Hormone Therapy 101 With Dr. Corinne Menn

We’re so lucky to be in this incredibly exciting time for menopause care. We love giving women the care they deserve and the tools they need to thrive in midlife. But, there are still a LOT of questions surrounding Menopausal Hormone Therapy. Like, does it cause breast cancer? (NO!) And, what’s the best dose for me?

Who better to help answer some of these questions than Alloy’s own community manager Rachel Hughes and medical advisor and prescribing physician Dr. Corinne Menn? 

Dr. Menn is a board-certified OB/GYN with over 20 years of experience and certified menopause practitioner with the Menopause Society. She has dedicated her medical practice to focusing on menopause management, the unique health care needs of female cancer survivors, and those at high risk for breast cancer.

Dr. Menn is also an over 20 year survivor of breast cancer and premature menopause, using her personal experience as a patient along with her professional training to help women navigate their own health challenges.

She is a dedicated advocate and volunteer for the Young Survival Coalition, serving on their Council of Advisors for Patient Education and leading their Provider-Survivor Support Group. She also serves on the Breast Cancer Alliance Research Grant Committee and  through her work with YSC and the BCA helps raise awareness on managing  collateral damages of breast cancer treatment and premature menopause.

We’re sharing highlights from their webinar, which has been edited for clarity and brevity below, but we highly recommend you watch the whole thing on our YouTube! As always, please note that this is for educational purposes only and is not meant to be used as personal medical advice.

Rachel Hughes: Thanks so much for being here! Let’s start by talking a little bit about Alloy and what we provide.

Dr. Corinne Menn: Dr. Sharon Malone always says that if you give women good information, they’ll make good decisions for themselves. And that’s what we’re trying to do. We exist because less than 7% of primary care doctors, OB/GYNs, and internists feel competent in giving evidence-based menopause care. They’re simply not trained in it. Alloy isn’t here to replace your gynecologist. We’re here to give access to evidence-based menopause management and access to menopause-trained physicians who know what they’re talking about and are actually following guidelines. We’re leveraging telehealth to provide access to that care. 

And then we’re giving initial consultations, treatment plans, medication delivered to you at home, and continued unlimited messaging and access to your doctor as long as you’re a member of Alloy. 

Rachel Hughes: Thank you. Let’s start with a question from our audience today: “Can we get a consensus on what to call hormone use for menopause? It gets confusing trying to figure out every social media doctor's acronyms. Is it MHT? Is it HRT? What should we say?”

Dr. Corinne Menn: I think that for now, we have to accept that we’re in a transition phase in this new menopause movement. The old school term is HRT. Then there’s this new school term, MHT. The reason is that when we use the word replacement, it signifies that we’re replacing levels of hormones at what you had when you were in your reproductive years. There are times when we do full hormone replacement. For example, if you go through premature menopause under the age of 40, we’ll do it. But, MHT is a more appropriate term for what we do today, when there are different doses and different levels. I think over time, more people will start using MHT, and to be honest, I’d like to just use HT. It’s alphabet soup!

Rachel Hughes: Thank you. So, you brought up dosing. Someone did ask, and this is a specific question to her, but if you would kind of bridge that gap for us about dosing being a critical aspect of hormone therapy. This person's question is, “What is too high an estrogen dose?” This person feels like she needs to go higher. What’s too high, what’s not too high? 

Dr. Corinne Menn: The best dose is the one that treats your symptoms while minimizing side effects. We are able to do that using FDA-approved, well-studied formulations and dosing options, which means you don’t have to stick to the lowest dose. They’re all FDA-approved. 

When is a dose too high? It would be too high if a practitioner was not practicing evidence-based medicine and was giving you very, very high doses that aren’t recommended. But, we have a wide range of formulations. For example, the patch comes in five different dose options. But the best dose is the one that treats your symptoms.

