#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.

Understanding the intricate hormone patterns of the female reproductive cycle is crucial, from ovulation to uterine preparation, perimenopause, and eventual menopause.

Menstrual Cycle Hormone Pattern For Ovulation and Uterine Preparation

Normal Menstrual Cycle Hormonal Pattern

At the start of the menstrual cycle, estrogen levels begin low and gradually rise, leading up to ovulation. The brain releases a hormone called luteinizing hormone (LH), around days 10 to 14 of the cycle, which serves as an indicator that it is time to ovulate. Following ovulation, the shell of the egg, known as the corpus luteum, produces a surge of progesterone. This begins the luteal phase, during which the presence of progesterone is notable. If fertilization does not occur, the corpus luteum dissolves, causing progesterone levels to drop and the uterine lining to shed, resulting in menstruation.

Perimenopause Causes Erratic Cycles From Declining Egg Release, Leading To Hormonal Swings

Rubin describes perimenopause as an erratic period when estrogen, progesterone, and [restricted term] are not produced consistently by the ovaries, thus leading to hormonal swings. The scarcity of hormones prompts the brain's follicle-stimulating hormone (FSH) to over-stimulate the eggs, resulting in overshoots of hormone levels. For instance, a woman's estrogen level might dramatically escalate from 200 to 900 on the tenth day of her cycle, demonstrating the extreme fluctuations during perimenopause.

[restricted term] levels can be particularly volatile during perimenopause. With declining numbers of available eggs, the body struggles with regular functions, such as ovulating eggs, which can lead to not ovulating or releasing multiple eggs in one cycle. These fluctuations contribute to symptoms that may emerge due to excessively low or high levels of [restricted term] or from the sudden shifts between these extremes. Rubin likens the experience to a car lurching from speeding to suddenly running out of gas, leading to inflammation and irritation that resonate with perimenopausal symptoms.

Symptoms such as brain fog and newly diagnosed ADHD in women can be linked to estrogen receptors in the brain fluctuating from full to empty. It's during perimenopause that inconsistency becomes the norm, which is evident fr ...

Health professionals and researchers like Rubin and Attia delve into the nuances of hormone therapy, discussing its potential risks and benefits for women.

Hormone Therapy Benefits Women: Eases Menopause, Protects Bones, Reduces Colon Cancer Risk, Lowers Mortality

Rubin addresses the balance between the risks of taking hormone therapy and not taking it. She explains the bodily changes in the absence of hormones, particularly the risk of urinary tract infections, pelvic pain, and osteoporosis—with hip fractures being as deadly as breast cancer. The isolation of hormone therapy as a significant antidepressant is a unique perspective Rubin brings, emphasizing its impact on mental health.

She expresses frustration at the lack of knowledge among medical professionals regarding hormone therapy’s benefits, such as the prevention of colon cancer. Rubin argues for a versatile array of specialists to understand the impact of menopause on various organs. She sees hormone therapy as not only beneficial but essential, citing how it aids in preventing Alzheimer's, osteoporosis, and other conditions.

Attia reinforces Rubin’s view by outlining the increased risks of dementia, osteoporosis, cardiovascular disease, and colon cancer in the absence of hormones. With hormone therapy, there’s a decreased risk of colon cancer, fractures, and diabetes, and a decline in overall mortality and cancer-specific mortality. Estrogen therapy alone resulted in a lower risk of breast cancer.

Women's Health Initiative Study Risks

Rubin highlights FDA-approved [restricted term] as evidentially supported for hormone therapy. She also points out that in the Women’s Health Initiative, those on estrogen had a lessened risk of breast cancer. When discussing surgical menopause, Rubin stresses the importance of hormone therapy in averting bone health and cardiovascular issues.

She further scrutinizes the WHI study's claim about the increased risk of breast cancer incidence with estrogen and progestin, questioning its validity and the placebo group's protection.

Whi Misinterpreted: Hormone Therapy Risks Vary By Formulation, Timing, and Delivery Method

Criticism abounds over the misrepresentation of the WHI study findings and the understatement of hormone therapy ...

Attia and Rubin critically analyze the controversies and misconceptions surrounding hormone replacement therapy (HRT), shedding light on the impact of misinformation and misguided studies.

WHI Study's Flawed Hormone Therapy Design Overstated Results, Causing Unnecessary Fear

The WHI study's flawed design substantially influenced public perception and medical practice around hormone therapy.

WHI Study Generalized Findings To all HRT, Ignoring Formulation, Dose, and Delivery Differences

Attia speaks on the National Institutes of Health’s (NIH) Women's Health Initiative (WHI) which set out to provide solid evidence on HRT through a randomized control trial. However, pitfalls in its design led to misinformation. The study generalized its findings to all forms of HRT without considering differences in formulation, dose, and method of delivery. Rubin notes that the WHI study used a birth control pill style of therapy, unlike the [restricted term] and progesterone medications prescribed today. Attia expresses concern about how the study generalized the findings to all forms of HRT without considering these crucial differences.

