Managing Menopausal Symptoms

Listen in as our expert panel covers the latest evidence on using menopausal hormone therapy and nonhormonal options for treatment of vasomotor symptoms (hot flashes, etc). You’ll also hear experts discuss treatments for genitourinary symptoms (vaginal dryness, etc) as well as low libido and brain fog.

Special guests:

• Veronica Vernon, PharmD, BCPS, BCACP, MSCP, FAPhA 
  • Associate Professor, Chair of Pharmacy Practice
  • Butler University
• Sarah M. Westberg, PharmD, FCCP, BCPS
  • Associate Dean for Professional Affairs Professor, College of Pharmacy
  • University of Minnesota

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Andrea Darby-Stewart, MD
  • Associate Director, Honor Health Family Medicine Residency Program
  • Clinical Professor of Family, Community & Occupational Medicine
  • The University of Arizona College of Medicine – Phoenix
• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University

None of the speakers have anything to disclose. 

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in March 2026.

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TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

Charts:

• Menopausal Hormone Therapies
• Managing Vasomotor Menopause Symptoms
• Managing Genitourinary Menopausal Symptoms

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Transcript

This transcript is automatically generated. 

00:00:07 Veronica Vernon

With brain fog, it’s multifactorial, that there’s conflicting evidence. 

00:00:12 Veronica Vernon

We’ve seen trials say menopause hormone therapy makes cognition worse, and then others say it makes it better. 

00:00:19 Veronica Vernon

Really, what we know now from the literature is that hormone therapy is neutral on brain fog. 

00:00:25 Veronica Vernon

But what makes brain fog worse and cognition worse is vasomotor symptoms. 

00:00:31 Veronica Vernon

And so by controlling the vasomotor symptoms, you can help with that brain fog.

00:00:38 Sarah Westberg

The National Academy for Science, Engineering and Medicine did a deep dive into the compounded bioidentical hormones…

00:00:44 Sarah Westberg

and really came out with the conclusion that there’s no evidence that they’re safer. 

00:00:50 Sarah Westberg

There’s overall a complete dearth of evidence to say that compounded are safer or more effective.

00:01:00 Narrator

Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources. 

00:01:09 Narrator

On this episode, listen in as our expert panel covers the latest evidence on using menopausal hormone therapy and nonhormonal options for treatment of hot flashes and night sweats. 

00:01:19 Narrator

You’ll also hear experts discuss how to manage genitourinary symptoms, such as vaginal dryness, as well as low libido and brain fog.

00:01:29 Narrator

Whether you're a clinician or a patient doing your own research, this episode delivers the clarity you've been looking for.

00:01:35 Narrator

Our guests today are…

00:01:37 Narrator

Dr. Veronica Vernon, Associate Professor and the Chair of Pharmacy Practice at Butler University. 

00:01:44 Narrator

She is also a Menopause Society Certified Practitioner with extensive clinical experience in women’s health.

00:01:51 Narrator

And Dr. Sarah Westberg, Associate Dean for Professional Affairs and a Professor in the College of Pharmacy at the University of Minnesota. 

00:01:59 Narrator

She has provided comprehensive medication management services in family medicine, internal medicine, and a women’s health clinic.

00:02:08 Narrator

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board

00:02:13 Narrator

Dr. Andrea Darby Stewart from The University of Arizona College of Medicine - Phoenix

00:02:18 Narrator

And Dr. Craig Williams from the Oregon Health and Science University.

00:02:22 Narrator

This podcast is an excerpt from one of TRC’s monthly live CE webinars. 

00:02:27 Narrator

Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

00:02:38 CE Narrator

And now, the CE Information.

00:02:43 Narrator

This podcast offers Continuing Education credit for pharmacists, pharmacy technicians, physicians, and nurses. 

00:02:50 Narrator

Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

00:03:00 Narrator

None of the speakers have anything to disclose. 

00:03:05 Narrator

Now, let’s join TRC Editors and clinical pharmacists, Drs Stephen Small and Sara Klockars, and start our discussion!

00:03:16 Sara Klockars

Sarah, can you just kind of review the differences between the oral, the transdermal, vaginal estrogen delivery, and how risks differ across those formulations?

00:03:28 Sarah Westberg

With oral and transdermal estrogen, of course, the estrogen is getting into the bloodstream and it's systemic absorption.

00:03:37 Sarah Westberg

With the vaginal, the Femring is a brand of a vaginal ring that is proven to treat hot flashes.

00:03:44 Sarah Westberg

So we know the dose is high, that we do get systemic absorption from the Femring.

