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Foreign.
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Welcome to the JAPA Podcast, where we explore how PAs contribute to healthcare and the practice of medicine. Today we are joined by JAPA authors Ashley Church and Megan Biaggi and JAPA OBGYN Department Editor Alana Zhang, and we'll be discussing emerging evidence surrounding menopausal hormonal therapy. Don't forget, listeners can now earn CME by listening to the podcast. To receive your CME credit and access your certificate, you just listen to the podcast and then complete the post test and evaluation in AAPA's learning central@cme.aapa.org so let's dive in about half of the population will experience menopause, and yet many of us did not receive much training on how to care for perimenopausal and menopausal patients. Hormone therapy has become a hot topic recently with several leading news articles and endless social media content. Before we jump into how to make sense of current guidelines, let's get to know our guests. Let's start with Ashley and Megan. Can you share how you met and what inspired you to write the JAPA article entitled Menopausal Hormonal Therapy Making Sense of the Guidelines?
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C
Hi.
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D
Certainly thanks for having us. My name is Ashley Church. I'm a primary care pa. Megan and I met at the University of Nevada, Reno when I was a PA student. I graduated in 2024, now practice in primary care in Grass Valley, California. I wanted to dive into a topic that I felt was extremely prevalent, important, and not well covered in medical curricula. 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. This is a challenging topic, so we wanted to provide a guide for clinicians to feel more comfortable addressing and treating menopause.
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E
Thank you, Ashley. I'm Megan Biaggi and I'm an associate professor at the University of Nevada, Reno program. I'm also a pa and I've had the pleasure of teaching Ashley when she was a student. So when she approached me about writing this piece, I immediately said yes. I've been a PA for about 12 years and despite my experience, I realized I didn't have a very strong grasp of the evolving data surrounding menopausal management. 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, something useful for new grads, experienced clinicians, and even patients who want to better understand their choices. That's awesome.
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B
Now, Alana, let's turn to you. You are our first JAPA department editor to be on the podcast. We would love to learn more about your journey to becoming an editor and can you share more about your role in supporting manuscripts on the road to publication?
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E
Yes.
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A
Thank you for having me on the podcast. My name is Alana Zhang. I am a OB GYN PA and I have been the department editor for the OB GYN department of Java for about a year. I got involved with JAPA and publishing and editing through my work with the association of PAS and OB gyn. It seems like JAPA in the last few years has really made a push to have department editors really be experts in their fields. And so our editor in chief, Rick Dane reached out to APAOG to get some volunteers for editing. And I have an interest in publications and academic writing and I thought that it would be a good fit. I've had a really fun time reading a bunch of different articles that have come across my in basket since then. And our process for editing and publishing these papers is very rigorous. All of our papers are peer reviewed, so when a paper comes in, it's screened by our editor in chief. If he feels that it is something that PAs could benefit from learning about, he'll pass it on to the department editor that will deal with that particular topic. Then I get to take a stab at it. If I feel like it's something that PAs should learn about, then I get to send it out to peer reviewers. We have to have at least two peer reviews for a paper to be published. So after the peers review the paper, they'll give feedback if they think it should be accepted as is or if it should have some revisions. 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. After the recommendations for revisions are given, the authors have a chance to revise and it kind of goes back and forth until we come to an agreement about a paper that we feel is worthy of publishing in japa. So like I said, it's been a really fun process and I'm excited to have seen this new paper that Ashley and Megan had lately. It was really helpful to read even as a OB GYN PA and we're.
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E
Super thankful for the editing team for our paper. We got a lot of insight from you for it.
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D
Yeah, thank you so much. That really warms my heart.
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C
That's awesome. So being a peer reviewer for JATA as well. I know how rigorous this is and I've always learned so much by reading those preprint articles. I think Kim and I, we both do some peer reviewing work and even our podcast is actually reviewed. This article covers a hot topic nowadays that's very popular, so we are very excited. And you guys start with some impressive stats like more than 1 million US women enter menopause each year and it is estimated that women may spend one third of their lives in a menopausal state. These are pretty serious stats if you think about it. So Ashley and Megan, tell me, can you define menopause and perimenopause for us? As a lot of people are talking about it, we hear about it on social media, but we would like to get your expertise and really define these two different terms. And can you also tell us some symptoms that women experience during these periods?