WHI Fears Slashed HRT Use, Blocking Benefits and Awareness of Current Safety Evidence

Following the WHI study, Rubin and Attia note that the use of hormone therapy plummeted, affecting the industry severely and continuing for 30 years despite evolving understanding and safety evidence. Rubin indicates that the misinterpretation of the WHI study's findings led to a significant reduction in the use of HRT, blocking many from accessing the associated benefits and from understanding its safety. Attia discusses performing an analysis to estimate the lives lost and disabilities incurred due to the lack of HRT usage since the WHI study. Rubin confirms that many doctors receive minimal menopause education, and this failure to train doctors in hormone therapy has had significant repercussions.

Reflection on the WHI Study's Impact and Need for Correct Education

Rubin points to discrepancies in the implementation of the WHI study's results concerning warnings on hormone products, implying that fears stemming from the study contributed to an overall decline in HRT use, blocking benefits and awareness of current safety evidence.

She reflects on the aftermath of the WHI study, which led to hormone therapy somewhat going underground, contributing to the emergence of compounded hormone therapies. Rubin's reference to the historical context implies that fears and misunderstandings from the WHI study influenced how HRT was perceived and practiced

Furthermore, Rubin sugg ...

The complexities of hormone therapy for women are coming to light as Rubin, a urologist, educates hormone doctors on prescribing practices.

Hormones to Address Menopause Symptoms and Health Effects

Rubin emphasizes that hormone therapy should be brought back into the realm of evidence-based medicine. There's a debate on the use of lab tests to monitor hormone therapy. Rubin prefers avoiding excessive testing, although labs can clarify perimenopausal fluctuations. Attia focuses on symptoms and sees [restricted term] levels and FSH as markers for therapy. Rubin also agrees with a symptom-focused approach, advocating for an individualized therapy, whether it be an estrogen gel or patch.

Rubin expresses caution about hormone therapy practices. Red flags include being pushed towards expensive products or being sold on "special" compounded products that claim to be safer and more effective. Moreover, the pellet industry for women lacks an FDA-approved product, raising safety and efficacy concerns.

Progesterone Opposes Estrogen Effects: Preventing Uterine Hyperplasia and Cancer, Delivered Orally or Vaginally

Attia notes that in the history of hormone replacement therapy (HRT), estrogen alone increased the risk of endometrial cancer. Rubin follows up by emphasizing the role of progesterone in protecting the endometrial lining for those with a uterus. Micronized progesterone is typically administered orally but can also be delivered vaginally to avoid sedative side effects. Daily administration can aid sleep and anxiety reduction, and depending on the estrogen dose, the starting dose of progesterone might be 100 milligrams, with some suggesting 200 milligrams might be necessary.

Topical and Transdermal Estrogen Offer Estrogen Benefits With Fewer Adverse Effects Than Oral Estrogens

The conversation shifts towards systemic estrogen vs. local hormones. Rubin differentiates between systemic estrogen for whole-body treatment and local vaginal hormones for genital and urinary symptoms of menopause, which she claims to be safe for every individual, including elderly patients at risk of urinary tract infections.

Oral estrogen is currently less used, and Rubin explains that sublingual estrogen reduces risks by avoiding first-pass metabolism. Patch adherence issues, as well as the convenience of gel applications, are discussed, offering flexibility in administration. Rubin further explains that local applications of estrogen, like the E string for genitourinary symp ...

Rachel Rubin suggests that there is a significant yet neglected role of [restricted term] in women’s health, especially during menopause.

Aging In Women Leads To [restricted term] Decline and Health Issues

Rubin points out that contrary to popular belief, [restricted term] is important for women and declines with age, starting in the 30s. While the prescribing of [restricted term] for men is often off-label and widely accepted, and the FDA has recently updated their stance on [restricted term] therapy for men, stating it's no longer a cardiovascular disease risk, similar considerations are often overlooked for women. It's implied that there is a decline in [restricted term] as women age, which leads to various health issues.

[restricted term]'s Importance For Women in Menopausal Hormone Therapy Is Overlooked

Rubin highlights the overlooked importance of [restricted term] in menopausal hormone therapy by noting its absence in the typical hormonal curve diagram depicting women's menstrual cycle. Given [restricted term]’s peak around ovulation, she debunks the misconception that regularly menstruating women can't have hormone problems, pointing out that this overlooks [restricted term]’s role.

She explains that vaginal hormones such as estrogen, which have receptors in the brain, are linked to the common symptom of brain fog during perimenopause. Moreover, she suggests that vaginal DHEA, which helps produce both estrogen and androgens, can have a substantial impact, decreasing the risk of UTIs by more than half. Rubin also indicates that symptoms like brain fog can be mitigated by adding some estrogen to keep the receptors satisfied.

[restricted term] Safely Boosts Sexual Health and Mood In Menopausal Women

Rubin endorses [restricted term] for its beneficial effects on sexual health in menopausal women. She states that guidelines recommend using FDA-approved [restricted term] for men, appropriately dosed for females, for women’s sexual health. Rubin suggests that an addition of topical [restricted term] to hormone therapy can be transformative for menopausal women, alleviating interstitial cystitis and sexual dysfunction.

She also describes a compounded product using [restricted term] to treat vulvar vestibule issues that cause pain during sex, urinary symptoms, and pelvic pain, and refers to global consensus that [restricted term] therapy works for low libido in post-menopausal women. Patients have reported effects such as increased libido, eas ...