00:03:49 Sarah Westberg

But every other vaginal estrogen option is locally absorbed with very minimal, if any, systemic absorption.

00:03:58 Sarah Westberg

So the low dose vaginal options are perfect for maybe an older woman who's having the genitourinary symptom of menopause, having those vaginal symptoms and are just no longer having hot flashes.

00:04:11 Sarah Westberg

So they just need the vaginal treatment.

00:04:13 Sarah Westberg

For treatment of vasomotor symptoms or night sweats, you do need the systemic delivery.

00:04:18 Sarah Westberg

And the key difference here between oral and transdermal is that the research is pretty clear that transdermal application minimizes the risk of venous thromboembolism.

00:04:29 Sarah Westberg

So if you have a patient who's in that situation where maybe there's a history of VTE that you know is not estrogen induced, or maybe you're on the fence a little bit about using it, or maybe you have a woman who has other risk factors for VTE, then a transdermal option is going to be best for her.

00:04:47 Sarah Westberg

And some women prefer to do the oral, it's easier, or maybe they have sensitive skin, and in that case, oral is a great option as well.

00:04:56 Sarah Westberg

And our combination products can vary between the oral and the transdermal as well.

00:05:00 Sarah Westberg

There's fewer combination transdermal products.

00:05:03 Sarah Westberg

So lots of options for patient choice and what works for them.

00:05:08 Sara Klockars

And Veronica, what is the role of progestogens in this hormone therapy and what are the differences between this micronized progesterone, synthetic progestins?

00:05:21 Veronica Vernon

The main role of progestogens, which for those listening, progestogen is the umbrella term for progesterone and our synthetic progestins.

00:05:30 Veronica Vernon

The role is to provide endometrial protection.

00:05:33 Veronica Vernon

In simplistic terms, estrogen leads to proliferation of the endometrium.

00:05:39 Veronica Vernon

And progestogen is going to prevent that overgrowth of the endometrium.

00:05:44 Veronica Vernon

And that's why we use it.

00:05:46 Veronica Vernon

We use it in individuals that have a uterus.

00:05:49 Veronica Vernon

in those that have had a hysterectomy, their uterus removed.

00:05:52 Veronica Vernon

We don't use progestogens typically.

00:05:55 Veronica Vernon

Micronized progesterone is structurally identical to progesterone that's produced by the ovaries.

00:06:03 Veronica Vernon

And micronized progesterone appears based off of retrospective data, meta-analyses, so no head-to-head trials…

00:06:11 Veronica Vernon

But some evidence tells us it may be a safer option in terms of side effects compared to some of our progestins and potentially a little bit better tolerated.

00:06:22 Veronica Vernon

Now, I will say it's very individualized.

00:06:24 Veronica Vernon

Everything we talk about with menopause depends on the patient, but I have found in my practice patients to appreciate micronized progesterone.

00:06:35 Veronica Vernon

It might help with sleep.

00:06:37 Veronica Vernon

We don't give it just to help with sleep, but I had some patients tell me when they take it at bedtime, they were getting really great sleep.

00:06:44 Veronica Vernon

But one thing that is a drawback to the micronized progesterone is it is formulated in peanut oil.

00:06:50 Veronica Vernon

So you have to be cautious of those with a peanut allergy and unfortunately avoid it.

00:06:54 Veronica Vernon

Now our synthetic progestins, that's what most of us are familiar with that are predominantly found in our hormonal contraception options.

00:07:01 Veronica Vernon

And those are going to be more potent, especially at the level of the endometrium.

00:07:06 Veronica Vernon

So if I had a patient who had diagnosed abnormal uterine bleeding and we had a cause for it, and we wanted to use a progestin to help control her bleeding, a synthetic progestin might be a little bit better at doing that.

00:07:18 Veronica Vernon

We've also used a levonorgestrel intrauterine device to provide endometrial protection and contraception for those perimenopausal patients and add on an estradiol patch

00:07:30 Veronica Vernon

to provide some of the vasomotor relief.

00:07:33 Veronica Vernon

There is a small trial that showed micronized progesterone by itself may help reduce some vasomotor symptoms in individuals that are unable to use estrogen, which I do find promising.

00:07:44 Veronica Vernon

We need continued evidence in that space.

00:07:49 Sara Klockars

And I wanted to touch a little bit more on the bioidentical hormones.

00:07:53 Sara Klockars

Sarah, are you able to define that for our listeners?

00:07:57 Sarah Westberg

Generally we use the term bioidentical to mean that the hormone is chemically identical to what the body produces naturally.

00:08:06 Sarah Westberg

So it's a really important differentiator because sometimes the word bioidentical is used to apply only to compounded hormones.

