Summary
In this insightful interview, Dr. Amy Louis Bayliss, menopause specialist and advocate for women’s healthy aging, explains menopause hormone therapy—who it helps, how it works, and when it’s recommended. She discusses the pros and cons of pills versus patches, how treatment is monitored, and why personalized care matters. Dr. Bayliss also shares her decade-by-decade women’s health plan, emphasizing prevention of heart disease, osteoporosis, and dementia, and offers practical advice on navigating menopause treatment in Canada.
To answer some of our burning questions on menopause, perimenopause, post menopause we’re speaking with Dr. Amy Louis Bayliss, a tireless advocate for women’s healthy aging. Dr. Louis Bayliss spent 20 years as an emergency medicine specialist with two additional years of training as a menopause specialist.
Today we’re going to dive into menopause hormone therapy or MHT and we’re also very excited to talk about Dr. Amy’s decade by decade plan for women to help prevent post-menopausal illness and increase women’s healthspan.
Transcript
Leslie Andrachuk: Let’s talk about menopause hormone therapy. It’s an evolving space. Tell us who MHT would be prescribed to today and why?
Dr. Amy Louis Bayliss: There are two parts to an assessment around whether or not an individual is a candidate for hormone therapy. The first piece is, do I think menopause hormone therapy will be helpful for you? And I think this is important to understand because I have a lot of women that I see who maybe have a misunderstanding over how hormone therapy may be able to support them. So menopause hormone therapy has four approvals for its use in Canada and then one approval is throughout the world, but not necessarily in Canada.
So the first is for the management and treatment of vasomotor symptoms, which is hot flashes and night sweats. This is the area that hormone therapy has been studied the most. When we use hormone therapy to address hot flashes and night sweats, we are expecting or aiming for about an 80 to 85 per cent reduction in symptoms. We have a goal or target that we’re working towards and sort of setting expectations that we may not get 100 per cent improvement, but we’re trying to find the right dose that will get you to about an 80 to 85 per cent improvement.
The second area in which hormone therapy has been approved is for the treatment of vaginal dryness. We know that local vaginal estrogen can be very helpful for the genital urinary syndrome of menopause, which are the genital changes that lead to pain with intercourse or urinary frequency, urinary tract infections, dryness or itchiness of the vagina.
Menopause hormone therapy has also been approved, but in the form of replacement therapy for women who go through menopause before the age of 40. We call this a premature ovarian insufficiency, and these women actually require a higher dose of hormone therapy than we would normally give just to manage symptoms because we’re trying to replace their estrogen until they get to the average age of menopause, which in Canada is about 51.
We would also consider this for women who go through menopause between the ages of 40 to 45, which is called early menopause for that same benefit of trying to narrow the window in which a woman has low estrogen compared to her peers that may go through menopause at the age of 51.
Not approved in Canada but approved throughout the world is the use of estrogen therapy for the prevention of osteoporosis. Now this is in our osteoporosis guidelines, but menopause hormone therapy would be used off label for the prevention of osteoporosis. For the right candidate, if a woman has risk factors or we think she may be at increased risk of osteoporosis, then we may do a bone scan around the decision tree and maybe if the bone mass comes back on the lower end we would use hormone therapy to try and prevent further bone loss for the development of osteoporosis.
And then there are two other areas that I’ll talk to women about in which hormone therapy, likely will help, but may not help. The first is for mood. We know that anxiety and low mood can be commonly impacted by loss of estrogen on the brain. And women who may be predisposed to having this are women that may have experienced postpartum depression or anxiety.
This would be another phase of your life in which your brain saw low estrogen. And so this would be something that might clue us in that hormone therapy would help with mood. Umm, if you struggled with PMS symptoms or premenstrual dysphoria – premenstrual mood symptoms – then that’s also a little bit of a clue that you may be someone who’s sensitive and may improve with hormone therapy in terms of mood. But when it comes to women that I see who had long standing histories of depression or long standing history of anxiety, they may have some benefit from hormone therapy, but it’s not going to correct for a mood disorder, right?
