"The groundwork of all happiness is health." - Leigh Hunt

Underprescribed menopausal drugs: women suffer unnecessarily

September 1, 2023 – An alarming gap plagues menopause In the United States, persistent myths about hormone alternative therapy and deficiencies within the training of recent doctors limit access to look after women. The result’s that countless women struggle with the physical and emotional consequences of this lifestyle change.

These shortcomings have led increasingly more doctors to maneuver from traditional practice to virtual startups that deal with women's health issues and treat patients who come to them desperate and frustrated after years of getting their problems unresolved.

The solution is usually so easy that it almost drives you crazy, specialists say: vaginal creams with low doses of estrogen that may relieve the symptoms of menopause, from vaginal dryness to recurring urinary tract infections.

“This is undoubtedly one of the most useful procedures I have ever offered a patient, and yet it is underused,” said Dr. Ashley Winter, chief physician and urologist at Odela Health, a digital women’s health clinic“Many companies thrive in the menopause space because it is not adequately covered by traditional health care – your gynecologist is usually concerned with reproduction, and when women are finished raising children, they are released from the care of their gynecologist.”

More than 1 million women within the United States undergo menopause every 12 months. According to a 2022 study Opinion poll4One in 10 women report symptoms of menopause which might be so distressing that they affect their work performance no less than weekly.

And yet many ladies don’t receive adequate treatment.

Doctors say the damaging legacy of flawed data is partly guilty. The first results of the government-funded Women's Health Initiative (WHI), published in 2002, showed that hormone alternative therapy led to an increased risk of heart attacks, strokes and breast cancer. But further evaluation showed the opposite: Hormone therapies have helpful effects on cardiovascular and bone health and usually reduce the chance of death in younger ladies or women in early postmenopause.

Hormone replacement therapy (HRT) provides Estrogen, sometimes along with progesterone, is delivered to the body through gels, creams, patches, pills, suppositories or a tool inserted into the uterus. Systemic HRT delivers hormones into the bloodstream, while local HRT – similar to a vaginal estrogen cream – specifically treats the vaginal symptoms of menopause.

Myths concerning the health risks of systemic and topical hormone alternative therapy have long been debunked, and research on topical hormone alternative therapy particularly shows that it poses no risk to Cancer or others chronic illness.

Yet though twenty years have passed since this misinformation began to spread, individuals are still shockingly uninformed about hormone treatments.

The FDA still requires that initial data on estrogen products be accompanied by a black box warning, though this has since been proven to be false.

“In my opinion, that is some of the damaging PR failures in modern medicine,” Winter said. “It has literally killed women. And it has made them unhappy.”

There is a glaring lack of public knowledge about how to deal with menopause, says Dr. Stephanie Faubion, medical director of the North American Menopause Society and director of the Mayo Clinic's Center for Women's Health.

Treating with low-dose estrogen is not a radical approach — in fact, it's the standard treatment for women who have many menopausal symptoms, Faubion said. But the issue has nuances, and some people get lost in the details.

“I don't think there's lots of general knowledge concerning the benefit-risk ratio of hormone therapy,” Faubion said. “New information comes out so continuously that it's hard to maintain track of all of it. The answer is complicated and relies on the dose, the duration of treatment and the formulation you're taking. It's hard for lots of people to know.”

But Winter believes that there is a bigger problem behind this lack of knowledge among the public: There are also gaps in knowledge among doctors, which are due to inadequate training in menopausal issues.

During her six years of residency in urology, she never learned about the role vaginal estrogen plays in urinary problems, Winter said. It was only during a year-long fellowship in sexual dysfunction that she learned about the treatment.

“Despite the problems with urination, incontinence, blood in the urine – training to deal with all these problems – Role of local hormones in the vagina to treat all of these cases was never taught, never discussed,” Winter said. “I never prescribed any of it.”

A 12 months ago, Winter left her job at Kaiser Permanente to start out working at Odela. After years of prescribing overactive bladder medications that had little to no effect, she now uses the knowledge she gained during her fellowship to assist women who’ve battled debilitating symptoms for years, she says.

Urologists will not be the one clinicians who lack the relevant training. Obstetrics and gynecology even have little knowledge of easy methods to treat menopause, said Ghazaleh Moayedi, DO, gynecologist and complicated family planning specialist at Pegasus Health Justice Center in Texas.

The problem is partly systemic, she said. Training programs often refer patients who’re uninsured or covered by public insurance to physician assistants. Patients who’re eligible for Medicaid or Medicare are sometimes either pregnant or over 65, in line with Moayedi, so women who’re transitioning can fall through the cracks.

“That means in a state like Texas, where I work, where it's difficult to qualify for Medicaid, the women we treat who qualify are pregnant,” she said. “And you don't get Medicare until you're 65. So most OB/GYN residents don't graduate with extensive experience in menopause.”

Accordingly Medicaid.gov80% of the national population covered by Medicaid is age 45 and younger.

Even when doctors have the suitable training and prescribe topical hormones, patients don't all the time adhere to the treatment plan, says Andrea Rapkin, MD, professor of obstetrics and gynecology at UCLA's David Geffen School of Medicine.

The failure to follow treatment is one other example of doubts that remain on account of misinformation spread in early studies, Rapkin said.

“I prescribe an estrogen supplement and find that they haven't taken it, even though I've reassured them,” she said. “While I think there is still some concern, I'm glad that there is increasing interest in vaginal hormones.”