00:08:15 Sarah Westberg

And the truth is we have bioidentical hormones that are in FDA-approved commercially available products, as well as through compounding pharmacies.

00:08:25 Sarah Westberg

So in our commercially available products, we have estradiol, and as we talked about, we have it in tablets and vaginal creams, as well as the transdermal products.

00:08:33 Sarah Westberg

And we have the micronized progesterone product that's available as a commercial available product.

00:08:39 Sarah Westberg

And that means that they're well studied, they're produced and manufactured in safe facilities,

00:08:45 Sarah Westberg

And they're typically covered by insurance, which is also really helpful.

00:08:49 Sarah Westberg

And because there's been over the years, and especially the last 20 years since the Women's Health Initiative, there's been sometimes our patients receive information that maybe compounded is safer.

00:09:03 Sarah Westberg

And so that led to a few years ago, it was in 2020, actually, the National Academy for Science, Engineering and Medicine did a deep dive into the compounded bioidentical hormones.

00:09:15 Sarah Westberg

and really came out with the conclusion that there's no evidence that they're safer.

00:09:20 Sarah Westberg

There's overall a complete dearth of evidence to say that compounded are safer or more effective.

00:09:26 Sarah Westberg

So it's really recommended that we limit the use of compounded for folks who need it for a reason.

00:09:33 Sarah Westberg

Like we talked about the micronized progesterone being formulated in peanut oil.

00:09:37 Sarah Westberg

So if you have a patient who has a peanut allergy, perhaps you could work with a compounding pharmacy to make that micronized progesterone in a different oil that would be safe for the patient.

00:09:48 Sarah Westberg

So that's just a little background on how the term has been used and to know that we have both commercial and compounded products that are bioidentical.

00:09:57 Sara Klockars

Andrea, did you have a comment?

00:10:01 Andrea Darby-Stewart

Yeah, I really appreciated the comments that were made about the lack of efficacy or safety data surrounding some of the bioidentical compounded hormones that are being put into the community.

00:10:15 Andrea Darby-Stewart

And I would like to specifically call out the fact that we really don't have any good safety data on hormonal pellets, which are all the rage in my community.

00:10:27 Andrea Darby-Stewart

And we are seeing women who have very super physiologic levels of both estradiol as well as testosterone…

00:10:34 Andrea Darby-Stewart

…which I'll know we'll get into later in the webinar, but would really recommend that we follow the guidelines of the menopause society and our endocrine societies… 

00:10:42 Andrea Darby-Stewart

…and avoid these compounds and pellets, except with very special situations where patients can't tolerate other formulations that we know are safe and effective for management of menopausal symptoms.

00:10:56 Sarah Westberg

I think it's important that patients understand that there's less opportunity for dose adjustment.

00:11:04 Sarah Westberg

Once a pellet is placed, it's there.

00:11:07 Sarah Westberg

And as Andrea, sounds like you've maybe experienced this as well.

00:11:11 Sarah Westberg

I can remember a patient who had pellets placed and a testosterone pellet placed, and she was having many testosterone-related side effects.

00:11:19 Sarah Westberg

And there was, we could do our best to try to manage them, but really we had to wait until the effects were mitigated by the ESSA pellet was completed.

00:11:30 Sarah Westberg

And so it's a long-term commitment in some ways with the pellets.

00:11:34 Sarah Westberg

And so it just brings different risks from quality of life and perhaps unknown risks to the lack of safety data as well.

00:11:43 Sara Klockars

Thank you.

00:11:45 Sara Klockars

So Andrea, would you want to comment on the current thinking on the optimal duration of hormone therapy?

00:11:53 Andrea Darby-Stewart

Absolutely.

00:11:54 Andrea Darby-Stewart

It falls into the banner of shared decision-making as people age into their menopausal status.

00:12:01 Andrea Darby-Stewart

So like we talked about earlier, the ideal time is to start menopausal hormonal therapy within that first 10 years of menopause from a safety perspective.

00:12:10 Andrea Darby-Stewart

And hopefully, the majority of our patients will be able to find the lowest effective dose of menopausal hormonal therapy, estrogens and progestrogens, if they're indicated, to help them with their symptoms.

00:12:23 Andrea Darby-Stewart

And as I talk with my patients, as they go through that first decade of post-menopausal status, we check in on a regular basis, at least annually.

00:12:33 Andrea Darby-Stewart

How are the hormones working for you?

00:12:35 Andrea Darby-Stewart

Would you like to consider a trial of reducing those doses?

