71 - Hormone Replacement Therapy (Dr. Alecia Allen)

Dr. Alicia Allen, physician at Family Medicine - Northridge, joins Dr. Arnold to discuss Hormone Replacement Therapy.

Do you have a question about a trending medical topic? Ask Dr. Arnold! Submit your question and it may be answered by Dr. Arnold on the podcast!

Submit your questions at: https://www.unitypoint.org/cedarrapids/submit-a-question-for-the-mailbag.aspx

If you have a topic you'd like Dr. Arnold to discuss with a guest on the podcast, shoot us an email at stlukescr@unitypoint.org.

Transcript

Dr. Arnold:

This is LiveWell Talk On hormone replacement therapy. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health-St. Luke's Hospital. Hormones are a part of life. They fluctuate from the first appearance at puberty and throughout life until women reach menopause. Joining us today is UnityPoint Clinic family medicine Doctor Alecia Allen to share information on hormone replacement therapy. Good morning. What is hormone replacement therapy?

Alecia Allen:

Good morning. Hormone replacement therapy is the treatment options that we use for women as they have gone through menopause. There's a couple of different options depending if they have a uterus or not. So if a woman does not have a uterus, then we typically resort to estrogen only. If a woman's still has her uterus, then we use a combination of estrogen and a progestin.

Dr. Arnold:

Okay. And what are the risks with this therapy, estrogen alone and progesterone with estrogen? What are the risks? There are obviously probably risk factors with this replacement. What are they?

Alecia Allen:

So whenever you're giving any woman estrogen, you have a risk factor for a blood clot and that's your biggest risk that you need to be aware of. So any woman who has a previous history of a blood clot or really even a stroke then they would not be a good candidate for such therapy.

Dr. Arnold:

And how do you treat the therapy when a woman has dysfunctional uterine bleeding and then they, I know sometimes the OB GYN docs still say, well, we need to add progestin or progesterone. How do you make that determination? What's the relationship there?

Alecia Allen:

As long as a woman has her uterus, they have to have some form of progesterone because unopposed estrogen is a risk factor for endometrial cancer. So if they have their uterus, they have to have some form of progesterone to protect them from developing endometrial cancer.

Dr. Arnold:

Okay. What are the common indications for, well let me rephrase that. Other than menopause, when do you replace the hormones in them?

Alecia Allen:

You really wouldn't, the only time for menopausal hormonal therapy would be menopause. If someone is having abnormal uterine bleeding, we use different forms of hormones for that. So we treat them with hormones. It's just different variations and kinds.

Dr. Arnold:

Okay. Still balancing the progesterone and estrogen. What are some natural options for hormone replacement therapy? I see some of the, whether it's advertisements and I think there's a clinic maybe down in Iowa City that offers hormone replacement therapy, natural hormone replacement therapy. What's that all about?

Alecia Allen:

So that's a very complex question. So there are what are called bioidentical hormones and that's really Estradiol. So that's the exact same chemical formulation that your body is making. And then there's, you know, different other forms of estrogen, like your Premarin estrogen. You can get Estradiol in compounded form or you can actually get it in prescription form from your provider. So I don't exactly know what some of those clinics are doing and which formulations, but you can get Estradiol in oral form or actually patches that is FDA approved.

Dr. Arnold:

Okay. And I know you mentioned in a previous podcast about menopause that it's a clinical diagnosis. There is no benefit to doing a blood test to see the estrogen level and try to influence that. That's kind of become vogue with testosterone replacement therapy. And you've probably seen that in your clinic or while your thyroid stimulating hormone is high normal, so therefore we need to bring it down to low normal for a constellation of concerns that are probably unrelated to that. So there's no indication for that, is there?

Alecia Allen:

Not really. It's very tricky because of your sex hormone binding globulin, which really affects your ability to do blood draws for Estradiol levels and progesterone levels. You use progesterone levels sometimes with gestation, so they do that if a woman is pregnant or early pregnant, has pregnancy complications, but not really as much for menopause.

Dr. Arnold:

Okay. You talked about the risk factors, the risk of blood clots developing with estrogen. How does osteoporosis tie into hormone replacement therapy?

Alecia Allen:

We used to use estrogen for osteoporosis treatment, but any more that there had been better and probably safer forms of just osteoporosis. So we don't use estrogen really as a first line osteoporosis therapy anymore to stick with the bisphosphonates or your first line agents.

Dr. Arnold:

Speaking of bisphosphonates, when do you send them to the infusion center to get the infusions versus taking in? How do you make that decision in your practice?

Alecia Allen:

Well, for me, I use your oral bisphosphonates as a first line. If they're not tolerated or they're not working, then we kind of up the therapy to some of more your injectables through the infusion centers.

Dr. Arnold:

Okay. So it's not necessarily a degree of severity, but it's the intolerance to the orals first and then you work up to that.

Alecia Allen:

That's how I make my decisions.

Dr. Arnold:

I'm the medical director of the infusion center, so I do see those patients come in. One patient is a spinal cord injury. So it's difficult for her to sit up. So obviously she can't take the bisphosphonate and so we do that. So that's interesting. It all ties together. All comes back to hormones, doesn't it? What are the other ways to manage hormone levels, if any in your clinical practice?

Alecia Allen:

Are you meaning specifically non-pharmacological?

Dr. Arnold:

Yeah.

