The Influence of Estrogen Depletion on Women's Health

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of estrogen in the body, the important role estrogen (or lack thereof) may play in rehab outcomes, assessing menopause in the clinic, and hormone replacement therapy.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.

CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. And y'all, the pelvic division has been just really busy over the last couple of weeks, couple of months, heck, the entire year. But if you did not see, we actually just sold out our first online cohort for 2024. And so that is sold out. So our next cohort for our online level one is March 5th. Our brand new inaugural cohort for level two, if you've taken level one, is April 30th. And in 2024, I am going to be in Raleigh, North Carolina with Rachel Moore, January 13th, 14th. And Alexis is going to be teaching in Hendersonville, 27th, 28th of January. And then we're heading over to Bellingham, Washington, February 3rd and 4th. Those are the first three courses of 2024 if you guys are interested in coming to our live course and doing some of our skills check for cert. ESTROGEN & REHAB Okay, so I kind of want to talk about estrogen and specifically estrogen in later life and lack of estrogen and how it influences rehab. So this has been something that I've been really kind of geeking out about over the last little while around, you know, not just as pelvic therapists, but as anybody working with a person going through menopause, if you are working with anybody over the age of 50, a female over the age of 50, you are interacting with a person who is going through estrogen depletion in their body. And As I've learned more about the influence of estrogen on our bodies, the more I am recognizing even outside or maybe even especially outside of the context of pelvic health when I'm seeing people who are postmenopausal, but in my orthopedic rehab, how much it is influencing our outcomes. and just a person, a person who is a female in an aging body, what the lack of estrogen may do for the way that we experience aging. And then I kind of want to cap this podcast off talking a bit about some of the myths and misconceptions around estrogen replacement therapy. or menopause replacement therapy. And we'll talk a little bit about the change in the labeling of these types of treatments and where some of the thoughts around risk for things like sex-related cancers has come up. So to start this off, I want to start with a story. So I was working with a woman who was coming in. She was in her early 60s and dealing with shoulder pain. She had a history about 10 years ago of frozen shoulder. So when it comes to adhesive capsulitis, we know that being a female and being kind of in middle age is a risk factor. And I never really thought about that risk factor being linked to estrogen status or like the beginning of perimenopause. Still wasn't really thinking about it. But she said, you know, that was a really long journey when her shoulder froze. And but it got better, got better over time. She realized that she was going through hormone replacement therapy or she was going through menopause. She got put on hormone replacement therapy. She was on it for 10 years. And then her doctor on a follow up where she was trying to get a renewal said, actually, you've been on it for too long. I'm going to take you off of it, which that That's a whole other ethical scenario, especially because we should be weaning off estrogen replacement therapies, not just going cold turkey. But however, took her off and within a couple of months of that weaning process, her other shoulder started to freeze. I've obviously been in the weeds of this research right now around the influence of estrogen on our body, but I was thinking about and reflecting on how many women I have worked with over my career. THE INFLUENCE OF ESTROGEN ON OUTCOMES I've been a PT for 10 years, so very still early on in my career, but how many have I not recognized the influence of a person's estrogen status on our outcomes? And so when we think about estrogen, we think about fertility, rightfully so. We think about pelvic floor physical therapists kind of specializing in the fertility space, granted, but estrogen, when we have a depletion in estrogen as women go through menopause, it affects every part of our body where there is an estrogen receptor. And I don't think that many orthopedic therapists or people who kind of aren't niching into this space, myself included until I got into this arena, recognize just how widespread that is. And in pelvic health, we've done an incredible job of advocating for individuals in the perinatal space. We still have, of course, ways to go. However, you know, there's this rise of individuals going through menopause who are starting to advocate that we need that same type of education. And too frequently now that I've been asking are my patients saying to me, oh, well, my doctor said it was just part of aging and I shouldn't be on hormone replacement for this long or like have just been dismissed about their symptoms and have not linked some of these other body systems and the experiences that they're having in these other body systems with their estrogen depletion. I have a client seeing me for ankle pain and she's kind of in that postmenopausal window and she said, I am trying to learn a new body that I do not understand. And I think that was such a profound statement because so many individuals are feeling this way and we have a huge role to play in rehab. And I'm not talking pelvic, I'm talking generally. THE ROLE OF ESTROGEN IN THE BODY And so when we think about estrogen, estrogen has receptors in our brain. It has receptors in our joints and muscles. It has receptors in our heart, and it influences our bone, right? Bone is probably the easiest one. We know that individuals who are postmenopausal are at increased risk for osteoporosis osteopenia, that there is an accelerated rate of decline in bone mineral density loss with estrogen as rates of, estrogen helps rates of bone build up. And with estrogen depletion, we see a switch in the slope of the line where bone breakdown exceeds rate of bone growth. And so rates of osteoporosis go up postmenopausally. We also see that individuals who are in an estrogen depleted state have higher rates of joint pain. So kind of an umbrella term of joint arthralgia. and we see links to risk factors around things like adhesive capsulitis in individuals going through perimenopause, but very little research has actually looked at individuals' experiences of