00:12:38 Andrea Darby-Stewart

And if patients are reducing their doses and their symptoms return, and it's been that 10-year time period post their final menstrual period, then we have a shared decision-making discussion about, okay, what are the benefits you're achieving with this therapy?

00:12:53 Andrea Darby-Stewart

What are the potential risks, particularly related to cardiovascular status or even prolonged exposure over time to these lower doses of hormones for breast and uterine cancer status?

00:13:05 Andrea Darby-Stewart

And we make a decision together about what's going to be the best for them.

00:13:09 Andrea Darby-Stewart

I was commenting a little bit earlier.

00:13:11 Andrea Darby-Stewart

I think there are so many other medications that we prescribe for very long periods of time that have higher risk profiles.

00:13:18 Andrea Darby-Stewart

And I'm happy to have a conversation about what is going to be the optimal use of hormones for my patients that supports them in their overall sense of well-being and reduces their risk.

00:13:34 Sara Klockars

Thank you.

00:13:35 Sara Klockars

Veronica, Sarah, Craig, do you guys always taper your hormones off slowly as well in practice?

00:13:42 Sara Klockars

Or do you ever have patients just stop cold turkey?

00:13:47 Craig Williams

Yeah, I'll just briefly say kind of yes to both.

00:13:50 Craig Williams

So our preferred approach is certainly to offer a taper.

00:13:54 Craig Williams

But it's worthwhile remembering that these are being used for symptoms.

00:13:58 Craig Williams

And fortunately, as we're learning, you know, they're safer.

00:14:01 Craig Williams

and we kind of were scared and thinking they were 20 years ago.

00:14:04 Craig Williams

So if someone does stop on their own or for some reason, insurance issues, they have to stop.

00:14:10 Craig Williams

There's not a risk of stroke or arrhythmias or there's not really medical physiologic risk to abrupt cessation, but certainly symptoms will potentially recur and be more severe.

00:14:20 Craig Williams

So taper makes sense from a symptom mitigation standpoint.

00:14:24 Craig Williams

Yeah, we've had patients for whatever reason stopped and symptoms recur.

00:14:28 Craig Williams

But again, there's not really a medical physiologic withdrawal that you have to be concerned about in that setting.

00:14:33 Craig Williams

So, but yes, we prefer to taper and our patients prefer to be tapered.

00:14:41 Sarah Westberg

I would often have conversations with patients to either visually describe or even draw that the drop in estrogen right at that time of menopause is a much steeper drop than dropping off your hormone therapy later.

00:14:55 Sarah Westberg

So you have a deeper drop of estrogen levels and we're bringing those estrogen levels up a little bit with MHT to treat the symptoms, but we don't bring levels back to pre-menopausal state.

00:15:06 Sarah Westberg

So sometimes that reassurance that, oh, it's not going to be the same as what I went through when I was 51 and I waited 18 months before I started hormone therapy.

00:15:15 Sarah Westberg

I was miserable, that stopping by the eight years later, whatever that time frame is, will be a lower drop.

00:15:22 Sarah Westberg

And that often helps empower patients to feel comfortable who are maybe reluctant to stop.

00:15:30 Steve Small

Sarah, what non-hormonal medications are available for managing menopausal symptoms and how do we determine which to try first?

00:15:37 Steve Small

And Andrea, perhaps you can follow up with maybe the prescriber's perspective on that?

00:15:44 Sarah Westberg

Yes, and it's so important to have non-hormonal options because women may have contraindications to using estrogen, progesterone, and they may have had personal experiences with family members, medication experience that makes them prefer to avoid hormone therapy, and we're treating symptoms.

00:16:01 Sarah Westberg

So we really want to match the patient where they're at and what meets their needs and what they're comfortable with.

00:16:07 Sarah Westberg

So the non-hormonal medications are really important to know and understand and to be able to offer.

00:16:12 Sarah Westberg

So this is a great figure here.

00:16:14 Sarah Westberg

We have our SSRIs in the top left with paroxetine listed there.

00:16:19 Sarah Westberg

We also have citalopram has good data in terms of non-hormonal options.

00:16:25 Sarah Westberg

We also have SNRIs.

00:16:26 Sarah Westberg

Venlafaxine has a good amount of data.

00:16:29 Sarah Westberg

Gabapentin, I think we've used that quite a bit in our practice.

00:16:33 Sarah Westberg

Sometimes sleep can be so disruptive with the menopausal transition and the night sweats and the gabapentin at bedtime can help with the hot flashes, but also help patients get some sleep.

00:16:46 Sarah Westberg

Oxybutynin is probably used a little less frequently, but it does have data to support reducing menopausal symptoms.

00:16:53 Sarah Westberg

So it can be a great option if patients also have overactive bladder.

