of anticoagulation or
antiplatelet therapy to that group of women may alter treatment.
Speaker 1: Right, I mean, if you're saying look, we're already anti coagulating.
Adding on topical estradisle isn't going to increase your right risk.
You're already treated here, You're already treated. And I would
also as you mentioned symptoms, I also would look at
you know, is this person miserable with night sweats and
hot flashes? And cardiologists don't want women who have heart
disease to have high stress hormone levels. And if you
want to see high stress hormone levels in a body,
check it out. And a woman who's having hot flashes
and night sweats and anxiety and fearfulness and you know,
on and on and on, you're better off to make
that woman comfortable and happy because that plays into their
cardiovascular healthy as well.
Speaker 4: Yeah, I get a ton of women who come with
vasomotor symptoms those flashes and night sweat say thank you,
and then they think they're having a heart attack or
they're dying because those symptoms are severe sometimes. And so
I think that balance of treating vasomotor symptoms appropriately and
doing appropriate cardiovascular risk assessment in those patients really becomes
a balance that we have to meet well.
Speaker 1: And I think that if cardiologists are just afraid to
prescribe hormone replacement therapy because they're not knowledgeable. Then they
either need to get knowledgeable or refer on to someone
who is. Because the one thing I really don't want
to hear is a patient coming back and saying, oh,
I saw my cardiologists and this has happened to me.
I've seen my cardiologists and they said I shouldn't be
on hormones.
Speaker 4: Well, and was there a risk calculator run? So did
we look within the evidence and balance that out with risk?
Speaker 2: You're talking about a risk calculator? Is this something I
can pull out of my pocket and type in numbers
or what are you talking about?
Speaker 4: So many? Yeah, in general, there are a lot of
risk calculators out there. For cardiovascular risk. It's a it's
an app, okay, and so most people can pull those
out pretty quickly. Medcalk is one of the apps where
you can find most of the risk calculators, and I'm
sure on some of the women's health websites there's probably
a cardiovascular risk calculator. I think that's important that if
someone has risk and wants to be treated, needs to
be treated, that the risk calculator calculation be done and
that that be discussed with the person and then we
weigh risk benefit as we do with anything, right. But
I think that's one piece of the problem solving. And
anybody who does that and says, oh, you are seeing
it too high risk because you're one point over, you
don't get hormones.
Speaker 2: Tough it out.
Speaker 1: They're not, Yeah, and get dismissed and told they can
just buck up and deal with it. Yeah, nobody wants
to be treated based on one calculator number. We're going
to take a little break right now and we'll be
right back, so stay with me.
Speaker 3: Welcome back.
Speaker 4: So this leans into one thing I wanted to ask
you which we haven't discussed yet, which is the timing
of therapy, because that became an issue with this most
recent analysis of the data. And so you know current
recommendations on how long do we take this and what
when do we stop it? Or do we stop it?
Speaker 2: Or so can I jump in? So a few sentences
before we went down doctor Miller's calculator rabbit hole, so
I was saying that five to ten percent benefit in
morbidity of various diseases is really impressive. And before we
got on here, Karen, you gave me a list. It
blew my mind of the level of diseases, morbidity rates,
the change with HRT. Can you run through that list?
Speaker 1: This is in response directly actually to how long should
we be on hormones? Because the other thing that happened
with WHI is you should be on hormones for five
years and then come off.
Speaker 4: That's correct, which is that that's what I was.
Speaker 1: I told my patience when they ever asked me this,
I'd say, look, let's treat you. Let's treat you if
risk factors change, if your benefits change, or at some
point you want to go off of it, and we
ty trate you off and you're doing great. Great. I
am not going to tell you you're coming off of
this in X amount of time. I'm not going to
do it because I'm not cookie cutter. I'm not a factory.
I treat people as individuals and I've always believed this,
and I listen. I had women in their eighties that
if I took them off there dial patch, they were sweaty, angry.
Speaker 4: Messes, sweaty and pissed.
