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- [00:01]
A
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B
Tell you something about my hormones. It said that that's that menopause kicking in, honey. My doctor told me you gonna add and he's coming, honey, it's coming. She said you can expect to. You can expect hot flashes and vaginal dryness. What? At the same time, Heat next to dry brush.
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C
What the hell?
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B
That was a perfect condition for a brush bar.
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C
Okay, so it's a little raw, but she just, she lays it out so perfectly. That's comedienne Rita Jones on her hot flashes and vaginal dryness at the same time. It's a great little skit. Anyway, that's. You can find that on YouTube. It's. It's cute. And, and again, oh, my goodness. You know, God bless women and all the things they go through. Hence why we do women's health. So in this episode, we're kind of going to piggyback off something that we covered last month on August 15th and on the 18th, which had to do with hormone therapy, menopausal hormone therapy, and how first of all, we tackled the issue on the FDA rev, the black box warning for systemic menopausal hormone therapy. And we said, it's definitely time to go. It's got to be revised. A lot of that data was skewed and not clinically appropriate anymore based on the new medications that are out there. And then we talked about bio similar progesterone as opposed to medroxyprogesterone acetate in a follow up episode that was done in the middle of August 2025. You can go back and listen to that now. Piggybacking off of this. We're sticking here with the menopausal therapy realm. I know it's not ob, but that's okay. People sometimes have been sending me messages saying, hey, you don't even give enough love to gynecology. No worries, I got you. That's what we're doing here. And this is again, true to form, hot off the press because this got published out of the American Heart association and the American Stroke Association. This got published in their journal Stroke. Okay. Now this was on the 21st of August 2025. So just short of about three weeks ago. Okay, three weeks ago in their journal, stroke. And it has to do with what we covered in the middle of last month. Menopausal therapy, not systemic. You got to go back and listen to the episodes, two of them, in the middle of last month when we covered that. But this has to do with local vaginal therapy. And since it's in the journal, stroke, it's in that population, right? So let me set the stage. And if you're thinking what, what is happening, I'm going to tell you. Remember that in some observational studies, systemic estrogen therapy, systemic menopausal therapy has a potential increased risk of stroke in women. Okay? So that's, that's the bad news. The good news is it wasn't a cause of, of of mortality. And the good news is, is that it's local therapy doesn't seem to carry that same risk. With some caveats. And I'm gonna explain the caveat in this episode. So let me read you the title of this and that's where we're going. We're gonna talk about menopausal therapy, but systemic. In other words, vaginal therapy for genital urinary syndrome of menopause in women with stroke. Okay? Now if you're thinking, oh my goodness, can this be any more niche? I mean, menopausal therapy, local in the vagina in women who have had stroke and the tr, though it's not necessarily my patient population, stroke is, is non discriminatory. Okay? Stroke is an equal opportunity offender. And if you think, oh, cardiovascular risk, that's much more of an issue in men, you know, stroke, not really that way. And remember that the number one killer of women is still cardiovascular disease. And stroke is part of the cardiovascular disease bucket. So look at these numbers. This comes directly from go for red. Go4redwomen.org and the American Heart Association. And the American Stroke Association. Let me give you these statistics here is going to be an eye opening thing for you. And even if you're asked, say on the oral boards or a colleague asks you, hey, I've had patient who's had a previous stroke, she seems to be fine, she's recovered, but she's having terrible vaginal dryness. And the over the counter stuff is not, is not working for it. All right? I mean you can do the moisturizers, the lubricants or whatever, the non pharmacological things are not working. Can she use local estrogen so let me give you the answer briefly. We'll show it in the intro. I'm