Alecia Allen:

So I will counsel women, there's a lot of things that they can do from what we would traditionally call behavioral modifications. One is they need to learn to dress in layers if they're having their hot flashes. Minimize alcohol, minimize triggers, and weight loss is actually a very important thing to managing other symptoms with menopause. I often will tell people to exercise. Exercise itself, when I just looked that up in the research is about 50/50 on does it help manage hot flashes. But I think general wellness does and if obviously you're losing weight with your exercise, that can be very helpful.

Dr. Arnold:

Okay. Well sticking on the hormone theme, what's the difference between a birth control pill and estrogen replacement therapy

Alecia Allen:

Doses and formulations.

Dr. Arnold:

Okay, because I know birth control pills are a risk, particularly if they're a smoker for blood clots. I've seen that. And so birth control pills are higher formulations or larger doses of estrogen?

Alecia Allen:

Per se. Yes.

Dr. Arnold:

And are birth control pills are they both progesterone and estrogen, correct?

Alecia Allen:

They're all. So it's an OCP, which is your typical, what you're talking about from a birth control is oral combined pill. So that C-word is combined. So it has an estrogen and progestin.

Dr. Arnold:

See, I always thought it was oral contraceptive pill. So the C is combined. See you learn something every day. But I'll probably forget it by the end of the day. So if I ask you again, just smile and give me the answer again. How should a woman determine what is best for her when she's considering the possibility of estrogen replacement therapy?

Alecia Allen:

So she has to kind of look at her own individual risk factors. Obviously we try not to use them in smokers, like you had mentioned. Anyone with a history of breast cancer we don't and anyone with a clotting disorder obviously it's a contraindication. But if you're a 51 year old female, perfectly healthy, you have no cardiovascular risk factors. You do not have a history of gynecological malignancies and you're miserable, you'd be a good candidate and should have a discussion with your doctor.

Dr. Arnold:

And if they choose to have a hormone replaced, how often do you see them? Once a year, every six months. Is it something like that?

Alecia Allen:

When you're first starting, because there's different doses, I usually will see them about every three months. Because if you replace a woman with too much estrogen you'll get symptoms from that too. So you want the least amount of medicine for the shortest duration of time to control their symptoms. So there is some titration you would say for the dosing.

Dr. Arnold:

And you mentioned the symptoms of estrogen replacement that a woman might experience. What are some warning signs that she should call your clinic?

Alecia Allen:

Well, if it's too high you would obviously want to counsel them on the risk factors of a blood clot such as leg swelling, shortness of breath. Those would be immediate concerns. Other concerns that are not an immediate or urgent problem would be they'll get bloating, breast tenderness, a really abnormal bleeding. That can happen too if they have an intact uterus.

Dr. Arnold:

So they could actually have a menstrual cycle after they haven't had one for a while?

Alecia Allen:

Yeah and that would be pretty typical that we would counsel them and we wouldn't worry that much the first time or if it's a little bit. But if it keeps happening or is heavy and clotting, then we would want to know about that. And obviously they would be getting a progesterone in addition to the estrogen if they have an intact uterus. So you're really looking at titrating two different hormones to get the right balance for them.

Dr. Arnold:

When the patient presents with the the bleeding with estrogen, do you ever image the uterus to look for endometrial disease or is it more of a clinical diagnosis?

Alecia Allen:

It depends. That's actually complex. If they are just started on hormone replacement therapy, we would expect some bleeding. If they've been on hormone replacement therapy for some time and now they're bleeding and there's a change, that's when you would kind of image more.

Dr. Arnold:

And what is the relationship between, you mentioned breast cancer and estrogen. So estrogen replacement puts you at risk?

Alecia Allen:

So the large studies actually do not show that in a 50 year old, 51 year old, young, 50 year old female. There really is not a clinically significant risk of breast cancer. But if you are a female who is at risk for BRCA 1 or has strong family history or a personal history, that's where you need to be concerned. Because if she has a personal history and it's an estrogen receptive positive breast cancer, we're not going to then give her estrogen.

Dr. Arnold:

So you brought up the BRCA, the genetic syndromes associated with breast cancer. In your practice, do you screen people for that?

Alecia Allen:

I do not. They get screened. They fill out a genetic risk factor at their mammogram. So that starts at the breast and bone imaging at age 40. Often if a woman truly has many family members who've had breast cancer, then I would send them for genetic consultation. If they're younger than 40, and it appears that they need to have a full fledge workup for that.

Dr. Arnold:

Alright. Sorry to surprise with that question, but I've always wondered how that happens. Is there anything else you'd like to, words of wisdom that you've picked up in your clinical experience regarding hormone replacement therapy?

Alecia Allen:

You know, it's kind of a scary topic for women. There's a lot of bad press, there's a lot of unknowns about it. So I would just say that my recommendation was evaluate yourself, evaluate your symptoms, and have a honest conversation with your provider.

Dr. Arnold:

And don't just Google symptoms and replacement, actually stick to certified or accredited sources of information. That's always good advice. Well, Dr. Allen, thank you for joining us today. This is great information. Once again, I've learned something that I didn't know before we started the podcast. Again, that is Dr. Alecia Allen, a physician with UnityPoint Clinic family medicine. If you have a topic you'd like to suggest for our LiveWell Talk On podcasts, shoot us an email at stlukescr@unitypoint.org. And we encourage you to tell your family, friends, neighbors about our podcasts. Until next time, be well.