The last I would say is body aches and joint pains. We do know that loss of estrogen can cause something called MSK or the musculoskeletal syndrome of menopause. However, the use of hormone therapy to manage this has not been well studied. So anecdotally, I may try some low dose estrogen to see whether or not it may cause improvement of symptoms in the context of also having another Health Canada approved indication. We may try and use hormone therapy just to see whether or not it would help with the body aches and joint pains.
An areas I get asked about hormone therapy often is hormone therapy for weight loss. Hormone therapy is not a weight loss medication, so I think that’s important to understand. And if you are having terrible sleep, if you are having debilitating hot flashes, your ability to manage lifestyle measures, to exercise, to be able to focus on nutrition is limited.
We know if you’re not sleeping while you’re very hungry, you eat more next day – up to actually 500 calories a day but in and of itself, hormone therapy is not a weight loss medication. So, we may optimize how you feel to be able to induce lifestyle measures or optimize your lifestyle measures, but it will not change your body composition. The second is around prevention of dementia and prevention of heart disease. We do not have any compelling research that would suggest the classic hormone therapy that we use, which is a combination of estrogen and progesterone, in women with uteruses directly impacts our risk of dementia or our risk our risk for heart disease.
They do help with some modification of the risk factors that lead to heart disease in terms of there may be a benefit to cholesterol, there may be a benefit to prevention of diabetes. However, the traditional ways of managing those two areas, managing diabetes, managing cholesterol traditionally have better outcomes than using hormone therapy for that management.
So that’s why we would use hormone therapy. And I do think that’s important because I see many women who feel like they’re missing out, but they’re actually not necessarily experiencing symptoms where I think hormone therapy may be helpful. And then the second is whether or not on an individual basis, you would be a good candidate in terms of your personal risk, your age, your family history or whether we would consider using something else.
For example, if you have a personal history of hormone sensitive breast cancer, we would not want to use hormone therapy. If you have established cardiovascular disease, this would become a nuanced conversation. If you have active liver disease or your body is at predisposed to forming clots, we might not want to use this. If you are over 10 years since your last period, so it’s been over 10 years since you’ve transitioned into menopause, the benefits of hormone therapy do start to go down, and the risks associated with hormone therapy may start to go up.
We do know that research shows that over the age of 60 does change the risk profile. So once again there’s kind of two pieces. Why are we using hormone therapy and are you a great candidate or someone who I think will do well or is there an alternative option that I think might be worth trying.
LA: First, thank you so much. That was an incredibly thorough explanation. I’ve actually learned quite a bit. My next question is around the actual product itself, patches versus pills. I’ve been reading that they that they work differently on the body and that there are times when you should take pills versus a patch. Could you explain a little bit more about that?
Dr. Amy: This is where personalized healthcare comes in because this is a nuanced decision. There are actually benefits to taking a pill and there are benefits to using the transdermal patch. So once again, trying to choose or decide around your personal choice is important. When you take oral estrogen, it gets absorbed by the gut and then it’s metabolized by the liver. So it’s metabolism by the liver where the risks of taking oral estrogen come from.
In terms of the benefits of taking oral estrogen, because it does directly impact the liver, it does actually have an impact on our cholesterol, which does tend to go up during the menopause transition because it impacts the cholesterol receptors on the liver that help clear bad cholesterol. So, it will have an impact on our cholesterol. It is not as beneficial as taking a statin. This has been compared head-to-head, but it does have a benefit.
And when we look at all the trials that have looked at really the impact of estrogen on cholesterol, on cardiovascular risk, on prevention of diabetes, it really has been around oral estrogen. The best studied in terms of long-term benefit has really been around oral Premarin, which is an oral estrogen and that’s what was studied in the Women’s Health Initiative.
The downside of taking an oral medication undergoing first pass by the liver is that it does slightly increase your risk for developing gallstones. And because the liver is where we synthesize clotting factors, it does have an impact on your ability to form a clot or the development of clot. We do think that the clotting risk that comes from taking an estrogen product when it comes to hormone therapy is increased with the oral estrogen versus the transdermal.