00:16:57 Sarah Westberg

So if both conditions exist, I think oxybutynin can be a really nice choice.

00:17:02 Sarah Westberg

Clonidine has really fallen out of favor as a non-hormonal treatment just because there's so many other side effects.

00:17:09 Sarah Westberg

And a lot of the original data with efficacy and clonidine has been in patients with breast cancer.

00:17:15 Sarah Westberg

So then we have our bottom right bucket, which is the neurokinin receptor antagonist, the fezolinetant and the elinzanetant.

00:17:23 Sarah Westberg

But our neurokinin receptor antagonists add a really nice option to our non-hormonal medication choices.

00:17:34 Andrea Darby-Stewart

From my perspective, that was an amazing summary.

00:17:37 Andrea Darby-Stewart

And what I like about this is if I have a patient who is having menopausal symptoms,

00:17:43 Andrea Darby-Stewart

and really doesn't want to pursue menopausal hormonal therapy, we do have options in our treatment bucket that are pharmacologic as well as non-pharmacologic.

00:17:52 Andrea Darby-Stewart

And this is where the art of medicine comes in, where you can potentially help patients with multitude of symptoms with one medication, depression, drop of these sleep disturbances, overactive bladder.

00:18:05 Andrea Darby-Stewart

In terms of our neurokinin receptor antagonists, I have had several patients ask about them, but they are definitely a challenge to have covered from an insurance standpoint.

00:18:17 Andrea Darby-Stewart

And for my patients who have been able to obtain these medications through coupon programs.

00:18:23 Andrea Darby-Stewart

They found them somewhat helpful, but perhaps not as helpful as they had hoped.

00:18:31 Craig Williams

I'll just add, Sarah. We've had the same real-world experiences as Andrea in using these, so I totally agree.

00:18:37 Craig Williams

It's nice having their neurokinin receptor antagonist as an option, but it is difficult to get them covered.

00:18:42 Craig Williams

And the response to them from patients has kind of been, yeah, okay, not great.

00:18:47 Craig Williams

So it's just you look at the studies used in the labeling.

00:18:51 Craig Williams

They included pretty severely perimenopausal symptomatic patients.

00:18:56 Craig Williams

They're, you know, 10 to 11 kind of vasomotor episodes per day in the trials used.

00:19:02 Craig Williams

And. And they can have nice effects.

00:19:03 Craig Williams

It'll go down by 60% with the drug and 40% with placebo.

00:19:08 Craig Williams

So that's kind of been our experiences yet.

00:19:11 Craig Williams

They're good, but not great, but certainly worth trying.

00:19:15 Veronica Vernon

I really appreciated the data that Craig shared is that's been consistent with what I've seen in practice as well.

00:19:22 Veronica Vernon

We haven't had any head-to-head trials with our neurokinin receptor antagonist and our SSRIs or SNRIs or the other agents that we've discussed.

00:19:32 Veronica Vernon

We just have that placebo data.

00:19:34 Veronica Vernon

There was a meta-analysis that reviewed elinzanetant versus our SSRIs and SNRIs.

00:19:41 Veronica Vernon

And it may have shown a little bit of benefit with our neurokinin receptor antagonist, but I will say take that with a grain of salt.

00:19:51 Veronica Vernon

Based off of the agents that were studied.

00:19:53 Veronica Vernon

They didn't look at citalopram versus these agents, and they mainly looked at desvenlafaxine, not venlafaxine, versus the neurokinin receptor antagonist data.

00:20:04 Veronica Vernon

I think these are exciting because we have new agents, new tools in our toolbox, like Sarah talked about earlier.

00:20:12 Veronica Vernon

I think we need to have more data.

00:20:15 Veronica Vernon

Elinzanotant interests me because of the dual receptor antagonism with neurokinin 1 and neurokinin 3, that perhaps we may see some improvement with sleep patterns and bothersome sleep.

00:20:29 Veronica Vernon

That might be a little bit better with this one, but I think we just need more data.

00:20:33 Veronica Vernon

Elinzanotant just hit the market and was FDA approved in 2025.

00:20:39 Veronica Vernon

So I would love to see a head-to-head trial and see some more data come out with that.

00:20:44 Veronica Vernon

And like Andrea had mentioned and Craig, I worry the most about insurance coverage for patients right now.

00:20:51 Veronica Vernon

And coming from a history of working in a system that had a very regulated formulary, these agents are non-formulary due to their cost and it is prohibitive for my patients.

