JAAPA Podcast Summary

Episode Title: Menopausal Hormone Therapy
Date: December 15, 2025
Guests: Ashley Church, PA; Megan Biaggi, PA; Alana Zhang, PA (OBGYN Department Editor, JAAPA)
Host: JAAPA Podcast Team

Overview

This episode centers on the practical and evidence-based use of menopausal hormone therapy (MHT), focusing on the latest guidelines, evolving research, and the need for better education around menopause care for Physician Assistants (PAs) and other clinicians. Authors Ashley Church and Megan Biaggi, along with OBGYN department editor Alana Zhang, discuss their recently published JAAPA article and offer insights on safe, effective, and individualized approaches to menopause treatment—addressing both the science and the social context surrounding hormone therapy.

Key Discussion Points & Insights

1. Why Focus on Menopausal Hormone Therapy?

• Ashley Church came to this topic due to the prevalence of menopause and the lack of education clinicians receive. She notes the complexity and confusion often encountered by practitioners.

  "There's so much new information and sometimes confusion. Despite my research and practice, I often still rely heavily on the women's health team at my clinic for insights and guidance." (01:38)

• Megan Biaggi points out that recent guideline updates make this a practical necessity for PAs, aiming for their work to be understandable and actionable for all clinicians.

  "The 2022 guidelines from the North American Menopause Society differ significantly from those that I learned in my training. Through this paper, our goal is to make the guidelines approachable and practical…" (01:54)

2. Peer Review & Publishing at JAAPA

• Alana Zhang details the thorough peer review process for JAAPA publications.

  "Almost all papers are going to have revisions. It's very normal and it actually shows that we're really taking it seriously and making sure it has the right information in it." (03:33)

• This process ensures that recommendations are credible, timely, and clinically relevant.

3. Defining Menopause and Perimenopause

• Megan Biaggi gives clear definitions and notes the variability in symptoms:

  "Menopause… [is] the permanent cessation of menstruation confirmed retrospectively after 12 consecutive months of amenorrhea without other cause." (05:54)
  "Perimenopause... can last an average of about four to eight years … about 60 to 80% of women experience something called vasomotor symptoms—these are hot flashes and night sweat..." (05:54)

• Symptoms include vasomotor issues, vaginal dryness, sleep and mood disturbances, cognitive changes, and more.

4. WHI Trial: History, Limitations, and Lessons

• Ashley Church reviews how the Women's Health Initiative initially fueled fears about MHT:

  "The mean age of enrollment of women was 63. This is a decade or more past the onset of menopause and these women had a lot of underlying risk factors..." (08:34)
  "The results overstated some of the risks like breast cancer and blood clots for younger perimenopausal or newly menopausal women." (08:57)

5. Cardiovascular Health & Timing of MHT

• The timing hypothesis matters:

  "[Estrogen] supports endothelial function... so when hormone therapy is started right after menopause, before significant vascular damage or plaque formation has occurred, those effects can really help slow the development of atherosclerosis." — Megan Biaggi (10:26)

• Supporting studies: ELITE trial, KEEPS trial—early initiation (within 10 years or before age 60) appears protective (10:55–11:33).

6. Osteoporosis Prevention

• Estrogen suppresses bone resorption, MHT is FDA-approved for osteoporosis prevention in early menopause.

  "For healthy women who are early in the menopausal transition, MHT is actually the most effective therapy for preventing osteoporosis, and it's actually FDA approved for this indication." —Megan Biaggi (12:34)

• Once discontinued, benefits rapidly fade. Lifestyle measures remain key.

  "Regular weight bearing and resistance exercise, adequate calcium, vitamin D intake, limiting alcohol, avoiding tobacco are all essential..." —Ashley Church (13:13)

7. Practical Prescribing of MHT (2022 NAMS Guidelines)

• Individualize therapy: type, dose, formulation based on age, time since menopause, and patient risk factors.
  • Transdermal estradiol preferred (lower risk of VTE, stroke).
  • For those with a uterus: add progesterone.
  • Genitourinary symptoms only: use local vaginal estrogens.
  • Annual reassessments: Symptoms, risk, cancer screening, comorbidities (14:00–15:42).

