Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
The Risks and Benefits of Hormone Therapy
Hormone therapy remains the gold standard for treating menopausal symptoms—hot flashes, night sweats, sleep disturbances, mood changes, and vaginal dryness. When started within 10 years of menopause onset, it offers a remarkable 30% reduction in all-cause mortality. Yet this fact rarely makes headlines.
Join Speaking of Women's Health Podcast Host Dr. Holly Thacker as she reads and discusses Chapter 10: The Risks and Benefits of Hormone Therapy from her book, "The Cleveland Clinic Guide to Menopause."
The most important takeaway? Don't let fear dictate your menopause journey. Work with a knowledgeable physician to assess your individual risks and benefits. Whether you're experiencing severe symptoms, concerned about bone health, or dealing with early menopause, safe and effective options exist.
Have you been avoiding hormone therapy based on outdated information? It might be time to reconsider.
Welcome to the Speaking of Women's Health podcast. I'm Dr Holly Thacker, your host and author, and thanks for joining me back in the Sunflower House for Chapter 10, the Risk and Benefits of Hormone Therapy. Hormone therapy is still the best available treatment to treat menopausal symptoms and the case is far from closed regarding its long-term effects in terms of helping blood pressure, reducing heart disease, colon cancer, potentially reducing Alzheimer's disease, depression, parkinson's, arthritis and even macular degeneration. We do need more study. Furthermore, lower doses of hormones than previously studied may provide some of the same benefits while reducing side effects, particularly on the uterus and breast. The use of progestogens, which are synthetic progestins or natural progesterone, may be part of the equation that affects the risk of breast cancer while protecting the uterus. Using estrogen transdermally, as in a weekly patch, like Climera or Climera Pro or Vivelle Dot or Minivel twice a week, or a daily estrogen gel or lotion or spray, may reduce the risk of blood clots, but it may not raise the HDL cholesterol as well as oral estrogen. In short, we always need more research, but in the meantime we have more options for treating menopausal symptoms than ever before.
Speaker 1:This should be the best time for midlife women and beyond, but instead many suffer needlessly. Take Anne-Marie, for instance. Anne-marie, I didn't know what to believe. One said he said don't take any hormones. Another one said estrogen use by older women could increase their risk of stroke. Every day there's a new headline with a different warning. Ah, you'd think I was treating my menopausal symptoms with illegal drugs.
Speaker 1:I took PremPro for several years without a problem before I discovered that I thought I was risking my life, at least according to the media reports. My doctor suggested I taper down the dosage, but I insisted on just stopping it completely. So I quit cold turkey. Well, the result of my rash decision was disastrous. I felt as if someone had pulled the rug from right out underneath me. I was anxious and extremely uncomfortable all the time. My hot flashes were so severe I sometimes wondered whether I could leave the house to run errands. I had never realized how much the hormone therapy had been helping me until I stopped. I tried some alternatives black cohosh in the form of remifemin for hot flashes, vitamin E oil for vaginal discomfort, but nothing worked quite as well as my original therapy. And to add insult to injury, I lost an inch of height and I found out on bone density, I had osteopenia, bone thinning. With so many misleading reports about what's good for women. Today it just seems as if breathing is a risk. But I decided I had to feel comfortable. So I went back on hormone therapy. I went on low dose PremPro and finally I felt normal again Taking hormone therapy.