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E
The definition of menopause is the permanent cessation of menstruation confirmed retrospectively after 12 consecutive months of amenorrhea without other cause. So this really means that menopause, it can really only be diagnosed a year after it started. In the United States, the average age of onset is about 51 years old. Perimenopause, on the other hand, is the transition period leading up to a woman's final menstrual period. It's a bit more variable and can last an average of about four to eight years as hormone levels start to fluctuate and menstrual cycles become more irregular. During perimenopause and menopause, about 60 to 80% of women experience something called vasomotor symptoms. These are hot flashes and night sweat. In addition, genitourinary symptoms like vaginal dryness, painful intercourse, and recurrent urinary tract infections can occur. Many women also experience sleep disturbances, mood and cognitive changes, menstrual flow and duration changes, and changes in body fat distribution. And it's estimated that about 2 million women enter perimenopause every year as well.
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D
And I'll add, because these symptoms can vary so widely and can be multifactorial, they're often under recognized. Even when clinicians suspect perimenopause is a major contributor, there may be uncertainty or hesitation around the safetiness, the safety and appropriateness of treatment. That's one reason why we felt it was so important to write this article to help providers feel more confident recognizing these patterns and navigating treatment discussions.
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A
And that's great.
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C
I think now every provider in every specialty need to be educated on that, because definitely I'm in cardiology. I hear about it almost every day. People have questions. And I think that Megan stated that she's in the emergency department, she hears about it, Kim hears about it. So we all are involved. In 2002, the Women's Health Initiative trial raised concerns about menopausal hormone therapy, specifically surrounding the risk of breast cancer and thromboembolic events. Subsequent studies have since led to a refined understanding of these risks and show that MHT is the most effective treatment for managing vasomotor symptoms and genital urinary symptoms of menopause. Even with this expanding body of evidence, hormone therapy remains controversial. As we know, there are so many different forms. I feel like I need a whole course on that to know which ones to use and which ones are FFDA approved or have studies on them. Can you expand a little on the limitations of the WHI trial, please?
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D
The Women's Health Initiative, or whi. It was really a bombshell. It really opened a huge discussion about menopause hormone therapy. Since it was the first randomized controlled trial. There were some definite serious limitations, though. The first being that 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 like cardiovascular disease to start with. The WHI was not designed to study therapy near the onset of menopause, when women are typically ideal candidates for symptomatic relief. And because of that, the results overstated some of the risks like breast cancer and blood clots for younger perimenopausal or newly menopausal women. The study also only tested one formulation and route of therapy. This was oral conjugated equine estrogen with or without medroxyprogesterone acetate. This limits the generalizability of the results to other more commonly used formulations such as transdermal estradiol and micronized progesterone. Follow up analyses and newer research have clarified these results. We now understand that timing, dose and route of administration all play a major role in safety. Starting MHT closer to the onset of menopause and using transdermal or micronized formulations can significantly change the risk profile.
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C
Thank you, Ashley, for that information. This is certainly helpful. In cardiology. We get asked those questions almost all the time. Is it safe? Should I start it? Should I not? Is it protecting? So recent studies have shown a cardiovascular benefit in starting menopausal hormone therapy within a decade of Menopause. And this is important, too. We explain to the patients, if you don't start it early, then the benefits don't outweigh the risk. At that point, it is surprising that estrogen can have a protective effect on the cardiovascular system early in menopause. So what is the pathophysiology behind this? It's kind of difficult to understand, especially if you're not working in that area. And what has the data shown regarding the timing of hormone therapy and slowed atherosclerosis progression? This is of high interest to me, so I can properly guide my patients in cardiology.
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E
It's basically exactly what you just said. So I'll just start with the basic pathophysiology. Once a woman hits menopause, her ovaries are going to stop producing estrogen. In terms of cardiovascular health, estrogen supports endothelial function, promotes coronary vascular dilation, and it helps regulate lipid metabolism. 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. But unfortunately, once the atherosclerosis, like you said, is already established, those benefits become much less pronounced.