gonna tell you the answer with a caveat. The short answer is it seems so as of August 2025 that low dose vaginal tablets, so I want to be very clear, tablets seem to be absolutely fine. And the reason tablets were singled out is because you can measure the dose, you know exactly what the patient is getting as opposed to a cream, for example. So at least as it goes to low dose vaginal tablets, there does not seem to be an increased risk of stroke recurrence. So whether it's primary stroke or in this case, of course we're talking about women with a stroke. So recurrence, it does not seem to raise that. And so in women who are just miserable, where non pharmacological agents have not seemed to help, it seems that low dose estrogen tablets appropriately place in the vagina. And guys, we're going to have to cover that because NAMS touched on that in 2022. Don't put that, that little T all the way up into the forn. You don't have to do that. The only one that goes way up there is the ring and that's because you don't want it to fall out. But for genital urinary syndrome of menopause, local therapies are in the the last third, the outer third of the vagina. That's what matters. You don't have to stick it all the way up there. Plus that's going to help minimize or the word that NAMS uses is attenuate. I love that it's going to attenuate. In other words, minimize the risk of systemic absorption. So let me read you the title here of this brand new publication out of Strok book that came out 21st of August 2025. And then we'll get out of the intro and I'm just going to tell you quickly, I'm going to tell you what it is. We should be done with this joker in about 25 minutes or so. So then you can continue on and we can all get on with our lives. Quote, recurrent ischemic stroke and vaginal estradiol in women with prior ischemic stroke. A nationwide nested case control study. And that's our study population menopause. Those with a history of ischemic stroke and local vaginal therapy. That's where we're going in this episode. The stats don't lie. We'll give you these stats and then we'll get out of the intro first. One in five women. One in five women between the ages of 55 and 75 will experience a stroke. One in five women, that's eye opening. Stroke is the third leading cause of death for women. And more women die from stroke each year than from breast cancer. Not to minimize the importance of breast cancer, but to highlight the importance of stroke history. And now here's the big catch, guys. As we, as we are in women's health, quote, more women have strokes than men each year and about 57% of all stroke deaths occur in women. End quote. So that's why we have to be symptomatic, symptomatic, sympathetic. Hopefully we're not symptomatic. Good lord. We want to be sympathetic to patients who have had previous stroke because it does carry this morbidity. But if they also get now this thrown in bonus of menopausal vaginal dryness, which is just really a quality of life issue if it doesn't get better with non pharmacological agents. We can now offer some, some insights at least for the low dose vaginal tablet. This doesn't have to do with, with the ring or, or the cream. This specifically looked at low dose vaginal tablets and we're going to talk about this, this study that just came out again at the end of August 2025. This was out of Denmark. All right, so it's a Denmark database query of course of Danish citizens. So that's where we're going to go. And now that we're done with all that fancy part, let's get back just for a little comic relief. Now it's a little but rea Jones, man, she tells it like it is. And then we'll get into the data. We'll be right back.
- [09:24]
B
What the hell is vaginal dry? What's dry coochie?
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C
What is that?
- [09:30]
B
Woman, sit down. She feel like she's sitting on dry corn flakes. Is that what I'm throwing the pea powder come out? Is that what I just dry coochie? I hope that shit don't kick in during sex. Poor guy gonna feel like he's screwing a pencil sharpener.
- [09:50]
C
I'm sorry. I know it's raw and it's a little out there, but. Oh my goodness, the pencil sharpener thing got me. All right, now that we've done all that, let's get out of the intro. We'll be right back. Tired of all the stuff spin in women's health education. Yeah, so are we. This is Dr. Chapa's OBGYN. No Spin podcast.
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D
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A
How did I not know Rack has Adidas?
- [10:57]
C
Cause there's always something new.