Speaker 1:Millions of women have done very well on hormone therapy, finding relief from the worst of their symptoms without increasing any other health risk. Hormone therapy was and still is the only FDA-approved treatment for the symptoms of menopause, including vaginal atrophy and the management of postmenopausal osteoporosis. Now we do have indications for non-hormonal treatments of vaginal atrophy, such as Asfina, aspemafen, asermirm, a selective estrogen receptor agonist antagonist. We have several options that are FDA approved to treat osteoporosis, to prevent and treat and we are going to go over that in a future chapter on boosting bone health. And we do have FDA-approved non-hormonal treatments to treat hot flashes in the form of Brisdell paroxetine and hopefully soon to be some candy neuron antagonist. So the FDA and most physicians regard hormones as having potential benefits. As, like with anything, potential risk. Nothing is 100% safe and effective with no risk, nothing, not even water. So unfortunately, the risk many times get completely overshadowed by fearful media hype. So where do all these misconceptions and fears come from? Well, the Women's Health Initiative, which was a large randomized trial that changed the way women, as well as much of the media and medical community, view hormone therapy, and this change was not for the better. My fifth podcast in the speakingofwomenshealthcom website podcast series was on the 20th anniversary of the WHI. Fear, anxiety, fewer choices for women resulted from misinterpretations of sections of the study that focused on hormone therapy in much older women who were several years past the age of the onset of menopause. Ironically, these studies had been initially designed to help women better understand the risk and benefits. So, unfortunately, the media friends, even some of our doctors and nurses, are inappropriately waving accusatory fingers at hormone therapy as a treatment for menopausal symptoms, and this should infuriate women and spark a new debate that asks some very pointed questions about the treatment of modern, mature women in modern America. For example, some might wonder how accurate are randomized studies when applied to different groups of women for different reasons? Why does the media scare women into thinking that they don't have options, and why otherwise good doctors into thinking that they don't have options, and why otherwise good doctors misinterpreted these studies and just followed what the media said? Hmm, where else have. We have seen that. What about the quality of life and sexual function for midlife women? How can women fairly assess what hormone therapy truly represents for their own individual case? In this chapter about the risk and benefits of hormone therapy, I'll discuss the facts that women absolutely must know. These are details that you're not going to read in the newspaper, because so many articles for the lay public just skim the surface, and there's far too much at stake with your health for research to be interpreted in such a glib and superficial way. Millions of women have done well on hormone therapy, finding relief from the worst of their symptoms without increasing other health risk. The FDA and most physicians regard hormones as having significant potential benefits as well as potential risk, just like with any prescription medicine and even non-prescription therapies. I mean, my goodness, there are deaths from acetaminophen Tylenol, which is over the counter. So just because something is off the shelf or available without a prescription doesn't mean that it's safer than prescription medicines.
Speaker 1:Women's Health Initiative the hard facts. In 2002, researchers halted part of the WHI, and this was a large preventive study funded by the National Institute of Health, nih, to focus on strategies for preventing heart disease, breast cancer, colorectal cancer and osteoporosis in postmenopausal women. It was a 15-year multi-million dollar project. The WHI involved over 161,000 women that ranged from ages 50 to 79. The segment of the study that was halted had been assessing the long-term use of hormone therapy as a prevention tool for chronic illness, and that's because a preventive agent can essentially have no side effects.
Speaker 1:It's important that this was not a menopausal treatment trial, so when you're using something to prevent something in a healthy person, the bar is set extremely high. It really can have no side effects or risk. When you're using something to treat an existing condition, you have to accept some amount of side effects and risk because you're treating a problem. And this is important to separate, because some women use hormone therapy just for treatment. Some women use it for both treatment and prevention and there's some women who just use it for prevention. And it's very important to clarify your goals and it's so important to understand that the WHI was not a menopausal treatment trial and in retrospect it actually really wasn't a very good preventive trial because most of the women were an entire decade past the age of menopause and within that decade you lose some of the effects on the estrogen receptor with methylation and many women get subclinical disease. Even if they're not diagnosed with heart disease, they may have some existing plaques.
Speaker 1:So it truly wasn't the preventive trial that we had thought it was, and early information indicated that women who are postmenopausal and using the combination prescription drug which was commonly prescribed at that time, called Prempro, which was a combination of 0.625 of conjugated estrogens and 2.5 milligrams of medroxyprogesterone acetate, or 5 milligrams of medroxyprogesterone acetate or five milligrams of medroxyprogesterone acetate that they faced a slightly increased risk of just being diagnosed with breast cancer, heart disease, stroke and blood clots, compared to the postmenopausal women who were just taking a placebo or a dummy pill. However, the increased risk of heart disease were seen only in women several years past the age of menopause, after the age of 70. Are seen only in women several years past the age of menopause, after the age of 70. And the risk of breast cancer was rated in the rare category, even less than what was in the package insert. This was not a treatment study of younger midlife women. It was a study of predominantly older women. Most of them were between the ages of 63 and 67. And they, by and large, didn't even have menopausal symptoms anymore. And because it was a so-called preventive study and the bar was set so low for accepting any risk, the WHI discontinued this study in this subset of women, saying that the risks were just too great to continue, not because more women taking hormone therapy were dying that's very important to note compared to placebo but because some risks were noted in the treatment arm. Well, there were also benefits noted, and that's really important. When you look at large studies, comparing some treatment option to a placebo is the one thing you absolutely cannot argue with is death rates, and that's an absolute outcome, and so you never want the treatment arm to have a higher risk of death, and in the WHI there was not. But clot was a risk, and there was one in every thousand women extra who took hormones for 10 years were diagnosed with breast cancer, didn't die from breast cancer, but were just diagnosed.