00:21:06 Craig Williams

And yeah, to echo Sarah's earlier thoughts that the, I don't know if pharmacist prescribers that are oriented this way or not, but the top three drugs you have there are the kind of three that meet the level 1 criteria in the latest menopause society guidelines on this, which is 2023.

00:21:20 Craig Williams

They say SSRIs, SNRIs, gabapentin all kind of meet that level of adequate evidence and safe enough to try oxybutynin and clonidine.

00:21:30 Craig Williams

They're kind of below that level 1 recommendation.

00:21:34 Craig Williams

The other thing I'll add is while SRIs and SNRIs be generally very safe and well tolerated, gabapentin a bit less so, I think worth trying, but don't be surprised if patients come back and say, I don't feel any better on this and they don't like some of the CNS side effects of it, especially if you have to go up to higher doses to get some relief from the vasomotor symptoms.

00:21:52 Craig Williams

I'd say we're less enthused about gabapentin in this space and maybe been a little disappointed by the neurokinin receptor antagonist response from patients that were able to try it.

00:22:03 Sarah Westberg

If I could just add to that too, I know paroxetine is the SSRI I called out here, which is a SSRI that has a lot of data to help with hot flashes, but it's also the one that has more weight gain.

00:22:15 Sarah Westberg

And as women move through that menopausal transition, it's often a time where they may see some weight gain or struggle to lose weight.

00:22:23 Sarah Westberg

So I always keep that in mind with paroxetine for menopausal symptoms as well, and I would lean more towards…

00:22:29 Sarah Westberg

…citalopram or escitalopram, just because you get less of that weight gain at a time, that can be a tough part of the transition.

00:22:38 Veronica Vernon

I'll tag on to what Sarah just said about paroxetine.

00:22:42 Veronica Vernon

Also looking at it from the breast cancer patient perspective, if you have patients on tamoxifen, paroxetine has an interaction with tamoxifen and makes tamoxifen less effective.

00:22:51 Veronica Vernon

So that would be a reason that I would avoid paroxetine for non-hormonal symptom management for menopause symptoms, for vasomotor symptoms.

00:23:03 Steve Small

Andrea, I'm sure a lot of our listeners are wondering how effective are lifestyle interventions, things like nutrition or exercise,

00:23:09 Steve Small

How effective are those in managing menopause symptoms?

00:23:11 Steve Small

And what does the evidence say here?

00:23:15 Andrea Darby-Stewart

Weight loss is something that certainly I want my patients to achieve if it's going to help their overall health.

00:23:22 Andrea Darby-Stewart

But the data is really mixed, not so great in terms of weight loss being helpful for reducing vasomotor symptoms.

00:23:29 Andrea Darby-Stewart

Now, women who are in the overweight or obese category may experience worse vasomotor symptoms at the beginning of their menopause, but losing weight does not necessarily improve that for them.

00:23:41 Andrea Darby-Stewart

That being said, cognitive behavioral therapy, mindfulness-based stress reduction, and interestingly, hypnosis have all been shown in some studies to help people have a reduction in many of their vasomotor symptoms.

00:23:55 Andrea Darby-Stewart

Certainly, fans help everybody, right?

00:23:57 Andrea Darby-Stewart

You get hot, you put a fan on, that definitely works.

00:24:00 Andrea Darby-Stewart

Cooling sheets and cooling pajamas are all the rage on social media as well.

00:24:07 Andrea Darby-Stewart

Always recommend smoking cessation for patients from an overall lifestyle benefit.

00:24:12 Andrea Darby-Stewart

And then certainly, if patients notice that they have particular triggers, alcohol, spicy foods, if one patient who, when she laughs too hard, she gets a bad hot flash, I certainly don't recommend she stop laughing.

00:24:25 Andrea Darby-Stewart

But, you know, knowing what those triggers are can certainly help people understand and manage their symptoms a bit better.

00:24:34 Craig Williams

Just add real briefly, Steve, because it is a great point.

00:24:37 Craig Williams

And the 2023 menopause guidelines do kind of, it's a nice discussion on all these different techniques and exercise, yoga, like patients doing their own mindfulness interventions, those all fell below the level of any good evidence.

00:24:50 Craig Williams

But as Andrea said, cognitive behavioral therapy and clinical hypnosis actually made like the level one.

00:24:56 Craig Williams

These are as good as the pharmacologic therapies we're recommending, but it does have to be done with somebody who kind of knows how to implement those correctly.

00:25:03 Craig Williams

And so for listeners that may have providers in the area that do those things, yeah, kind of true cognitive behavioral therapy and clinical hypnosis can work.

00:25:14 Craig Williams

But yeah, it's very different than just, again, exercise or mindfulness that patients may kind of do on their own.