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D
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A
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- [11:42]
C
Learn more@WhatsApp.com so you always notice that if it's a big nationwide, you know, cased nest control study, it's always coming from Netherlands, it's coming from Denmark or one of the the European ish locations because they have that national healthcare system. Think about every system through that's government funded or our public access, everybody having epic. So and through one system, that's kind of how these big organizations, these countries can do these nationwide queries. Because man, it's pretty much like EPIC here. You put in the code, spits it out. And so it's phenomenal for data collection. Although as my friends in Canada have told me, the side effect of that is, yeah, you got to wait forever sometimes for some surgical procedures. I just posted about that on our Instagram page where somebody said, oh, you need a knee mri. No problem. Yeah, it's like a year, a year and a half. No offense to my Canadian peeps, eh? So just the way it is. Just call it for what it is. In this new publication from 21 August 2025 in the journal Stroke, which uses a Danish population with Danish researchers. It states, in Denmark, access to healthcare is provided through the fully tax funded Danish National Health Services and is freely available to all Danish citizens, regardless of socioeconomic background. We conducted a nationwide nested case control study based on data from the Danish registries. End quote. All right, so that's what we're talking about. It's not a prospective study, it's a data mining issue because you need a lot of people, a lot of data to put this into one place to do this kind of study. Now this specifically used is only used low dose vaginal Tablets. So let's be clear. This is not using all kind of vaginal estrogen. It's knowing the set amount, that the right amount of medication that you're using. And according to NAMs in their 2022 position statement, this should be applied in the lower third of the vagina, since that's really where most of the discomfort lies. Okay, now the good news from this, and this was also done as a press release from the American Heart Association, American Stroke association that came out on August 21, 2025. You can find out of the AHA news brief quote, hormone replacement therapy using vaginal estrogen tablets. There it is. Not the cream, not the ring. Using vaginal estrogen tablets was not associated with an increased risk of ischemic stroke for postmenopausal women who have already had a stroke, according to the data analysis from the Health Registry in Denmark. So this is nice because it's one of the first studies to look at recurrent stroke in this population specifically with vaginal therapy. So this is all very good news, unlike, unlike the risk with systemic estrogen. And I have to say that for clarification, this has, this has no implication or crossover extrapolation to systemic. Systemic is still. You got to watch that one. But for vaginal therapy, quote, there was no increased risk of a second stroke, which was found low dose, current use of vaginal therapy, end quote. Of course, right now we stick to the, the low dose. Hold on, I think I need to clarify a little bit on systemic estrogen therapy, whether oral or transdermal, and the contraindication for use for menopausal hormone therapy. Because right now NAMS says that the data on stroke, the whole stroke issue, and this is out of the 2022 position statement, it's a little confusing if it's used. If it is initiated for women within 10 years from menopause onset and those who are younger than age 60, quote, the 2015 Cochrane Meta Analysis found no increased risk of stroke in women who used it in that fashion. End quote. So that's good. Okay, so if you use it appropriately, it seems to be okay. However. However, when it's done outside of that range, which we shouldn't do anyway, or when it's conjugated equine estrogen alone, the data is a little bit more gray. All right, now, again, you would think that transdermal estrogen may have less risk of stroke and that makes biological and chemical sense. We don't really have a lot of that data because most people consider a history of stroke just Like a history of MI as traditional contraindications for systemic hormone therapy. Okay. Is right out of the NAMS update conjunction for hormone therapy, either oral or transdermal. Are stroke, MI or VTE all under the bucket, of course, of cardiovascular disease, even prior coronary heart disease, all that's considered a contraindication. All right, but that's for systemic. I just want to put that out there that the data on stroke is a little gray, but as of right now, it is considered a contraindication. Even though if you use it within 10 years of menopause or less than age 60, there was no significant risk in developing a stroke. But once you have a stroke, then that's considered a contraindication. So that makes sense. So somebody asks, hey, I'm otherwise healthy, I want to start systemic therapy. No problem, as long as you start it. As we talked about in our previous episode, within 10 years of menopause start, and within the age of 60, no later than 60, you should be okay. There's no increased risk of stroke. But in those who have had a stroke, systemic therapy is considered a contraindication. Just wanted to clarify. The short answer is, is that vaginal estrogen therapy, especially as used in this formulation, did not increase the rate of recurrent stroke. And that is very, very good news. Okay. So, you know, when I saw this come out, and of course there's been some things that kind of delayed us and distracted us since this publication first came out, I thought, well, people already know that. You know, we'll just kind of let that go. You know, my producer put it on the list. I'm like, I don't know, it's kind of boring. But sure enough, I mean, somebody asked about vaginal therapy a few days ago. I'm like, you know, the study just came out. I guess we'll put that back on the list because this really is a big deal. Stroke does happen to women, and vaginal dryness, should that be an issue at least? The interpretation of this evidence is that as far as we know for right now, limited to, again, to low dose vaginal tablets, the risk was not any greater. So that's good news. There are some limitations here. Again, more work is needed to see if other formulations would be the same, which you would think would be the same as long as it sticks to, again, the low dose formulation. But we need more data specifically on other kinds of formulations to make sure that it's okay. Although, again, as we just stated, it would seem that that would not be any, any real different. So thankfully from this Danish cohort, yes, low dose V estrogen therapy in women with a stroke seems to be okay. And this is a wonderful, wonderful publication and reassurance for patients who suffer with this. Let me leave you with a quick quote from an epidemiologist who evaluated this study. This is out of the Aha. The stroke commentary, the news brief, and then we're going to call it a wrap. Okay, this is nice. Again, from an epidemiological standpoint.