Speaker 1:Now, another two years later, the NIH halted the other portion of the WHI, which was the component just investigating Premarin 0.625, an estrogen-only oral option in women who had already had a hysterectomy. In this study, the participants who were older than 60 had a very slightly increased risk of stroke one extra case per 1,000 women but they didn't show any increase in heart disease and they actually had a marked 33% decrease in the risk of being diagnosed with breast cancer, and that reduced risk persisted into the 70s. But by this time many women who had undergone a hysterectomy had already stopped taking estrogen therapy, spooked by all the negative media reports in 2002. And it's so ironic that so much of their fear centered around the reported increased risk for being diagnosed with breast cancer and heart disease, which did not materialize in the estrogen-only arm. Most women didn't realize that there's a risk in not taking hormone therapy when it's needed. The latest information from the WHI study is that for women who are within 10 years of menopause, who've taken hormone therapy for five or more years whether it's estrogen alone, hysterectomized women or estrogen plus progesterone if you have a uterus there is a 30% reduction in all-cause mortality. That's significant, significant. There was reduced risk of death.
Speaker 1:So what are we to believe about hormone therapy? In my opinion, misunderstanding surrounding the WHI study has designed unnecessary panic. This was a prevention, not a treatment study, and two-thirds of the women, as I mentioned, were over the age of 65, which is a good 10 to 15 years later than most women would even start hormone therapy, and the study's purpose was to see whether hormone therapy prevented certain diseases, it was not designed to measure the effectiveness on treatment of menopausal symptoms. Furthermore, the American College of Clinical Endocrinologists announced in 2008 that the benefits of hormone therapy in women under age 60 far outweighs the risk. This was based on a reanalysis of the data of the WHI in women under 60. It took several years for the WHI investigators to release the age stratified risk and benefits, and that again, is important anytime you're looking at any intervention for any prevention or treatment arm, because age sex comorbidities dramatically can change someone's risk for a condition. So it's concerning to me that these WHI investigators withheld this age stratified data from the beginning and they didn't release it until years later.
Speaker 1:So much of the increase in cardiovascular risk that was publicized in 2002 was just seen in those older women over age 70, who were so many years past menopause, who were starting quote preventive hormone therapy more than a decade after being exposed to any of these hormones. And so we know from the timing hypothesis that if you start with healthy arteries and a healthy brain, the hormone therapy does seem to have some beneficial preventative effects. But if it's been over a decade or more and there's some underlying disease of the arteries, of the neurons in the brain that adding estrogen to the mix may not at all be helpful and in a very small percent may be harmful. May not at all be helpful and in a very small percent may be harmful. So this is in contrast to older women who have been on hormone therapy since the beginning of menopause and done well and not demonstrated any evidence of blood clot. So just because you're over 60 or over 70 doesn't mean you can't continue safely on hormone therapy.
Speaker 1:The biologic age and especially the age of actual menopause and the time a person has gone without hormones those time frames are very important in helping your physician interpret the benefit and risk. And it's also important to know that in women without a uterus taking estrogen under the age of 60, even with oral estrogen, there was no increased risk of stroke. In fact there were two less cases per thousand compared to placebo. So I see women every day who said oh, my doctor said increased risk of stroke. That's the reason I should stop the estrogen. And you can mitigate this in women over 60 or 65 by simply changing to transdermal or cutting the standard 0.625 conjugated estrogen down to 0.45 or 0.3. Or if someone's on a milligram of estradiol, cutting that down to 0.5.
Speaker 1:So the bottom line is hormone therapy is still the absolute best treatment for recently menopausal women who are having significant symptoms. Women have no reason to fear hormone therapy or doubt its efficacy as a solution for uncomfortable and potentially debilitating side effects. The key is to tailor hormone therapy to each woman's individual needs, and with so many options available, let me tell you this is so much easier than it's been ever before. Now one of the things that I run into is just whether insurance covers it, and that is a big hassle, and I will have future podcasts on the speaking of women's healthcom uh regular podcast going over um tips to reduce the cost of medicine, because that's the one thing that we end up dealing with most, most of um the office visits, sadly.
