Chasing Life

'Welcome to Paging Dr. Gupta. I like to think of this as office hours. You get to pay me a visit, I get to hear what's on your mind, and we dig into the health topics you care the most about. You've been sending in a lot of great questions and comments lately, I really appreciate it. Today we want to tackle a few that feel particularly relevant and newsworthy. You've probably seen the headlines: FDA announcing that it's planning on dropping the black box warning on hormone treatments for women with menopause symptoms. It's referred to as HRT, hormone replacement therapy. Some refer to it as MHT, menopausal hormone therapy. Now, hormone therapy involves taking medications that contain hormones, obviously, oftentimes estrogen and progesterone. Why? To replace those that the body stops making after menopause. When you go through menopase, the body starts making certain hormones. Hormone replacement therapy was designed to replace them. Now, couple things about the black box warning. It is the strongest type of alert that the FDA puts on a drug label. About 400 drugs actually carry this type of warning. And for context, there's about 4,000 FDA approved drugs. So about 10% carry black box warnings. Though hormone therapy has been on the market for decades, what happened in 2003 after the blackbox warning was added was that prescriptions plummeted. Before the black box warning, about one in four women were taking hormone replacement therapy or hormone therapy, and then it plummeted to about one and 25, plummeting more than 70%. Now, what was happening at that time? Well, there was a large government-funded study called the Women's Health Initiative, and some of the early results were announced. In it, they found that women taking hormones after menopause did have higher cancer and cardiovascular risks compared with women who took a placebo. The study participants had an average age of 63. That's important. We're going to come back to that. Point being that many of these women were well past menopause when they started the therapy. Now if you looked at the black box warning carefully, it described increased risks of cardiovascular disease, stroke, breast cancer and dementia. But here's the thing, further analysis of the data found that the risks may not be as significant depending on a couple of things. When a woman actually started the treatment. In fact, if women started within 10 years of menopause, the FDA now says hormone therapy could actually be protective against cardiovascular disease, Alzheimer's, and even bone fractures. So those three things are really important. How old were the women that were actually being studied? When did they actually start the hormone replacement therapy? And also, what formulations of hormone therapy were they using? Was it patches and creams and sprays? Or was it pills? There were different risk profiles for these things. Bottom line, FDA is changing the warning. They're getting rid of the black box. And this is huge news. This is a shift expected to give women more options for treatment and probably generate a flood of new prescriptions. I should say, since this discussion has been going on for close to 25 years, I've had conversations about this with my mother and then with my wife. I think just about every woman in America who is going through perimenopause or menopause has thought about this issue. Now that said, there are still going to be some risks. Women who've had a previous history of cancer, women who have had a previously history of blood clots. You've got to talk to your doctor about this. Just because the black box warning is going away doesn't mean all of a sudden, everybody is going to be eligible for hormone therapy or that everyone should take hormone therapy. Today, let's dive into what all of this might mean for you by tackling some key questions from all of you. So Jennifer is with us today. Who are we hearing from first?

Today's question is from Michelle in Clifton, Virginia. She's 42 years old and is wondering when to start exploring HRT. She wants to know, are there any tests, blood or otherwise, that can determine if HRT is needed?

All right Michelle, great question. I think a lot of women wonder about this. First of all, there is no magic number to when you should consider starting hormone therapy. Okay, there's no magic age or cutoff or anything like that, but there are a few things you should consider. I'm going to tell you what you need to know right after this break.

'All right, so couple things first of all. When it comes to blood tests, there is not a single blood test that can tell you whether you're in menopause or you're not in menopsause. And if you check hormone levels at any specific point, you're just getting a snapshot in time. You need to keep in mind that hormone levels can fluctuate throughout the day. So unless you're monitoring hormone levels regularly, it'd probably be tough to read into that at all. What the FDA-labeled recommendation will be is if you're going to start hormone replacement therapy to do it within 10 years of menopause onset or before 60 years of age. Let me repeat that. You want to start within 10 of menoppause onset or before 60 years of age. By the way, what is menopause? I think a lot of people know this, but a woman is considered in menopause when she goes 12 months without a menstrual cycle, without a period. Menopause often happens in the 40s or 50s, but in case you're curious, the average age in the United States for menopause, age 51.

There's no single right age to begin hormone therapy, but for many women the conversations really should begin in their early 40s when perimenopause is most often going to start.

'That's Dr. Mary Claire Haver, an OB-GYN and certified menopause practitioner based in Texas. I gotta say, she is a sane voice in all of this. I think she is the person that a lot of people turn to when talking about menopause. She's an adjunct associate professor of obstetrics and gynecology at the University of Texas Medical Branch.

The hormonal shifts, remember, begin eight to 10 years before the final menstrual period, and symptoms can appear even when you're still having regular cycles. So if, Michelle, you start noticing changes in your sleep, in your mood, in where your weight is distributed, like new belly fat, in your periods or your energy levels, or especially if you're experiencing hot flushes, anxiety or brain fog, that is the time to start exploring options with a clinician who understands menopause and you don't have to wait until your period stops.

And Michelle, again, as far as your point about blood tests:

There's no single blood test that can diagnose perimenopause or determine whether hormone therapy is actually needed. Our hormone levels fluctuate dramatically from day to day during the perimenopause transition. So a single lab value like FSH, LH, or estradiol may not tell you the full story. We make the diagnosis clinically based on your age, your menstrual pattern, and most importantly, your symptoms. Sometimes baseline labs are important and can help rule out other conditions like a thyroid disorder or maybe an iron deficiency. Or to help guide individualized care, but treatment decisions should never rely on lab values alone.