musculoskeletal pain in the postmenopausal window. So we could have individuals who are not responding as quickly to rehab, even though we're throwing everything at them that is evidence-based and evidence-informed, because they are going through menopause and it's the influence of their hormones is changing the way that their body is responding to some of our rehab interventions and we don't know about it. Our body also has estrogen receptors in the heart. And so we see that men tend to have a higher rate of cardiovascular disease and heart disease than women, but that change in rate between men and women starts to change in that postmenopausal window. So rates of heart disease start to go up postmenopausally because of the protective effect of estrogen on the heart. What we also see from a metabolism perspective is that there is a change to the way that fat is laid down when individuals are postmenopausal. So where we have the protective subcutaneous fat that tends to be something that is kind of a net, potentially neutral way of laying down fat, the more dangerous fat is visceral fat lay down, and that tends to accelerate in a postmenopausal female because of estrogen deficiency. which then increases risk for a whole bunch of different metabolic diseases, including, you know, heart disease, stroke, Alzheimer's disease, like all these diabetes, all of these things that we know are linked to pro-inflammatory cascades. It accelerates for individuals as they go through menopause. And then finally, from a cognition perspective, we have systematic review evidence that Individuals who go through premature ovarian insufficiency. So individuals who go into menopause before the age of 40 are at an increased risk for cognitive decline. So rates of Alzheimer's are higher in individuals who go through early menopause. And we see that there may be a protective effect, preventative effect of the development of cognitive decline for these individuals who are going through menopause early if they are on hormonal contraception. Which gives a very strong argument for the link between estrogen status and cognition. And when we think about symptoms of menopause, we kind of put them into different buckets. We talk about, you know, vasomotor symptoms, which are night sweats, issues with sleep, sleep disturbances are very high around the postmenopausal or menopausal transition, and hot flashes. Right? And there's kind of like this immediate withdrawal effect of estrogen. Like you could almost think about it as like a drug withdrawal. Like when we get withdrawn from estrogen, those vasomotor symptoms kick up. And then eventually our body gets used to being in that state of estrogen deficiency and those withdrawal symptoms kind of go away. But genitourinary syndrome of menopause is really focused on the aging of the pelvis and its influences. And so when we're in pelvic health and we're talking about estrogen deficiency, we see, you know, adhesions in the labia minora to the labia majora. We see an increase in friability of tissues. We see an increase or a changes to the pH of the vaginal microbiome. And so these all have influences, but the genital urinary syndrome very much focuses on the pelvis. ASKING ABOUT MENOPAUSE And so if you are not in pelvic health, you may not be really considering it a reason to be asking about symptoms of menopause and when you went in through menopause. But if you are an individual who is working with anybody who is a female over the age of 50, you should be asking, are you in menopause? Have you gone through menopause? When did you go through menopause? And menopause is diagnosed as the 12 month mark of not having a period. So when you have not had a period for 12 months consecutively, that is considering being in menopause. Average age is 50 to 51 in the United States. asking around changes in symptoms around the menopausal transition. Did you notice a change to your mood? Did you see a change to your sleep? Did you see a change to your cognition? Did you see a change to all these other things? Because we know that if you're depressed and not sleeping and your joint pain is up, we're probably gonna have a lot of conversations that we need to have around recovery. It's gonna influence the way that our treatment is going to go. And then we can be an advocate for ways to manage. Too often, and there is nothing that makes me more mad. Like when I see individuals who have gone to their doctor and they say, I am suffering with vasomotor symptoms. I am suffering with all of these things. And they say, I have no libido. And they say, well, you are going through menopause. And that's kind of the way it is. Men will get Cialis or other types of hormone replacement for their sexual dysfunctions very readily. And it is met with hesitation when we are talking about female reproductive aging. And I was just at a course where it has some individuals who are part of the military and the military nurse practitioners were there, which is really cool. But they said, you know, we are so willing to prescribe Cialis but we are very hesitant as a division to give hormone replacement therapy. HORMONE REPLACEMENT THERAPY And so the next part of this conversation, one, estrogen affects everything. It's absolutely gonna influence our pelvic floor. It's absolutely gonna influence our pelvic health. But then the next thing that people are asking is around estrogen replacement therapy, sex hormone replacement therapy, and its safety and efficacy. So I wanna do a little bit of a history lesson here around where this risk is coming from. So there is a large longitudinal study called the Women's Health Initiative that has been collecting data on women for a very, very long time. And early, early on in about 2001, a study was released from the Women's Health Initiative that said that there was a 25% increased risk of sex-related cancers for individuals who are on hormone therapy than individuals who are not. This was, potent, like kind of true, but it missed the forest for the trees. And so when we kind of zoom out and we look at relative risk of sex-related cancers, that, well, that translated into, instead of it being three in 1,000, and these are not perfect numbers, I don't remember off the top of my head, it changed to a four in 1,000 rate or incidence of sex-related cancers. When if you think about it like that, that is not the biggest difference. However, that one study came out and it changed everything. It was largely disseminated, many media outlets put it up, and it made everybody very, very fearful of prescribing hormones. So there's a couple things