Speaker 1:So what the WHI study showed us is that in much, much older women who don't have any symptoms of menopause, they should not only take hormone therapy solely for just prevention. In fact, there isn't one pill that we encourage all women to take not aspirin, not vitamin E, certainly not a single prescription medicine. For instance, we advise women at high risk for heart disease and stroke potentially to take aspirin to reduce the risk of stroke, but it can increase hemorrhagic stroke and GI bleeds. We certainly don't tell all menopausal women to take aspirin. We don't tell all people to take statins cholesterol-lowering medicines. The message is that one size does not fit all. All treatments have to be individualized and periodically assessed, and every medicine, prescription as well as non-prescription supplements, carry potential risk and potential benefits. So don't throw the baby out with the bathwater.
Speaker 1:Statins and hormone therapy an interesting comparison. Like hormone therapy, many medicines used for prevention, such as using statins, cholesterol-lowering medicines, have risks and side effects. However, we certainly don't tell all people with high cholesterol just to throw out their statin because a small number of them may have a side effect. Yet this is exactly what happened to millions of women when the proverbial hormone therapy rug was pulled out right from underneath them. Breast cancer rates with statin therapy are actually comparable to breast cancer rates with hormone therapy. Rug was pulled out right from underneath them. Breast cancer rates with statin therapy are actually comparable to breast cancer rates with hormone therapy. And still, statin agents are the most commonly prescribed class of medication.
Speaker 1:Women on hormone therapy actually have a reduced risk of death and cardiovascular mortality if they start hormone therapy within 10 years of menopause, something that can't be said for primary preventions in women with statins. Now men have some evidence of primary prevention with statins, and both men and women who already have existing heart disease have evidence of reduced risk of heart disease with statins, but not primary prevention for women in their 50s. What's more is, statins have only been shown in women who already have heart disease or at very high risk for heart disease, and so there's not really good definitive information on the usefulness of using statins in younger women solely as prevention. In fact, statin use in women increases the risk of diabetes, and diabetes is our worst risk for women for cardiovascular disease than diabetes is for men, and hormone therapy actually reduces the risk of diabetes type 2 by 30 to 35%. So no medicine or substance is perfectly risk-free.
Speaker 1:But that doesn't mean we don't use agents. We need perspective. So that requires you and your healthcare clinician to provide and perform an individualized risk-benefit assessment. Don't let the media hype scare you. They're not your doctor and have known heart disease. Data from Tommy McCullough out of Finland shows that women that are on statins and hormone therapy have a lower risk of heart attack and stroke compared to women over 60 just on statins or just on hormone therapy. So it's not that I don't recommend statins in some women, but this rush to use them and put them in the drinking water when they don't improve menopausal symptoms or help the genitourinary atrophy or the sleep or reduce the risk of fracture, when we know hormone therapy does those items. It's just helpful to make that comparison, so informing the debate. You've probably read plenty of contradictory reports by now, leading you to question whether you should use hormone therapy or, if you started, how long you should continue. I hope by listening to this podcast, your anxiety is going to be quelled.
Speaker 1:Let's take a look at some of the most important questions concerning hormone therapy. Here are my conclusions, drawn from years of clinical practice, careful interpretation of many well-designed scientific studies, which includes observational data, randomized controlled trials, meta-analysis, case reports, because all of those have their role to play. What exactly is hormone therapy? Well, hormone therapy is when the body is given a bit of estrogen plus minus progestogen, in the form of either a synthetic progestin or progesterone if one has a uterus slash, an endometrium lining of the uterus. So sometimes, even in women with hysterectomies who have endometriosis, we still may use progesterone. The ovaries are responsible for producing estrogen and progesterone, and some testosterone in women, but during menopause and especially following complete hysterectomy, when both the ovaries are removed, we might not produce the amounts that we need to regulate several bodily functions. So, essentially, by replacing some of these missing hormones with a pill or a patch or gel or other forms we'll discuss in future chapters the body stays balanced. So estrogen relieves hot flashes, vaginal dryness and other symptoms associated with menopause, such as dry, itchy skin, and, taken in combination with estrogen, progesterone prevents the cell overgrowth in the lining of the uterus, which is very important at reducing endometrial hyperplasia and endometrial cancer.
Speaker 1:Some women prefer estrogen in the form of just human estradiol, which is the same exact potent estrogen that's produced in the egg. Other women prefer conjugated estrogens, which last for a whole 24 hours, as opposed to oral estradiol, which needs to be dosed at least twice a day, and conjugated estrogens are a mixture of several estrogens that are usually derived from either horse urine or synthesized in a lab. If a woman's had a hysterectomy and is particularly concerned about breast cancer risk, I actually do recommend the conjugated estrogen Premarin, because it's the estrogen that's been studied in the longest format in women with hysterectomy up to 11 years and not only has it not shown any increase in breast cancer. In fact, the Premarin estrogen-only arm of the WHI showed a decreased risk of breast cancer in hysterectomized women even into their 70s. Now there's some women who don't want to use an animal source of estrogen. So in the past there was a synthetic form of conjugated estrogens called Injuvia on the market, but it's not exactly bioequivalent and I don't think it's commonly able to oogen.