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D
Exactly. And this concept is referred to as the timing hypothesis. The idea that the cardiovascular effects of menopause hormone therapy depend largely, largely on when it's initiated relative to the onset of menopause. We also see support for this in studies like the ELITE trial, which found that women who started estradiol within six years of menopause had slower progression of carotid intima media thickness compared to those who started later. Similarly, the KEEPS trial showed neutral to favorable vascular benefits and recently, menopausal women using hormone therapy. Taken together, these data suggest that in the right candidate, starting MHT within 10 years of menopause or before age 60 may reduce atherosclerotic risk.
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B
This is fascinating. And of course, my colleague Martine, the cardiology pa, had a question. Near and dear to her heart. Now, the next one is very near and dear to my heart. As you know, I have family members who develop osteoporosis when they're menopausal. We know that postmenopausal bone health is a leading public health concern. However, our understanding prioritizes treatment of osteoporosis and not prevention. Does menopausal hormonal therapy play a role in preventing osteoporosis?
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E
This one is also near and dear to my heart. I feel that, especially as a woman in my perimenopause period of life. I see older women aging and I see them falling or just getting pathologic fractures, and it's concerning. We want to live long, but we want to live well as well. So estrogen plays a role and it's a very protective role in bone health. It suppresses bone resorption and remodeling during menopause, the bone mass density declines rapidly as your estrogen declines. Estrogen replacement with menopausal hormone therapy has been proven to markedly reduce development of osteoporosis and decrease the risk of fragility fractures by maintaining that bone density for as long as the patient's on it. However, unfortunately, once it's discontinued, those benefits are lost really quickly. 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. That said, hormone therapy isn't recommended solely for bone health in women older than 60. Additionally, once a woman has already developed osteoporosis, alternative medications seem to be more effective at this time. So in the right patient at the right time, MHT can be a powerful tool not just for symptom relief, but also for maintaining bone health and preventing osteoporosis.
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D
While this data for MHT is really impressive for maintaining bone health, lifestyle measures remain foundational for all in regardless of whether they use hormones. Regular weight bearing and resistance exercise, adequate calcium, vitamin D intake, limiting alcohol, avoiding tobacco are all essential strategies for maintaining bone density and overall musculoskeletal health.
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B
Ashley and Megan, you've convinced us there are multiple reasons to provide MHT to eligible patients. Now, as Martine said, there are many forms of MHT available tablets, patches, gels, creams, pellets, vaginal products. What did the 2022 hormone therapy position Statement of the North American Menopause Society, or nams recommend when selecting hormonal therapy? And what are some key considerations every PA should remember when prescribing MHT?
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D
The 2022 NAM statement really emphasized individualization therapy should be tailored on a patient's age, time since menopause, symptom type and personal risk factors. So what does this mean? In general, transdermal estradiol delivered through a patch, gel or spray is preferred because it carries a lower risk venous thromboembolism and stroke compared to oral estrogen. Start with the lowest dose and increase only until adequate symptom relief has been achieved. In my practice, I typically start with a 0.025 milligram per day estradiol patch that's replaced twice weekly because I find it's well tolerated. The patch is quite small so it stays on the skin well and if it starts to peel up they replace it twice weekly anyways. For patients with an intact uterus, always add a progesterogen such as micronized progesterone, 100 milligram capsules at bedtime to protect against endometrial hyperplasia and cancer. Progesterone is often used at bedtime because some women find that it can be helpful with sleep. For women with genitourinary symptoms only, local therapy with vaginal estrogen is a great option. It can also be added if genitourinary symptoms are still bothersome despite systemic therapy. A great option is 0.1 milligrams of estradiol cream. Vaginally, you start with three times per week for about eight weeks and then it can move to one to two times per week for maintenance as needed. It's important to reassess the appropriateness of systemic therapy at least annually. This includes checking blood pressure, bmi, lipids and CPC if indicated, and also updating breast and cervical cancer screenings and reviewing medications and overall risk profile. Finally, remember the contraindications for systemic therapy. This includes history of breast cancer, coronary artery disease, stroke, venous thromboembolism, active liver disease, or unexplained vaginal bleeding.
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B
That was a lot. We're gonna need some spark notes.
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E
That was great.
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B
So when it's time to start a patient on mht, what anticipatory guidance would you provide? And is there a discontinuation syndrome when stopping the hormonal therapy?