Speaker 1: They were sweaty and pissed for sure, and I would
just put them back on look's fine.
Speaker 3: I don't care.
Speaker 1: I mean, you know, so, why in your eighties, if
you're miserable because you don't have your esther dial patch,
Why are you doing that to an eighty three year
old woman? I mean so.
Speaker 2: One of the things you've taught me, Karen, and the
years that we've known each other is I've been very
much trained in epidemiology, so herd health, big populations, and
all of these studies look at ten thousand people, you know,
five hundred thousand people, and what's best for a population
of America. One of the things I've been very impressed
with you is what's optimal for the individual patient that's
in your exam room. And that's kind of what you're
referring to now, is that you know, the studies say this,
and we're going to take that into account, but what
are you feeling day to day and what's best for
you may not be necessarily what the demiological studies say.
They give me the list of the benefits, because I
that blew my mind.
Speaker 3: Yeah.
Speaker 1: So this is specifically a study that came out in
May of twenty twenty four in the journal Menopause.
Speaker 3: It was looking at.
Speaker 1: Women over sixty five and they looked at ten million
senior Medicare women. That's a lot focus and they looked
at it based on the prescriptions used and the visit records.
So they were looking at chart review. They're looking at
the chart and they looked at the effects of different
preparations of menopausal hormonal therapy on all cause mortality, five cancers,
six cardiovascar diseases, and dementia. So they examined those areas
compared with those women who never used or discontinued menopausal
hormonal therapy after age sixty five years. The use of
estrogen monotherapy, so we're talking about just using estradil beyond
the age of sixty five years, was associated with significant
risk reductions. And I know this is a lot of
your patient population, Stephen sixty five years in older mortality
risk reduction was reduced by nineteen percent.
Speaker 2: Plus death death nineteen percent five and ten is impressive, nineteen.
Speaker 1: Breast cancer by sixteen percent, this is all risk reduction,
Lung cancer by thirteen percent, colorectal cancer by twelve percent,
congestive heart failure by five percent, clots in the veins
three percent, atrial fibrillation by four percent, heart attack by
eleven percent and dementia by two percent, and among senior
medicare women in general, risk reductions appear to be greater
with low rather than medium or high doses of estradyle
and by using either vaginal or transdermal rather than oral HRT,
and using bioidentical estradle rather than conjugated estrogen, which again
that's what was in the WHI study was so.
Speaker 4: This is a retrospective cohort study, and so of ten
million women, which is a huge population, and so I
guess really be interested in subpopulation analysis on that group
of people.
Speaker 2: You can ask them ten million, that's a lot of questions.
Speaker 4: Carrie just gave me a look like Stephenovan as string.
Speaker 1: You want to microphone or superrand.
Speaker 4: I think it the scientist in me right now. I'm
not living with the issue of lack of estrogen and
basomotor symptoms. I'm not living that, but just the scientific
brain of me wants to know, among the ten million
women who had those benefits, how did that break out?
How many had cardiovascular disease pre existing? And I know
I'm going down a rabbit at a bit, but I
think on this side of fairness, I do think that
it's important to say and preface this with this group
of women included these people.
Speaker 1: Well, and I'll send you the whole study. I try
to for the listeners. I try to share the conclusion, yes,
because I don't know that people are tuning in to
hear every last detail of a study, but there are
all those things in there.
Speaker 4: Yeah, no, no doubt, Like in that group of women
at that age, I know that the subpopulation analysis includes
a fib and athoscrite disease and this and that. I think,
and this might be a nice follow up for the
podcast to look at that, and just because I might
dare say there might be some increased benefit in those subpopulations, right.
Speaker 1: Well, you mean the risk reduction numbers would be better
right in certain populaces. Yeah, I get that, and I
guess I bring this up, especially with you, Stephen, who
works in cardiology, to know that if there is somebody
who comes in to see you, a cardiologist, any cardiologist
who's sixty five, sixty eight, and they've been on hormone
replacement therapy and they're still on hormone replacement therapy, they're
on an estradial patch, I hope that nobody's ripping them
off that right, and especially with this study because they
don't they haven't seen as many as ten million women.