Rachel Hughes: Terrific. Thank you so much for that. Let’s talk about formulation choices. There are various forms available: patches, pills, sprays, gels. Why does the choice matter? How do we navigate the options and make the best decisions for ourselves? 

Dr. Corinne Menn: There's lots of formulations out there. Let’s start with estrogen formulations. First, there’s the pill. The pill is easy to take, it’s something you’re probably familiar with, and you take it once per day. If you have a uterus, you’ll also be prescribed oral progesterone.

Then, there are some transdermal options, which are absorbed through the skin. With these options, if you have a uterus, you’ll also be prescribed oral progesterone. First, we’ll talk about the patch. You adhere it to your abdomen and change it twice per week. Lower doses have a slightly smaller patch and higher ones have a slightly bigger patch. You can exercise with it on, swim with it on, shower with it on, etc. But, some women may be irritated by the patch, or it may not stay on, and if that’s the case for you, there are other options. 

One is Evamist® spray. It’s very, very easy to use–you just spray it on your forearm–and it’s easy to titrate up (as advised by your doctor) if you need a higher dose without having to get a whole new medication. You can use one, two, or three sprays. 

There’s also an Estradiol gel, which comes in little packets, and you just squeeze out the gel and rub it on your inner thigh. People like it because it comes in single-use packages which make it easy to know how much you’re putting on and easy to travel with.

So, there are some scenarios where you’d choose a transdermal form of estrogen over an oral estrogen. The main reason to choose transdermal is if you’re a person who is at increased risk of blood clot. How do you know if you’re at increased risk? First, age. Every year, you have a higher baseline risk of getting a blood clot. And then there are other personal factors. But I want to be clear that if you choose oral estrogen, you are not putting yourself at great risk for a blood clot. It’s just that when we use transdermal estrogen, there is no activation of clotting factors from the liver at all.

There are a lot of questions that come up when it comes to choosing a transdermal estrogen. Like, should I use Evamist® if I have kids or pets? And there’s really no reason not to, unless they’re going to be licking your forearm right after you spray it every single day. There’s also the question of timing. If you exercise or shower in the morning, you shouldn’t use it immediately before doing those things. In that case we would probably recommend spraying it on before bed. But these are really just preferences. And if you’re nervous about it, it’s probably not the right formulation for you, and there are other options. But, in general, when it comes to form factors, the best one is the one that works for you!

There are also some scenarios where you’d choose oral estrogen over transdermal. The main one is cost, as oral estrogen tends to be less expensive.

Rachel Hughes:

I’ve had women ask about combining forms, like, “I use the patch. Can I add a spray of Evamist® if I feel like I need more?”

Dr. Corinne Menn: I don’t usually recommend combining different forms. We would either just change the dose of the form you’re on or switch to a different one.

Rachel Hughes: Fantastic, thank you. Next question: What’s the safest dose of MHT for women with endometriosis or fibroids? And, should these women get annual vaginal ultrasounds if they use MHT? Or not necessary? And, is cramping or bloating a concern, especially with adenomyosis? 

Dr. Corinne Menn: Okay, so, let’s take these as three separate things. People with endometriosis are often dismissed and denied access to many treatments, including hormone therapy, and they should not be. If you still have a uterus, we will prescribe you estrogen and progesterone, and if you do not have a uterus, which you might not if you’ve had surgery for your endometriosis, we will just prescribe estrogen.

It is reasonable to start on a lower dose if you have endometriosis. That’s because if any tiny endometriosis implants were left behind, there is a theoretical risk that estrogen could stimulate them and cause cramping or pain. So, you might want to start a bit lower, but you definitely should not be denied treatment. Another thing we might do is if you have advanced endometriosis, you might have a lot of implants or adhesion scar tissue on your bowel or bladder, and even if you’ve had surgery and don’t have a uterus, some may be left behind. So, we might also recommend you take progesterone because it can counterbalance the estrogen that may stimulate any endometriosis implants.