'I think another point Dr. Haver has made is that HRT, hormone replacement therapy or hormone therapy is not a one-size-fits-all, okay? It's not going to be the same for every single person for sure. Michelle, thank you for your question. I know a lot of the information around this can be confusing, so I hope that clarifies things at least a little bit. I'm going to take a little quick break here, but up next, how long should you be using hormones? And if you can't use hormone therapy, what alternatives are there to reduce menopause symptoms? We'll be right back.

I know that sound, sounds like another question has landed. Jennifer, what do we have next?

Okay, so our next question comes from Mavis. Mavis is calling from Macon, Georgia, and she wants to know how long a person should be on hormones.

All right, Mavis, first of all, again, it's gonna vary from person to person, but let me give you a little bit of context. According to the Mayo Clinic, most people take hormone therapy for five years or less. But there is no set length of time, and it can vary depending on your symptoms, what type of hormone therapy you're taking, and your preferences. Dr. Haver's back with us as well. This is what she had to say:

You can stay on hormone therapy as long as for you, the benefits outweigh the risks and you continue to feel well. And for some women, that's a few years and for others, it's much longer. There is no mandatory age to stop. Our current guidelines no longer recommend automatically ending therapy at 60 or 65. The key is to reassess each year with your clinician and adjust based on your health, your symptoms and your goals. Hormone therapy should be guided by your body, not by the calendar.

I love that. It should be guided by your body, not the calendar. There are big differences in how long menopause symptoms might persist from one woman to the next. Everyone's going to be different. Key takeaway here is if you're on estrogen and you're 60 years old and you are happy and your benefits still outweigh your risks, then you probably don't need to stop. But again, this is a topic you'll want to revisit every year with your doctor. I know we say this all the time talk to your doctor about this. But this is really important and timing of when you start and when you stop really depends on you. Okay, Jennifer. I think we have time for one more question.

Our last one is from Christine, calling in from Chandler, Arizona. She's a uterine cancer survivor going through menopause and has been advised not to use hormone therapy. So she wants to know, is there anything available for people like her to reduce menopausal symptoms?

'All right, Christine, look, first of all, you should know that it's estimated more than 80% of menopausal women have these symptoms, hot flashes, night sweats, what doctors refer to as vasomotor symptoms. Good place to start is to be aware of your triggers, okay? So caffeine might be a trigger, sugar might be trigger, lack of sleep could be a triger. So best you can, trying to avoid things that trigger some of those symptoms. Manage your environment. Try and make it as comfortable as possible for sleeping, keep it cool in your room, open windows. You probably know all this, but I just wanna reiterate it. You know, just even making sure that your covers and your mattress topper and your nightgown are natural fibers, because synthetic fibers trap heat. Maybe you have a memory foam pad on the bed that is trapping heat. Could you get a cooling mattress toper instead? These things are gonna help, because people who are experiencing night sweats, they'll often fall asleep okay, but they'll wake up frequently. Now, as far as meds go, we're talking about non-hormonal meds for menopause. There are broad classes of medications, antidepressants, anticonvulsants, neurokinin antagonists. As your estrogen levels drop, non- hormonal things are not going to replace that, okay, just to be clear. But they can kind of mediate the neurological changes that are happening in your body in response to a lack of estrogen. So antidepressants, known as SSRIs or SNRIs, can be given, typically at a much lower dose, or certainly a lower dose than for depression. They can be effective to treat hot flashes or night sweats, but be mindful they can have their own side effects, like nausea and GI issues, so you gotta find that balance. An anti-seizure medication, anti-convulsant medication known as gabapentin, that would prescribed off-label, that can help with the neurological disruption of estrogen withdrawal that might be causing mood swings or sleep disturbances. Again, I wanna be clear, there can be other side effects from these medications that need to be weighed and carefully balanced. There are two neurokinin antagonist drugs that can address the neural signaling of hot flashes. And the way that they work, as estrogen is decreasing during menopause, nerves in the hypothalamus, which is an almond-sized region deep inside your brain, it serves to regulate your body thermostat, that area becomes hyperactive and produces an overabundance of chemical signals called neurokinins. So new drugs, neurokinin antagonists, can block the doorways on the cells where neurokinines dock, which turns down their ability to stimulate the brain to cause hot flashes. These drugs are not panaceas, and as I mentioned, some of them have to be prescribed off label. But point being, there are non-hormonal options. And Christine, Dr. Haver said that many women who have survived uterine cancer may face the same struggle as you because they're not able to use hormone therapy because of the risk of recurrence. But you can still get some relief, and you can do that perhaps by targeting individual symptoms you might be experiencing.

So lifestyle is important, cooling your environment, regular exercise and mindfulness, or CBT can also help. For vaginal dryness, you are a candidate for local vaginal estrogen, but check with your oncologist if appropriate and definitely invest in lubricants and moisturizers. You don't have to suffer through this. Ask your doctor for a menopause specialist referral experienced with cancer survivors to create a safe and effective plan for you.

'Christine, I hope that helps. You're not alone. Reach out, and thank you for reaching out to us today. All right, that's all the time we have for today's episode. Thank you to everyone who sent in questions, your curiosity, your compassion, your stories, your voice. It's what brings this show to life. So keep the questions coming. If there's something health related you've been wondering about, send it to us and we might answer it next week. Record a voice memo, email it to AskSanjay@CNN.com, or give us a call at 470-396-0832 and leave a message.