Speaker 4: I can tell you that much, right, I will tell
you it is not a comfortable consolet for someone to
send you and say should I continue the therapy? Much
of my job is not comfortable. But if you do
due diligence, especially in light of the new FDA labeling
and with retraction of the old information, it is now
worthy of having the conversation and going in and looking
yourself at the data set and the subpopulation and saying
to the person, you've got athersk right disease. I ran
the risk calculator, which is the a SCBD risk calculator
that's put out by the American College of Cardiology and
American Heart Association, readily available, and if your risk is
this or this or this, this is what's recommended. I'm
not a hormone expert, don't claim to be, you know,
but this is on the cardiology side, what's fair and reasonable.
Speaker 1: Right, But I would say, if you want to have
a little bit of a CYA again, I would just
draw off fibriantage and level on them. Yeah, I agree,
that's the clot risk period. That's the clot risk is
if fibriantage and levels go up.
Speaker 3: I've checked these levels.
Speaker 1: Many, many, many many times over the years on patients
who are higher risk and who were on transdermal therapy
because of their risk, and I have never, not once
had a fibridsion level that bumped up and was always normal,
but never bumped up, never even moved transien. Yeah.
Speaker 4: Yeah, I think in this time where newer and clearly,
to God, after twenty four years of belaboring this, we
have really good evidence to say that risk with transdermal
therapy is pretty low.
Speaker 1: Yeah, believe me, I was doing this twenty four years ago.
That's how I started doing compounded hormone therapy because I
had all these women who got yanked off of their
hormones and they were miserable RECs. I thought there's got
to be another way, and all we're looking at is
permar and I have never written a permiram prescription in
my career, not one. And that's how I started. That
whole thing was wh I should be thankful for WHI
I'm not, but I should be thankful full.
Speaker 2: But maybe twenty two years earlier.
Speaker 1: I mean it led me to look at what other
options we have because no one was writing anything any
hormone therapy at that time.
Speaker 4: And I think if you're not seeing someone who's interested
in hormone related issues right then across providers, it's a
challenging population that requires a focused evaluation. If that person
hasn't had the expertise in that focused area, then clearly
there's a broad space for people who care about helping women.
The vasomotor symptoms are debilitating.
Speaker 1: Hot flashes and night sweats. Yeah, they're terrible, but that's
the tip of the iceberg. I mean, so many women
get put on antidepressants because all of the symptoms in
perimenopause and menopause are almost identical to depression symptoms. Tired,
gain way, we have no interest in anything. We have
low sex drive, we're fatigued all the time, we have
brain fog, we have poor mood, we have anxiety. When
you give them that list to a provider, they're like, oh,
let's put you on lexapro.
Speaker 4: They're like, do I have my magic Wand today I
do have a magic wand it shoots blanks, but I
do have one.
Speaker 3: But you know what, the easy fix is just to
put you on this one pill a day.
Speaker 4: But then you're just shoving pills at people, right.
Speaker 1: Well, and you're not addressing the problem. Right, The problem
is perimenopause or menopause. And I'm not saying you can't
also need an antidepressant, but don't use that as a
fix all for women's hormonal symptoms. That's not right, And
that's why I was so busy for all those years.
Speaker 4: Clearly, I don't think it's treating root cause well no, right,
So again, you might need depression medicine for a period
of time to get through some of the symptoms. So
not under estimating the impact of treatment of depression, but
more about focusing on root calls and solutions.
Speaker 1: Well, oftentimes new patients I would probably say at least
sixty or seventy percent of the time when I saw
a new patient, they were already on an antidepressant that
they'd never been on antipressant their entire life, but that
minute they hit like forty eight, then they needed an antidepressant,
and so I would say to them, look, I think
you're antidepressant was started to address your pyramidopousm menopostal symptoms.