Now, fibroids. Fibroids are not a contraindication for hormone therapy. It will not make your fibroids grow. Same with adenomyosis. If you have had adenomyosis in the past, we can give you menopausal hormone therapy. You should also understand that in perimenopause, fibroids and adenomyosis sometimes flare. That's because what happens in early perimenopause is that we get a lot of estrogen being produced and our ovaries aren't always ovulating. We don't always get progesterone. So times of perimenopause are actually times, sometimes, of hyper estrogen. There's a lot of estrogen being produced and not a lot of ovulation, or inconsistent ovulation. So women might find that their fibroids have grown a little bit in their forties or they've gotten this new diagnosis of adenomyosis. That's where we can step in and help these women, either with a birth control pill to stop that crazy irregular up and down secretion, or we can start giving them back some progesterone only, and a very low dose of estrogen if these hormonal fluctuations are causing symptoms when they dip. So, none of these are contraindications, but they can help the doctor with nuance and dosing. 

Rachel Hughes: Thank you so much. Can you talk about starting menopausal hormone therapy after age 60? Also, when is the best time to start? And, how long should you stay on it?

Dr. Corinne Menn: So, we shouldn’t really be thinking about 60…you don’t just turn into a pumpkin at age 60! We should be talking about 10 years from your last menstrual period. In terms of getting the most bang for your buck when it comes to long-term preventative health benefits, the earlier you start, the better. So, we say the best time to start is within 10 years of your last period.

As far as how long you should stay on it, that should be a decision between you and your prescribing doctor, which The Menopause Society says in their 2022 position statement. It should be based on how you’re feeling, whether you have any new contraindications to hormone therapy, anything in your history that, now that you’re older, may change things?

But, if you’re doing well, you have the agency to stay on it as long as you like. And there’s data to support that. 

Rachel Hughes: Thank you. There is a lot of confusion about vaginal estrogen, and whether it’s safe to use while taking oral or transdermal estrogen. Dr. Corinne Menn:

YES. This is so important. Vaginal estrogen is safe with birth control pills. It’s safe with systemic hormone therapy. It’s safe whether you are 40, or 50, or 80.

Vaginal estrogen is local. It’s not systemically absorbed. It can be used by people of all ages, and it can be used in people who are otherwise contraindicated from using systemic estrogen. And, it’s great for perimenopausal women who are on birth control. The birth control pill is a wonderful option in perimenopause to help control symptoms and give you birth control. But in a small percentage of patients, it will cause more vaginal dryness because the birth control pill does lower testosterone levels and can cause vaginal dryness. And it is very safe to use a birth control pill and some local vaginal estrogen cream. It can be a real game changer. 

Rachel Hughes: Thank you. This next one is super popular. Can you break down common side effects of MHT and how to manage them? 

Dr. Corinne Menn: Yes. Most of the side effects are similar to side effects of the birth control pill: breast tenderness, bloating, some irregular spotting and bleeding. I’d say up to 80% of women might experience one or some of those symptoms, and they can come from either the estrogen or progesterone you’re on. Most of these side effects go away in the first few weeks to a couple of months. So, if they’re mild and you’re feeling good in terms of symptom relief, you might just want to stick with what you’re doing and see if they resolve themselves. 

If they are very bothersome, we can try to lower your estrogen dose. You can break your pill in half, or your doctor can instruct you on how to cut your patch in half. And then on refills, we’ll just send you the lower dose.

Progesterone also has some of its own side effects. The most common ones are bloating and GI distress. It also is a relaxing hormone, so it may cause you to have reflux. These all tend to go away, but again, if it’s really bothering you, we can try to change your formulation.

Rachel Hughes: Dr. Menn, you are phenomenal and we’re so lucky to have you in the Alloy world. You’re an incredible voice of reason and passion and real scientific information. Thank you so much for being here. 

Dr. Corinne Menn:

Thank you! 

For way more from Rachel and Dr. Menn, watch the whole webinar on our YouTube! To learn about upcoming webinars, follow us on Instagram @myalloy.