00:25:20 Craig Williams

That being said, it's all about managing symptoms.

00:25:22 Craig Williams

So it can be surprising what some patients find effective.

00:25:25 Craig Williams

But yeah, well-administered cognitive behavioral therapy makes the list of level 1 recommended interventions.

00:25:33 Steve Small

Great.

00:25:34 Steve Small

It's excellent to have those non-drug options.

00:25:36 Steve Small

And then Sarah, do we have any questions from the audience right now that are coming through?

00:25:42 Sara Klockars

I do have one that kind of fits in here to piggyback off of the weight loss.

00:25:46 Sara Klockars

Is there any data for adding GLP-1 receptor agonists to hormone therapy for weight loss in menopause?

00:25:53 Sara Klockars

Sarah, would you want to comment on that?

00:25:58 Sarah Westberg

Yes, it is interesting that we do have data looking at adding GLP-1s to menopause hormone therapy.

00:26:06 Sarah Westberg

There is a small study from 2024 published in Menopause that I thought I'd highlight.

00:26:12 Sarah Westberg

It was they compared women on semaglutide with and without menopause hormone therapy, and they looked at cardiometabolic outcomes as well as weight loss.

00:26:22 Sarah Westberg

And there was similar improvement in the cardiometabolic outcomes, the lipids, the glucose, the blood pressure.

00:26:29 Sarah Westberg

But the women who were on both semaglutide and menopausal hormone therapy had higher weight loss.

00:26:35 Sarah Westberg

So it does appear from this study and other small studies that there may be an additive effect.

00:26:42 Sarah Westberg

And in all of these situations, I think it's important that we highlight the importance of strength training.

00:26:47 Sarah Westberg

We know that's important with the GLP-1RAs to have that strength training to maintain that muscle strength and muscle mass.

00:26:56 Sarah Westberg

And that's also important as we age to maintain muscle strength.

00:27:01 Sarah Westberg

So incorporating strength training is an important part of the lifestyle part of this too.

00:27:07 Sara Klockars

Excellent.

00:27:07 Sara Klockars

Thank you.

00:27:08 Sara Klockars

I'm going to move us along to managing the genitourinary syndrome of menopause.

00:27:14 Sara Klockars

And so, Sarah, could you comment on, I guess, defining more of what that is and what are some treatment options for these symptoms?

00:27:24 Sarah Westberg

Yes, absolutely.

00:27:26 Sarah Westberg

Very common to see genitourinary syndrome of menopause... vaginal irritation, dryness, itching,

00:27:34 Sarah Westberg

And that can be bothersome all day long, can be uncomfortable sitting, could be uncomfortable, like just a lot of discomfort with a lot of vaginal dryness.

00:27:42 Sarah Westberg

Pain during intercourse, pain that can impact libido, it can impact relationships, and then urinary urgency and frequency.

00:27:50 Sarah Westberg

So our treatment options for GSM are, we can do lubricants as well as vaginal estrogen.

00:28:01 Sarah Westberg

So we have our non-hormonal vaginal moisturizers and lubricants.

00:28:05 Sarah Westberg

And so these would be things like Replens, where they're designed to be longer lasting.

00:28:11 Sarah Westberg

As A vaginal moisturizer, we have the vaginal estrogen, like we talked about.

00:28:15 Sarah Westberg

We have tablets, creams, the rings, really talking with patients about what would work for them, knowing that Estring is a nice option.

00:28:22 Sarah Westberg

It's only once every three months.

00:28:24 Sarah Westberg

And even if a patient needs help getting started, it could be placed by a provider because sometimes there's so much dryness and atrophy.

00:28:30 Sarah Westberg

be that placement can be difficult.

00:28:33 Sarah Westberg

We also have the oral tablet, which is a selective estrogen receptor modulator, the ospemifene, that has data to help with that vaginal dryness.

00:28:42 Sarah Westberg

And then we have prasterone, which is basically vaginal DHEA, which is then converted into estrogen to treat the symptoms that way.

00:28:50 Sarah Westberg

So lots of options.

00:28:52 Sarah Westberg

These are locally applied to treat a local problem.

00:28:57 Sara Klockars

Veronica, could you comment, please, on the role of ospemifene and prasterone?

00:29:06 Veronica Vernon

Ospemifene is an oral option that's available for the treatment of dyspareunia or painful intercourse that I would use for my patients who had tried vaginal products, didn't get great relief, or that's not an option that they wanted to try and were interested in.

00:29:25 Veronica Vernon

One thing to remember about ospemifene is it is a SIRM, a selective estrogen receptor modulator.