  "Transdermal estradiol delivered through a patch... is preferred because it carries a lower risk venous thromboembolism and stroke compared to oral estrogen..." —Ashley Church (14:14)

8. Initiation and Discontinuation Guidance

• Most patients experience symptom relief within 2-4 weeks, but full effects may take 3 months.
• Systemic MHT isn't automatically discontinued after age 65 if risk remains low.
  • No clear evidence favors tapering vs. abrupt cessation—symptoms may return after stopping but typically less severe.

  "...continuing hormone therapy beyond 65 does not pose the same high risk as starting in an older woman." —Megan Biaggi (16:52)

9. Removal of Black Box Warning for Estrogen

• Removal allows for more nuanced, evidence-based conversations—the risk is individualized, not universal.

  "Removing the black box warning is great for evidence based care. For years, that warning overstated the risks and discouraged clinicians and patients..." —Megan Biaggi (18:10)

10. Addressing Allergy Concerns and Non-Hormonal Solutions

• Skin irritation with estradiol patches is rare, patches should be rotated. Other non-oral formulations exist.
• Non-hormonal options:
  • SSRIs/SNRIs (e.g., paroxetine, venlafaxine),
  • Gabapentin,
  • Neurokinin receptor antagonists (e.g., fezolinetant, elinzanetant),
  • Vaginal moisturizers, lubricants for genitourinary symptoms,
  • Lifestyle modifications (20:19–23:42).

  "Paroxetine is actually FDA approved for this indication..." (21:14)
  "Fezolinetant... has been around for a little bit longer. I've had several patients that take it and they really like it... but it's very, very helpful for the vasomotor symptoms." —Alana Zhang (22:11)

Memorable Quotes

• On Empowerment:

  "Menopause care to me is really about empowerment... When we update our understanding, we can offer women safe and effective options grounded in evidence, not in fear." —Ashley Church (24:03)

• On Closing the Evidence-to-Practice Gap:

  "...on average, it takes about 17 years for new evidence to translate into practice change. Let's not wait that long." —Megan Biaggi (24:56)

• On Committing to Evidence-Based Practice:

  "I really encourage everybody to review this article and just refresh your skills on the hormone therapy, be a resource for your patients on misinformation..." —Alana Zhang (25:14)

Timestamps for Key Segments

• 00:06–02:25 — Introductions, why focus on MHT, motivation behind the article
• 03:33–04:49 — Overview of the publication and peer review process
• 05:54–06:56 — Menopause & perimenopause definitions, symptoms
• 08:21–09:32 — Limitations of the WHI trial; modern understanding of risks
• 10:23–11:33 — Cardiovascular risks/benefits; the timing hypothesis and supporting studies
• 12:01–13:13 — Role of MHT in osteoporosis prevention
• 14:00–15:42 — Practical MHT prescribing per NAMS 2022 guidelines
• 15:55–17:58 — Patient counseling: expectations for symptom relief, discontinuation practices
• 18:10–18:50 — Black box warning removal and patient-provider conversations
• 20:19–23:42 — Addressing patch allergy, non-hormonal options, neurokinin antagonists
• 24:03–25:13 — Final thoughts: Empowering women, staying current, encouraging evidence-based practice

Final Thoughts

• Menopausal care is multi-disciplinary and relevant to all healthcare providers, not just those in women's health.
• Evidence supports the safe, individualized use of MHT for symptom relief, bone health, and cardiovascular protection—especially when started early in menopause.
• Providers should stay up-to-date, engage in shared decision-making, and actively address misinformation.
• Non-hormonal options and lifestyle measures remain important for those with contraindications to MHT.
• Empowerment and patient education are central; use current guidelines and evidence to guide every clinical conversation.

For more details, consult the full JAAPA article "Menopausal Hormonal Therapy: Making Sense of the Guidelines" by Ashley Church and Megan Biaggi, and remember to check for updates from the North American Menopause Society.

Note: For CME credit information, visit the AAPA’s CME Learning Central as mentioned at the end of the episode.