If you had a history of maybe a clot in your leg previously, women who maybe have a migraine history with aura want to avoid oral estrogens. If you have maybe increased risk of cardiovascular disease meaning you’re getting a little bit older, and we really want to try and avoid anything that would increase clot of the blood vessels then maybe using an oral estrogen is not the right approach
But if you’re younger, maybe in your 40s, using a transdermal like gel or a patch is not something that you want to take on. It’s easier to take a pill. It actually may be a better choice for you in terms of some benefit to the cholesterol and ease of use to use an oral estrogen. With the transdermal, it’s not going through the liver, it’s absorbed through the skin. Then you do mitigate that risk for gallstones and we do believe it mitigates the risk of a clot to the leg as well.
And the other one is oral estrogen which may decrease libido. And we don’t see that with transdermal estrogen. I don’t see it too often, but just a consideration once again around personal choice and maybe your goals of care. And so that’s kind of the decision-making tree.
Most of the women that I speak to that are over the age of 55, tend to, at least at some point, transition to transdermal. Even if you’re on oral estrogen, we would transition and that’s just as you get older, as your risk of heart disease goes up. We just want to make sure we’re mitigating that risk of clot.
LA: Very interesting. Once you’re on the medication, how is it managed? Do women get their blood tested regularly for hormone levels or how do you assess whether or not the therapy is working?
Dr. Amy: It’s about symptom management, especially when we’re talking about menopause, hormone therapy. These are the first 3 indications that I talked about, which were using it for hot flashes and night sweats. If we’re using hormone therapy for mood, if we’re using it to see if maybe if it has an impact on joint pain, although I will not push estrogen for that. We’re really looking for that 80 to 85 per cent benefit that I mentioned around the vasomotor symptoms.
I will try and match the lowest dose that gives that benefit when it comes to what the appropriate dosing should be. There are side effects to your estrogen dosing being too high. It can cause you to feel pregnant, it can cause breast tenderness, it can induce migraine, it can cause vaginal bleeding. So, we want to kind of use the dose that you don’t struggle with the side effects of too much estrogen but are able to manage the reason why we use the hormone therapy in the first place.
I don’t tend to do blood work around effectiveness unless there’s a concern about absorption. If someone was using a patch or a gel and they weren’t getting better and I was pushing the dose and their hot flashes were not getting better at all, then I would start to ask if you are even absorbing the medication? And so, we might do blood levels then.
When it comes to prevention of osteoporosis, basically all of the doses that we use for estrogen have been shown to preserve bone mass or be helpful for preventing osteoporosis. We wouldn’t do bloodwork for that as well.
LA: You talk about prevention of osteoporosis, is it ever used off label for someone who has osteoporosis?
Dr. Amy: It is used off label, for someone who has osteoporosis, but it’s not what I would recommend. If someone is refusing to use a bisphosphonate or refusing to use one of the anabolic agents or an osteoporosis medication, maybe they don’t tolerate it, then we can use estrogen. But it hasn’t been as well studied, in terms of treatment of osteoporosis and it doesn’t have the same robust evidence that the other osteoporosis medications do so the most robust evidence for this is really around prevention of osteoporosis as opposed to treatment.
LA: Now what I would love to hear about the decade-by-decade action plan that you’ve come up with and that you’ll be talking about at The Menopause Show in Toronto on October 18th. I would love to hear about that and get a sneak peek.
Dr. Amy: I’m happy to give you a sneak peek. We just spent a lot of time talking about hormone therapy. And to your point, I mean, there’s a lot of buzz happening around the perimenopause and menopause space right now, which is very positive and can definitely be overwhelming. But it’s really focused on access and the importance of education around hormone therapy.
