Transforming care for menopausal symptoms

Tyler Pierce, MD, is a board-certified ob-gyn with more than 15 years of experience. He practices at Novant Health Dayfield Park OB/GYN in Charleston. Trained in hormone replacement therapy, he also focuses on minimally invasive gynecological surgery, comprehensive office-based care and complex and high-risk pregnancy care.

Symptoms associated with the stages of menopause can be a minor inconvenience for women or can be significantly disruptive to their daily life. Novant Health is leading the way to dispel myths about hormone replacement therapy (HRT) and improve the quality of life for women as they age. In this Q&A, Dr. Pierce shares expertise about when and how to provide HRT medical treatment to bring relief to women who experience moderate to severe symptoms related to menopause.

What is hormone replacement therapy (HRT) and who can benefit?

HRT is the use of synthetic or bioidentical hormones (most commonly estrogen and progesterone, but also testosterone) to replace the hormones the body no longer produces in sufficient quantities. Essentially, HRT gives back to the body what it has naturally lost.

Patients who usually benefit the most from HRT are those experiencing moderate to severe vasomotor symptoms (hot flashes and night sweats), vaginal dryness, pain during intercourse, sleep disturbances, mood changes (irritability/anxiety) and brain fog.

What are common misunderstandings about HRT?

Hormone therapy can be safe and effective. The most prevalent misunderstanding stems from the flawed 2002 Women's Health Initiative study, which caused an almost 80% decrease in hormone prescriptions. Over the past few decades, a more reasonable understanding about the safety of hormone replacement has emerged.

While older oral configurations carried some notable risks, modern bioidentical hormones and routes of delivery, such as transdermal patches, topical gels and vaginal localized treatments, provide safer and more effective treatment.

Another common misconception is that perimenopausal and menopausal symptoms are all the same. Ask your friends or mother and they will likely share stories of their own journey into and out of menopause, and each woman’s experience may differ.

When should a primary care provider manage hormone-related symptoms versus referring to a specialist?

In most cases, primary care providers may manage standard, uncomplicated menopausal transitions and standard symptom relief discussions. Specialists, such as clinicians with OB-GYN or endocrinology and hormone clinics, are used to help manage standard symptoms but also handle complex symptoms or patients with complex medical histories. Seeing a specialist is recommended when:

• Patients have complex coexisting medical histories, such as borderline estrogen-sensitive risks
• Localized conditions require advanced diagnostic procedures (e.g., endometrial biopsies or diagnostic hysteroscopies)
• Considering "off-label" hormone tracking such as testosterone management

Which symptoms suggest a patient would benefit from a referral to a specialist?

• Moderate to severe vasomotor symptoms, such as debilitating hot flashes and night sweats, that fail first-line therapies
• Severe vaginal atrophy (burning sensation in vagina or painful intercourse)
• Intractable brain fog, sleep disturbances or intense mood transitions that complicate typical management
• Abnormal or unexplained postmenopausal bleeding, warranting swift diagnostic investigation

Which patient population should not receive HRT treatment?

• History of breast cancer, however current data shows safety in transdermal routes
• History of blood clots (deep vein thrombosis or pulmonary embolism)
• History of stroke or active liver disease

For patients in these populations who cannot safely take hormone replacement, several highly effective non-hormonal treatments are available that can help manage symptoms.

What can I tell patients to expect from a referral?

Patients should understand that menopause is a highly personalized journey. They can expect the specialist to closely review their specific medical history, assess symptom severity and work with them to design a custom regimen. Patients should know that it takes time to find the best route and ideal dosage, so patience and being proactive will be very helpful. Also understanding that self-advocacy regarding insurance coverage and symptom tracking are part of the process.

What value does specialized HRT training offer to patients?

HRT is not a one-size-fits-all treatment. Advanced training enables a clinician to navigate the vast array of delivery routes, dosages and safety as well as customize regimens effectively. Referring physicians should ideally look for a healthcare professional trained in women's health, such as a board-certified ob-gyn, to ensure the patient receives expert, up-to-date guidance.

What HRT treatment options are available today, and how are they typically customized for patients?

Modern bioidentical and standard HRT treatment pathways include:

• Estrogens: available via transdermal patches, topical creams, oral tablets and vaginal suppositories
• Progesterone: available as oral capsules or vaginal inserts/gels
• Testosterone: frequently prescribed "off label" by specialists via topical gels or creams to treat hypoactive sexual desire or low libido

What are the risks and benefits of HRT?

Benefits

Patients often experience substantial relief from their hot flashes, night sweats, symptoms. HRT also protects bone health, significantly reducing bone loss and osteoporotic fracture risks. When initiated appropriately, HRT decreases the risk of cardiovascular mortality, the number one killer of women in the U.S.

Risks

Oral configurations may slightly increase the risk of serious blood clots when compared to other routes, especially in older populations. To mitigate these issues, clinical protocols generally recommend using the lowest effective dose possible for the shortest duration necessary, ideally initiating treatment within 10 years of menopause or before the age of 60 to secure the safest risk-to-benefit ratio.