nuanced to this. When we are taking any type of medication and our sex hormones are not anything different, there is always going to be potential risks. Those have to be balanced by the benefits. We see, for example, that individuals who are on replacement therapy have a lower risk of Alzheimer's, dementia, especially if individuals are going through a menopause early. We see sexual health, sexual, satisfaction increases on hormone replacement therapy. We see an increase or rather a decrease in rates of urinary tract infections. And if you are working in the geriatric space, move this into Wednesday. It makes a huge difference. A urinary tract infection can change a person's life. A person can die of a UTI because it can end up, they get in hospital, UTI becomes sepsis, sepsis becomes a full blown, you know, it's now a full blown infection and individuals don't get out of hospital or they see a consistent change in function. All of these benefits for many are going to outweigh that slight increase in risk. Now, we have evidence since then that that risk percentage may have actually been when we replicate a study, which is super important before we're making very broad sweeping statements. There is a range of that relative risk and it actually might be lower. And because of that, we now have good evidence for individuals who are going through chemo to be able to have, because it can irradiate and bring you into a low estrogen state, where they may use topical estrogens. We have more evidence for individuals who are on estrogen receptor blockers, like tamoxifen, to, again, have topical estrogens. Because, obviously, we're not gonna wanna ingest estrogen when we're trying to block it so that cancer doesn't regrow, but to put it on the external genitalia, that would allow us to remove some of those pelvic-related symptoms for individuals being in low estrogen as a consequence of cancer treatment. And this evidence is continuing to grow. NO EVIDENCE FOR AN OPTIMAL HORMONE REPLACEMENT WINDOW The other question, when I go back to my patient that I talked about, is that he said, well, you've been on it for enough, this physician, and I'm gonna take you off. We actually, again, don't really have any evidence around where that window is. Like how long you can be on it before the risks start to outweigh the benefits. And because we don't know, individuals are just creating a risk tolerance zone for themselves and then unilaterally kind of applying it in their practice. And so we still have so much work to do in this space. We are starting to see a change in our language around hormone replacement therapy, and it's being changed to MHT, menopausal hormone therapy. And it is actually encompassing a variety of different treatments. It is not just a systemic pill that you can take that is a natural replacement, there is those. There are progesterone replacements. There are estrogen and progesterone combos. There is evidence for testosterone replacement and testosterone replacement helping individuals with hyposexual disorders. And then there are topical estrogen therapies where individuals who are experiencing recurrent UTI, individuals with issues with labial adhesions, individuals with clitoral adhesions, all these different things can see a huge benefit to this type of hormone replacement. And so, The role that we have to play here, if you were a pelvic clinician listening to this, we have a ton of advocacy to work on. Staying up to date with the evidence, referring back for potential counseling on hormone replacement, and continuing to have those conversations with our physicians is gonna be super important. If you are a person who's an orthopedic specialist, you need to be asking about estrogen status. Have you lost your menstrual cycle? That puts you in low estrogen. Have you recently had a baby? If you're a postpartum and you're dealing with a wrist injury, that low estrogen is gonna impact your ligaments. It's going to make it so that you may be more likely to have things like mom wrist decorvains tendosynovitis. And then if you're working with individuals who are older, then again, we're gonna be asking about when you went through that menopausal transition and how you're feeling. A lot of people feel like, oh, well, I'm going okay through my menopause right now. I don't really need it. The thing is estrogen deficiency is accumulative. So it is also a discussion around the preventative aspect of continuing to have individuals on hormone replacement. I don't know the answer to this, but it is a continual conversation. It is one that is happening in lots of spheres and one where there is a role for rehab. And this has been such an important part of the development of our research base in pelvic and a huge portion of the proportion of individuals that we are seeing in our practice that we have put it into our level one. So we have an entire week on the influence of menopause on the female body and an entire module on the way that we would work towards treating individuals and advocating for individuals who are going through menopause, who are subsequently feeling issues with pelvic health. So if you are interested, get into our March cohort. I could rant about this all day. I'm already 20 minutes in. I'm gonna get off here, but it's important. And it is not just important to our pelvic health clinicians. It is important for everybody who is working with a female body over the age of 50. And we're not even going to go into the perimenopause part because perimenopause could be 10 years before. So if you're working with anyone over the age of 40, this is relevant and it influences our rehab outcomes. All right. I hope you all have a wonderful week. Merry Christmas. If you are off, happy holidays. Whatever denomination you are, please hopefully have some time to spend with loved ones. And I hope that you get some of the rest and relaxation that is just something that you are looking for. I have two little ones, four and two, and the magic of Christmas and the holiday season is so alive and well in our house, and it is such a beautiful thing. So I hope you all get that. You are so welcome for me talking about this. I promise you, I will be diving more into this onto my personal Instagram, and it's definitely gonna come onto ICE because I think it's really important, and I think it's a huge miss that we have. So thank you for listening, and I am so excited to continue these conversations. Merry Christmas, happy holidays, and hopefully you get all of that rest and relaxation for the end of 2023.

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