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A
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C
Quote as an epidemiologist, I see your study as a valuable contribution because it focuses on a population often excluded from hormone therapy research. Midlife women with a prior stroke. And it examines an increasingly used route of administration, which is vaginal tablets. They go on to say, quote, while the study did not find a statistically significant association with stroke recurrence, the findings should be interpreted with caution. Real world data can't account for all clinical and behavioral factors and prescription fill records don't confirm whether the medication was actually used. Still, here's the good news. Still, studies like this allow us to explore important questions that are often not feasible to address and in clinical trials, end quote. So I love that it's put in it, that that's putting it all in fair balance in front of you going, hey, this was a database query. We think they took it. They were prescribed it. We didn't see them take it. And we got to make sure that patients don't put three tablets up there in the vagina when they just should be putting one. So there's all of these, these caveats and that, I mean obviously it's like, duh, of course, because this is not, you know, monitor therapy, because that'd be weird. Let me watch you put your tablet in your vajayjay. We're not doing that. So there are these limitations, but nonetheless, it makes the point that I've made on several other episodes in the past that vaginal therapy is okay even with a previous history. If you've got a BRCA mutation, your patient has a strong family history of breast cancer. NAMS says there is no evidence that even in those with historic or genetic risk factors for breast cancer that local estrogen therapy is going to increase that risk. It's just not there. So even with BRCA mutation, it's not there. It's okay. Even patients with breast cancer are not a traditional straight up contraindication for vaginal estrogen. Estrogen therapy, they can use it as long as they're not on aromatase inhibitor. And the oncologist is part of the discussion. All I'm trying to make here, guys, I got all worked up there. Did you see that? Jeez, Decrease the caffeine. I don't. Oh, speaking of caffeine, can I give. Can I give you a little. Here's a little heads up that I have not fully signed yet. But, but it's, it's, it's on, it's on our desk. All right, so I was approached by a, A, a commercial sponsor that says, hey, your love of coffee is legendary. For which I said, yes, it is. And so, and, and I use this product. This is why they reached out. We have a new commercial sponsor that haven't signed yet, but it may be coming that said, look, publish data. I'm like, oh, I'm listening. And you love coffee. Yeah, I'm listening. We would love to partner with you to give your listeners listen to this. Guys, it'd be 20 discount if you put in our promo code. Again, I haven't signed yet, and I'm not telling you what company that is, but I looked up. I mean, they actually got pub. They got clinical evidence out of the journal Nutrition that their formulation of this instant coffee mixture, which is caffeine, natural caffeine, as well as some other components that are not only neurotropics, but also help boost metabolism. And I'm like, hey, you know, that's why I use it. I just use it. I thought it tastes good. Somebody gave me one as a sample, and it. I like it. But they reached out that they'd be wanting to be a corporate sponsor and we would have our own promo code. So that may be coming, and I'll give you more details on that. But anyway, part of the perks of listening to our show is you would get 20 off of that order. But I haven't agreed to that just yet. But it may be coming. Why am I saying all this? Oh, Oh, I got all worked up. Yeah. Anyway, probably the three cups of coffee I've had just this morning. Podcast family. I think we've done what we're supposed to do. We've covered a new study from the journal Stroke, recurrent ischemic stroke, and vaginal estradiol in women with prior ischemic stroke. A nationwide nested case control study. Podcast family, we're thankful for you. We're thankful that we are an international community. We love you guys. Now that we've done all that, Michael, let's hit it. Come on. Take it home. Podcast family, we're thankful for all of the support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode. Sam.