But when we look at women as they’re going through the perimenopause and menopause transition, this is actually a period in which we see a pivot in terms of our risk of chronic disease. So, you know, the diseases that impact women the most as we get older are osteoporosis, which we just discussed, heart disease, the number one cause of death for women, dementia, and then cancer. And I find that there’s a missed conversation happening around having a prevention plan in terms of mitigating that risk because it’s being overlooked by accessing hormone therapy; the importance of both can be true. It’s just important to understand having a comprehensive health approach.
So, when I talk about the decade-by-decade plan, it’s really understanding when we start to see your risk of disease go up and then what role you can play in terms of trying to mitigate that risk. Because we do know that we as individuals have the power to change a lot of the risk for both heart disease and cancer deaths through screening and even we know we have about a 45 per cent modifiable risk when it even comes to dementia.
In your 30s, it’s really about paying attention to anything related to pregnancy complications because we do know that female risk specific risk factors are often overlooked when we try to risk stratify or try and calculate what your risk of heart disease is.
If you have a history of gestational diabetes or gestational hypertension, these actually have a significant impact on your risk of heart disease later on. We think that when this happens during pregnancy, it’s almost like a stress test. It’s like when your body is maximally stressed, does it show a little bit of insulin resistance or trouble with glucose regulation? Impact on the blood vessels during pregnancy can be a sign that you are at increased risk of developing diabetes or high blood pressure later on and shouldn’t be ignored.
You should have your cholesterol closely looked at and your blood pressure watched as you get older. If you have a history of polycystic ovarian syndrome, we do know that that increases your risk of developing type 2 diabetes, so something to pay attention to in your 30s. The third would be anyone who loses their periods in their 30s should be worked up for premature menopause which I spoke about earlier because we do know that loss of estrogen for more than 10 years from the average age does have a significant impact on our risk of heart disease, dementia and osteoporosis.
Just in the last three weeks I’ve seen two women that were missed with this diagnosis, and this has very serious consequences. You should pay close attention to that. When it comes to your 40s, this is when we start to see the perimenopause stage happen.
Most women going through perimenopause will have a period of higher estrogen before their estrogen goes down and this presents as really heavy periods. A lot of women experience heavy periods. You may develop fibroids. This often leads to significant anemia, and low iron, making you feel terrible. I’ve had women bleeding on the chairs when I’m seeing them.
And it’s been almost normalized – women think…a period’s not that bad, but I’m changing and super plus tampon every two hours. So, there’s a lot of, there’s a lot of heavy bleeding happening, a lot of women feeling terrible and tired. And it’s not being managed. And this is usually a sign that you’re sort of starting to enter perimenopause.
Cancer screening really should start in the 40s with breast cancer. You should be having paps in your 30s. That breast cancer screening should start in your 40s and you should understand what your breast density is. Women who have higher breast density so category C or D are at increased risk for missed cancer diagnosis on mammogram and should advocate for breast ultrasound because it will pick up more cancers. A mammogram plus an ultrasound together.
LA: How do you determine your breast density?
Dr. Amy: It can only be determined by mammogram. As of two years ago, the Ontario breast cancer screening program mandated that you were told your breast density. So, you’ll get that letter but before two years ago it wasn’t mandatory. So, you may or may not have gotten it, but you should know if you’ve had a mammogram in the last couple of years.
And the other thing we really start to see in the 40s is the cholesterol starting to creep up. So having an annual cholesterol check, especially if you have risk factors. Family history of high cholesterol is something to pay attention to. I’m not going to get into lifestyle measures because they are kind of the same as we go on.
When it comes to your 50s, this is when most women are starting to go through the menopause transition. So, if you are starting to skip periods, if you’re starting to develop vasomotor symptoms, so hot flashes and night sweats, if you do not feel like yourself, if you’re developing mood symptoms, once again, this is in keeping with the menopause transition. We do not need to do blood work to confirm this. There are treatment options available.
Colon cancer screening should start in your 50s. And this is when we really start to see a change in cholesterol. So definitely cholesterol annually. And then the blood pressure starts to creep up.
I usually recommend a conversation about whether or not you are at risk for osteoporosis. Right now, the current guidelines suggest that this is discussed at 65, and because our guidelines are looking for osteoporosis, they’re not around prevention of osteoporosis.