- [15:56]
D
When starting mht, I like to set clear expectations. Most patients notice relief from hot flashes within about two to four weeks, but the full effect can take three months. General urinary symptoms like dryness or discomfort often take longer and may, like I said, may require local therapy for optimal improvement versus systemic therapy. For some women with starting systemic therapy, they might experience mild temporary breast tenderness or spotting in the first few months of treatment. This typically results on its own. I will say though, if the bleeding continues, hormone therapy should be stopped and the cause of the bleeding needs to be thoroughly investigated. Because vaginal bleeding after menopause is not normal with transdermal patches, mild skin irritation can occur, so rotating application sites is.
- [16:39]
E
Important and I'll cover the discontinuation portion of your question. Something interesting to notice is or to note is that although the Beers criteria labels systemic estrogen as potentially inappropriate in women over 65 years old. The North American Menopause Society does not recommend routine discontinuation based on age alone. This is supported by longitudinal observational data that suggests that continuing hormone therapy beyond 65 does not pose the same high risk as starting in an older woman. In practice, if a woman older than 65 wishes to continue MHT and she remains at low risk, then it's completely reasonable to continue therapy with periodic attempts to taper or reduce the dose. Keep in mind that any new contraindication like a venous thromboembolism, stroke, a hormone sensitive cancer, or even a significant change in health status or lifestyle should prompt you to reevaluate your patient and discuss discontinuation if appropriate. When it comes to discontinuation of therapy, the evidence shows there's really no clear advantage to tapering versus stopping abruptly. Either approach is completely reasonable. After stopping, about half of women may experience a return of vasomotor symptoms, which are those hot flashes and night sweats, but they're often milder than they were at the beginning. So just like initiation, discontinuation should also be a shared and individualized decision guided by symptom recurrence, patient goals, and overall health status.
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B
So when thinking about talking to our patients about starting hormonal therapy, many patients bring up that there is this black box warning. And as we know from turning on the TV or reading our papers, that warning is gone.
- [18:11]
E
Can you guys talk a little bit about that? In my opinion, I think this is a great move for women. Removing the black box warning is great for evidence based care. For years, that warning overstated the risks and discouraged clinicians and patients from even considering estrogen therapy. Despite very strong data showing that for healthy women under 60 or within 10 years of menopause, those benefits often outweigh the risks. Taking the warning off doesn't mean estrogen is risk free, but it does mean that the FDA now recognizes the nuance and trusts providers a little bit more. It opens the door for more informed conversations, individualized decisions and treatment plans that actually align with what the evidence has shown for a very long time.
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A
I agree with that, Megan. When I am prescribing hormone therapy in clinic, I spend a lot of time educating patients about the risks and the benefits and reviewing these studies that you've referenced in the article in japa, because there is that hesitancy, you know. Oh, I heard it can cause X, Y and Z. And once patients are presented with the evidence, I find that they're able to make a more informed decision. So I agree. I think this is a very timely and important update from this fda.
- [19:25]
C
I totally agree, ladies. And I feel like women always left behind not getting treatment on time because of all these red tape. And it was time that some of these things are being reconsidered. And I have two parts of my question I want to ask Ashley since she mentioned the different forms that are used. I know I have friends who chose not to try to use the patch because they're afraid they would have allergic reactions. They tend to develop allergies to topical medications or even gloves or some tapes, and they are afraid that they would have a reaction and they would choose another route. So I want to know what is your experience with that, how often or have you seen or any woman developing an allergic reaction to the patch? And also, as we know, not every woman will qualify for mhc. What are some non hormonal treatment options that you can suggest to these women?
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D
I'm in primary care, so I don't get as much exposure to MHD as my Women's Health colleagues. But I will say I don't see nearly as many reactions to the estradiol patch as I do to something like the nicotine patch, which causes a lot of skin irritation. I don't know if, Alana, you have anything to add on that front.
- [20:35]
A
I don't see a lot of irritation either with the estradiol patches, but we do usually recommend that they are moved to a different place each time so that we can avoid irritation if possible. There are other options for non oral dosage forms. So for example, there is an injectable form of estrogen. I don't think there's a lot of people that choose that option, but it is an option. And then there are creams and other formulations as well.
