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[@PeterAttiaMD] Is It Too Late for Hormone Therapy After Menopause? | Rachel Rubin, M.D.

· 6 min read
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@PeterAttiaMD - "Is It Too Late for Hormone Therapy After Menopause? | Rachel Rubin, M.D."

Link: https://youtu.be/KiZ7KauLOfQ

Short Summary​

This video addresses common concerns about hormone therapy post-menopause, arguing against the "timing hypothesis" and the need to stop therapy after 10 years, emphasizing shared decision-making based on individual needs and risk factors. The speaker suggests that women, even those with a history or risk of breast cancer, should be given all available information to make informed choices about hormone therapy, similar to the approach in men's health with testosterone and prostate cancer.

Key Quotes​

Here are five quotes that represent valuable insights and strong opinions from the transcript:

  1. "We shouldn't really be forcing people to like say you cannot start hormone therapy after 60. So I think this is where shared decision-making really comes into play of what are we treating? What are we trying do you care about your bones? Do you care about your sexual health? Do you care about you know sort of your mental health? And do you want to see if hormone therapy helps with these things?"
  2. "There is no data to suggest stopping it. In fact, stopping it, all of your bone gains go away. They all go away quickly."
  3. "If you are not going to give someone endocrine therapy of any kind and they're done, they have surgery, they're done, there is no reason why they can't take hormone therapy."
  4. "That patriarchal divide happens is we're willing to take those risks and focus on quality of life when it comes to men's health. We castrate women with the mere thought that they may develop an abnormal cell in their body and completely ignore their quality of life and all of those things that go with it."
  5. "I want every woman to be offered the menu, right? I want them to know what they are like like uh just like I want people to know how to exercise and lift weights and eat healthy. Here's the menu. If you choose to smoke and drink and do drugs, that is your choice. But I want you to know that the menu exists."

Detailed Summary​

Okay, here's a detailed summary of the YouTube video transcript, presented in bullet points, covering key topics, arguments, and information:

I. Addressing Concerns About Starting Hormone Therapy Later in Life (Timing Hypothesis)

  • The Question: Is it too late to start hormone therapy at 56 if menopause finished at 49? The questioner buys the argument that hormones are safe.
  • The Timing Hypothesis: The video discusses the "timing hypothesis" or "window idea" in menopause medicine, which suggests there's a limited window of opportunity for safe hormone therapy.
  • Fears Underlying the Hypothesis: The speaker identifies the primary concerns driving the timing hypothesis:
    • Blood clots
    • Cancer
    • Heart disease
  • Questioning the Data: The speaker argues that the data supporting the timing hypothesis, often derived from studies using Prempro (a specific hormone therapy), might not apply to all hormone therapies used today.
  • Challenging Existing Research: Susan Davis from Australia has written a paper questioning the data.
  • Shared Decision-Making: The speaker emphasizes the importance of shared decision-making, considering the individual's needs and goals.
  • What To Treat: Shared decision making, what are we treating? Bones, sexual health, mental health? Do you want to see if hormone therapy can help?
  • Indications for Hormone Therapy: The speaker lists the approved indications for hormone therapy:
    • Vasomotor symptoms (hot flashes, night sweats)
    • Prevention of osteoporosis (speaker views this as a strong argument for hormone therapy)
    • Genital and urinary syndrome of menopause (vaginal estrogen/DHEA is considered safe and helpful even in pre- and perimenopause to prevent UTIs)

II. Addressing Concerns About Duration of Hormone Therapy

  • The Question: Is it necessary to stop hormone therapy after 10 years, even if started during perimenopause?
  • No Data Supporting Stopping: The speaker asserts that there's no data to support the idea of stopping hormone therapy after a specific duration.
  • Bone Loss Reversal: Stopping hormone therapy leads to a quick loss of bone density gains.
  • Potential Harm of Stopping: Taking a woman off hormones could disrupt plaques or cause vasospasms.
  • Reason to Stop: The primary reason to discontinue hormone therapy is active cancer where hormones are a target for treatment.
  • Hormones Not the Cause: Hormones may not be the cause of the cancer.

III. Managing Hormones in Women at Risk of or with a History of Breast Cancer

  • Categories of Women Addressed: The speaker addresses managing hormones in women:
    • At risk of breast cancer due to family history (BRCA patients)
    • Diagnosed with DCIS (Ductal Carcinoma In Situ, which is not cancer but increases the risk)
    • With active breast cancer or a history of treated breast cancer.
  • Importance of Individualized Approach: The speaker emphasizes spending time with patients, understanding their concerns, and reviewing the available data together.
  • Patient Empowerment: Patients should not blindly follow doctor's orders, but instead they need to do their own research and find out what is important to them.
  • Surgical Menopause: When surgical menopause is performed in BRCA patients without cancer, hormone therapy must be given or one problem will be traded for another.
  • DCIS: If a patient with DCIS is done with surgery and not going to do endocrine therapy, then they can take hormone therapy.
  • Emerging Questions in Active Breast Cancer: There is a lot of emerging questioning in this patient population.
  • The Pregnancy Argument: "If you're allowed to get pregnant, are you allowed to take hormone therapy?"
  • The Prostate Cancer Analogy: Compares breast cancer concerns to earlier fears around testosterone and prostate cancer. The current understanding of testosterone and prostate cancer is a saturation model concept. This model can be applied to breast cancer. The speaker asks, "All breast cancer is estrogen receptive, but that doesn't mean estrogen causes cancer."
  • Women Are More Than Breast Tissue: Women are more than breast tissue.
  • The Car Analogy: Patient is the driver of the car, and the doctors are the pit crew. Patients get to decide what doctors are on the pit crew.
  • Women Making Informed Decisions: When women are given information on how their bodies work, they make great decisions.
  • Social Media: Social media can be negative about hormone therapy. There are people out there saying they're anti-HRT, but they use HRT.
  • Offer the Menu: Not every woman needs hormone therapy, but the menu should be offered.

IV. Podcast Advertisement

  • Premium Subscription: The presenter, Peter Attia, provides an advertisement for his podcast.
  • Premium Member Benefits: Premium members get access to back catalog of AMA episodes, longevity focused premium articles, unrivalled show notes for each and every episode, and quarterly podcast summaries.