LA: Oh, I see.
Dr. Amy: I think that we should be having the conversation because if you’re 65 and, and you have osteoporosis, you’ve missed that window to be able to use estrogen, to be able to use strength training, to be able to use nutrition to really support preventing bone loss, right?
And then we talk a lot about in your 50s that window of modifiable risk for dementia prevention. Hearing loss in your 50s actually has a 7 per cent risk for developing dementia. And I’ve actually picked up on quite a bit of hearing loss in my clinic – thinking about 10 per cent. So having your hearing checked, especially if there are any concerns, is something that I would consider.
Also present in your 50s are elevated cholesterol, you know, increased alcohol intake, sedentary lifestyle, smoking, high blood pressure and diabetes and so once again, optimizing our risk factors to try and prevent disease can have a significant impact in 10/20 years later.
And then once you’re in your 60s, if you weren’t able to have that screening done in your 50s for osteoporosis, this is when osteoporosis really does start to present itself. Understanding whether or not you have osteoporosis, advocating for getting a bone scan is an important piece to this. All the cancer screenings should be continuing. And then this is really when we start to see hypertension. Almost 70% of women over the age of 70 have elevated blood pressure.
There are interventions we can use and lifestyle measurements. We know that nutrition can make a big difference, but because you don’t feel high blood pressure, keeping a close eye on it is really important.
LA: What kind of MD’s should women trust for their menopause care?
Dr. Amy: Change is coming. So just last week, Ontario Health released new quality standards around menopause for primary care physicians. There are six expectations that family physicians in Ontario need to adhere to and will actually be measured and tested over the next five years. And one of these quality standards is that your doctor proactively brings up the menopause transition and uses it as an educational opportunity to let you know about what to expect and also educate you around risk of disease.
I do think these quality standards are a massive move in terms of enforcing how important this is and prioritizing education around menopause for family doctors so that these quality standards can be met.
It’s going to take time for physicians to be able to feel comfortable with this, but it’s coming. In the meantime, probably the best way to understand is to go to the Menopause Society site. This is the United States organization. It used to be called the North American Menopause Society, but they offer a healthcare provider exam twice a year that’s challenging, that you would need to study for and be well versed in menopause care to pass and receive the qualification, called the MSCP designation. And on their website, you can see all the Canadian physicians that have obtained that MSCP designation. You can search by where you live and would be able to see who in your area may have this extra training.
LA: Good to know. What are the top three or five questions that women should be asking proactively of their healthcare provider about their perimenopause or menopause transition?
Dr. Amy: If I was going to bring up any questions I really think it should be around the disease prevention piece. I do think that menopause is an opportunity to really get serious about your health and take some time to become health literate. What should I have on my radar for the next 10/20 years?
There are a lot of women who are not bothered by the menopause and perimenopause transition. So, if you are not having hot flashes, you don’t have to go on hormone therapy, you’re not missing out. Alternatively, if you don’t tolerate hormone therapy, I also think advocating for what else is available is an important question.
I would say it really depends on how you feel. But I do think if you are symptomatic, book your doctor’s appointment to only address your menopausal symptoms. It’s important enough that it’s not part of a list of things you would like to address. You really want your appointment to be only about this. I think being able to articulate specifically what you were experiencing and how it is impacting you will be very helpful. If you just say you’re feeling hot, it doesn’t go as far as saying I am having 20 drenching hot flashes a day and I need to bring a change of clothes to work to even be able to function.
And then the other piece I would say is as you’re leaving to ask when you should be following up. Because I do think it’s really important that there’s a check in, you know, around six weeks after initiating any medication because no physician’s going to get it perfect out the gate and there’s so many options in terms of alternating dose delivery of the medication that having checkpoints that, if it’s not working, if you’re having symptoms, if you’re actually not tolerating the medication, there’s a booked appointment in place to be able to discuss how you’re doing
LA: Doctor Amy, Amazing tips, fantastic information. I can’t thank you enough for your time today.
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