- [21:05]
D
To answer the second part of your question, it's good to know the non hormonal options because not everyone will qualify for hormone replacement. It depends on the symptoms that are most bothersome. So for vasomotor symptoms like hot flashes and night sweats, sri's can be helpful. Paroxetine is actually FDA approved for this indication. You could start at the low 7.5 milligram dose. Insurance coverage can be a little tricky sometimes, so I will occasionally start at 10 milligrams. Others, such as venlafaxine or escitalopram, don't have the FDA indication, but can improve vasomotor symptoms and can be helpful if there are concurrent mood disturbances. Gabapentin is another option, particularly for night sweats because it can be sedating and help with sleep disturbances. More recently, two oral neurokinin receptor antagonists have been approached. Approved for treatment of hot flashes. These medications help the body regulate temperature. The names are a little tricky, so I might butcher them, but the generics are besolanitant, which was approved in 2023 and then most recently, actually just earlier this year in 2025, Elizanatin was approved. I don't prescribe these medicines. So Alana, did you have anything to add about these?
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A
Yeah, these medications are a really good option for people who have contraindications to menopausal hormonal therapy. The Feso linitan in particular, because that one has been around for a little bit longer. I've had several patients that take it and they really like it. It is a daily medication. You do have to do some monitoring of liver function because there is a black box warning about hepatotoxicity. But it's very, very helpful for the vasomotor symptoms. I do usually talk with my patients about the fact that it doesn't help with any of the other symptoms of menopause that hormone replacement may help with. So for example, it's not going to help with vaginal dryness. It's not going to help with libido or brain fog or fatigue or some of the other, I guess more vague or difficult to treat. Perhaps symptoms of menopause that may be improved with hormonal therapy. The sequence.
- [23:15]
D
Don't do that.
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A
That last one is new and I haven't actually prescribed it yet. So sorry for butchering the name.
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E
And on that note, some other non hormonal treatment options. So for those genital urinary symptoms that you were mentioning, vaginal moisturizers can be used for the dryness and then lubricants for sexual activity are often first line therapies. And then of course, lifestyle measures always play a key role in lessening symptom burden. So maintaining healthy weight, staying physically active, prioritizing good sleep, that all supports overall wellbeing.
- [23:42]
B
Great.
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C
Such great information. I feel like I did a whole course in this episode and I feel like I should have taken notes actually. So Ashley, Megan and Alana, thank you so much for providing your insights in such a hot topic and not develop enough in school. Before we wrap up, do you have any final thoughts for our listeners?
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D
Menopause care to me is really about empowerment, especially on this journey to learning about this topic. The more I dove into it, the More I realized there was to learn. When we update our understanding, we can offer women safe and effective options grounded in evidence, not in fear. For most healthy symptomatic women under 60 or within 10 years of menopause, hormone therapy can be a very safe and effective treatment. It's about giving women informed choices and improving quality of life.
- [24:29]
E
Absolutely, Ashley. Individualization, shared decision making, they're all at the heart of good menopause care. MHT is really, it's not a panacea, but it is a really valuable tool that we can utilize in the appropriate setting. The right therapy at the right time can really transform a woman's quality of life. It's also essential that we listen to our patients, stay current with the literature and keep an open mind as new data emerges. I was reading a study recently that found that on average it takes about 17 years for new evidence to translate into practice change. Let's not wait that long. Let's be the providers our patients come to first confident that we're offering up to date evidence based care. With over a million women entering menopause each year, this isn't solely a woman's health or primary care issue. Like you stated earlier, it's really something that every healthcare provider, regardless of specialty, should understand and feel equipped to address.
- [25:13]
C
Totally agree.
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A
Yeah, I'll just add, as somebody who works in OB GYN and prescribes this regularly again after reviewing Ashley and Megan's paper, I think we can agree it's actually not very hard, but people are scared of prescribing this medication or these medications and there's a lot of buzzwords out there on social media these days. It's a very hot topic. So 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, how to combat that and like you both mentioned, really to give them evidence based care because it can be life changing for patients.
- [25:58]
C
Very well said Alana. And I am all for evidence based medicine and it's one of our goals of this podcast and highlighting those wonderful articles educating our PA community so we can be more comfortable in providing evidence based care, not what's in and having the trials, having all the data to back up our practice and what we are recommending and I hope that this podcast was able to achieve that goal. I will say thank you to all our listeners for joining and before you go, don't forget that the podcast is associated now with CME and to receive your CME credit and access your certificate. You just listen to the podcast, then complete the post test and evaluation in AAPA's learningcentral@cme.aapa.org until next time.