We're going to work on fixing the menopausal perimenopausal symptoms,
but we are not taking out your safety net from
under you're I'm leaving this antidepressant on board, and when
we're ready, we will look to discontinue and see how
you do.
Speaker 2: So how much of that was the harm of the
black box? The warning that if you were a provider,
the antidepressant didn't have a black box, so you weren't
going to get into trouble prescribing that. Where if you
prescribed something with a black box, then suddenly.
Speaker 1: I think that's a piece of it. I think it's multifactorial.
I think it's lazy practitioners, to be honest with you,
I think it's lazy care. Look, I have a passion
for this and I always did, and you sort of
have to have that. To help menopausal paerimenopausal women. You
need a passion, and most people don't have the passion.
They don't want to take all the extra training.
Speaker 3: That I did.
Speaker 5: And hormans are complex and they're so complex and nobody
has the time anymore because it's just a business.
Speaker 1: Now. Medicine is a business. You know, if you can't
get somebody in and out the appointment within fifteen minutes,
you're losing money. So you have to want to spend
time with people and that you have a passion to help.
Speaker 2: Them treat the patient, not the paper.
Speaker 1: That's right. That's right, the long and short of it.
That's sort of the long of it right now. I
do want to wrap this up, but we didn't get
into the other things that are so important for in
terms of having estradyle as we go into menopause is
brain health and bone health. And I've talked about both
of those things on previous episodes, so you can always
look that up as a listener. But brain health is huge.
There is a reason that Alzheimer's hits more women the men,
way more women than men. Not that lack of estrogen
causes Alzheimer's or dementia, but we are much more susceptible
because our brains don't work very well without estrogen, and
so that's why we get brain fog and then word
recall problems, and then dementia or mild cognitive impairment whatever.
Speaker 3: There are a lot of.
Speaker 1: Pieces of the puzzle that estradile. Just reminding everybody that
if you have a uterus, you can't just do estradiyle alone.
You have to have progesterone too. Having hormones is key
in terms of your overall health in menopause, and now
we have studies showing that even after age sixty five,
it's super important.
Speaker 2: And hopefully this outrage that started this whole conversation, yes,
will be resolved and all of the people in need
will have access, and providers will step up, and the
pharmaceutical companies will start producing and the insurance companies will
stop protesting and life for everyone can get better.
Speaker 1: I think the production is better. I think people are
able to get their estradial patches more easily.
Speaker 3: So that's good.
Speaker 2: That's good. Good.
Speaker 3: Yeah, do you have any last comments?
Speaker 4: Steven, I was trying to fund that subgroup and els
I wanted to have a little wrap on the Oh.
Speaker 1: Well, we can do an addendum on the next podcast.
We'll do that next time, I promising.
Speaker 3: So.
Speaker 1: I want to thank Keith and Steven so much. This
has actually been fun and lively conversation. I really appreciate it,
and many thanks to all of you for listening. Wherever
you listen to this podcast, please leave a review and
rate the podcast. Your reviews and ratings matter. Also, make
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website is itchymbitchi dot com, where there are blogs with
some of our subjects available for you to read. Thank
you to Forrest Winsl, my son, our producer and composer
of our theme music and the person who does all
the behind the scenes work to make this podcast possible.
And Forest will be sharing his producing knowledge and expertise
with Stephen and Keith to help with the transition.
Speaker 2: Thank you for one of your son.
Speaker 3: Thank you for help. You guys are fast learners.
Speaker 2: You'll begin.
Speaker 1: Forest continues to thrive at Peabody Music Conservatory and is
finishing up his final final semester of the Master's program.
Forest was recently informed that he was admitted to the
Peabody Doctoral Program to receive a Doctor of Musical Arts
in Composition. His dad and I are so happy for him.
It is fun to see his immense musical talents being recognized.
If you want to listen to what he is creating,
You can go to his website Forrestwinsl dot com and
always remember that your health is in your hands.