00:29:30 Veronica Vernon

So we do still have to think about things like the potential for the risk of venous thromboembolism with this.

00:29:37 Veronica Vernon

And I did find some benefit with patients with it.

00:29:41 Veronica Vernon

And prasterone is going to be a vaginal product that DHEA that gets converted to estrogen and testosterone for patients that have vulvovaginal atrophy.

00:29:53 Veronica Vernon

And I found some benefit with it.

00:29:56 Veronica Vernon

I will say one of the reasons I didn't always use it for my patients was sometimes due to coverage and having lower cost alternatives available for my patients.

00:30:06 Veronica Vernon

But I think these are good options to explore for patients.

00:30:09 Veronica Vernon

I always put them out as options to try.

00:30:12 Veronica Vernon

There are other good tools in our toolbox that we have.

00:30:16 Steve Small

How do we address sexual dysfunctional libido changes in menopausal patients?

00:30:20 Steve Small

And does testosterone have a role, like we were kind of mentioning before?

00:30:24 Steve Small

Andrea, can you help us sort that out?

00:30:28 Andrea Darby-Stewart

You know, libido and sexual function are complicated issues, and there is not one thing that will fix or improve those.

00:30:38 Andrea Darby-Stewart

And as everybody on the call is aware, mood, sleep, relationships, stressors, all play a role here.

00:30:46 Andrea Darby-Stewart

Management of genitourinary symptoms of menopause, painful sex is certainly going to reduce your libido.

00:30:52 Andrea Darby-Stewart

But we do know that in some women who have symptoms related to low libido, topical testosterone can be helpful.

00:31:00 Andrea Darby-Stewart

That is the only reason that we would prescribe topical or testosterone in Gymo for women in the menopause and perimenopausal space.

00:31:09 Andrea Darby-Stewart

And there are other non-hormonal options, including Addyi, which if an out, for, gosh, quite a while, almost a decade now.

00:31:19 Andrea Darby-Stewart

Most of my patients who have tried this have not found it to be particularly helpful.

00:31:22 Andrea Darby-Stewart

And the most benefit that I've seen with my patients is with appropriately dosed topical testosterone in women who are suffering from low libido.

00:31:35 Sara Klockars

One last question.

00:31:36 Sara Klockars

Veronica, does anything help brain fog?

00:31:41 Veronica Vernon

This is such a common complaint.

00:31:43 Veronica Vernon

And I think, first of all, I want to say, reassure your patients that are reporting this, that this is a very common symptom in the perimenopause and postmenopause phase.

00:31:56 Veronica Vernon

With brain fog, it's multifactorial that there's conflicting evidence.

00:32:01 Veronica Vernon

We've seen trials say menopause hormone therapy makes cognition worse, and then others say it makes it better.

00:32:07 Veronica Vernon

Really, what we know now from the literature is that hormone therapy is neutral on brain fog.

00:32:14 Veronica Vernon

But what makes brain fog worse and cognition worse is vasomotor symptoms.

00:32:20 Veronica Vernon

And so by controlling the vasomotor symptoms, you can help with that brain fog.

00:32:25 Veronica Vernon

This is also an important time to talk about exercise.

00:32:29 Veronica Vernon

Physical activity can help with sleep, making sure that people are choosing the right time of day, that women are not exercising right before they're trying to go to bed, but they have appropriate sleep hygiene habits.

00:32:39 Veronica Vernon

They're looking at their diets.

00:32:41 Veronica Vernon

There is data to show that the Mediterranean diet may have some benefit for helping with the brain fog and with cognition.

00:32:49 Veronica Vernon

But this is a really great time to talk about lifestyle interventions that can be made to help with that brain fog.

00:32:55 Veronica Vernon

So the shorter answer is there isn't a magic pill that can help with the brain fog, but by looking at the symptoms and what might be contributing to that brain fog can help you determine the best steps to take with your patient.

00:33:10 Craig Williams

On this brain fog point that so overdue, the FDA removed the dementia risk from black box warning.

00:33:16 Craig Williams

Again, these are often pretty savvy, educated patients coming to us with questions and, you know, to see a black box warning for dementia on this product, that's been problematic for some time and that really never deserved to be on the black box warning.

00:33:29 Craig Williams

So I kind of put this in the area of cardiovascular risk.

00:33:32 Craig Williams

So it's, yeah, it doesn't help, doesn't hurt, as Veronica said.

00:33:36 Craig Williams

But being reassured that doesn't cause dementia, it's not going to worsen that, can be very reassuring for women who otherwise benefit from this therapy.

00:33:43 Craig Williams

But yeah, unfortunately, it doesn't fix brain fog.

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