Speaker 1:So just as many women have preferences regarding the type and dose and route of estrogen, many women also have some strong feelings about progestogens. Again, one size does not fit all. Some women prefer to take natural progesterone in the form of prometrium, but it's mixed in peanut oil so it's not suitable for women allergic to peanuts. Other women feel too sleepy or groggy on prometrium, which has to be taken at night with a little bit of food. Rarely the natural progesterone relaxes the lower esophageal sphincter and heartburn happens.
Speaker 1:Some women may prefer a progestin such as norethendrone acetate. It's in very many common birth control pills such as low estrin. It's also in low-dose FemHeart and Activella or generic MIMV, and comes in different doses, like Activella is one milligram of estradiol and a 0.5 of norethadrone acetate, or the low-dose activella or low-dose MIMV is only a half a milligram of estradiol and the 0.1 of norethadrone acetate. Now when you combine the estrogen with the progesterone in a pill form or a patch form, it lasts longer If you separate the two. Oral estradiol has a very short half-life.
Speaker 1:Now there's a newer progestogen, drosperinone, which is actually a derivative of spironolactone, and that's in birth control pills like Yaz and Yasmin and Safral and B-Yaz. But it's also found in a menopausal formulation of estradiol, which is bioidentical estrogen. With drosperinone, and because it's similar to spironolactone, it may give some benefits to skin and hair, especially if women have had some negative effects from too much androgens or testosterone, and drosperinone is a mild diuretic and it might lower blood pressure and help cholesterol. Some women cannot tolerate systemic progestogens and need to use progesterone in the form of a gel, like a 4% vaginal gel. Other women who've done well on Prempro are using it in lower doses, with only 1.5 milligrams of medroxyprogesterone acetate, which was well studied in the Women's Hope trial. Now I'm not a fan of using medroxyprogesterone acetate for over five plus years because it's very anti-estrogenic and so I think it's probably the worst one. On the breast. Most progestins don't have independent bone effects, but there's some evidence that norethendrone acetate, which sometimes we use alone in women with severe endometriosis, may have some bone benefit. Some women like the natural sedating and anxiolytic effects of natural progesterone. And there's only one combination of oral estradiol with natural progesterone in the form of bijuva, which we've now had for about four years, but it only comes in one standard dose. I really wish we had three doses. So it comes in one milligram of estradiol with 100 milligrams of progesterone, but instead of being mixed in peanut oil it's micronized in coconut oil, so this is taken after dinner.
Speaker 1:Other women who don't want to take a pill, maybe because they have nausea or gallstones or they've had a history of a blood clot or they've not ever used hormones and they want to use the lowest risk option might want to use a weekly patch of ClimeraPro, which is estradiol, bioidentical and levonorgestrel in a fixed combination of 0.45 of estrogen. Now women who are concerned about low testosterone might want to use transdermal or vaginal hormones which don't increase sex hormone binding globulin, because that protein is increased in the liver when you take oral estrogen, which then lowers testosterone. So women with hair loss and acne actually may prefer oral over transdermal transdermal. There is a twice a week estrogen progesterone patch with 0.05 estradiol and two different doses of norethadrone acetate 0.14 and a higher dose, 0.25. And that's changed every 84, which is 3.5 days. So there are plain generic estrogen patches and generic and brand name twice a week patches. In women who spend lots of time in the water or humid climates they might find that the patches don't stick well and they might want to use a transdermal estradiol but don't want to be marked with a patch.
Speaker 1:E4 is being studied and it's another natural estrogen and it's in a current birth control pill, nexstellis, and it is being studied in postmenopausal women as well, but at the time of the taping, which is March of 2023, we don't have that available. In the past we had this wonderful soybean-based estrogen oil called Estrazor, but that's not on the market anymore. We do have a couple of quick-drying alcohol-based gels DiviGel, which comes in three little packets in three different sizes 0.25, which is uber low dose, 0.5, and 0.1. And even the 0.1 dose, the highest strength dose, is a pretty low dose. There is Estrogel one squirt a day to the skin, or elesterin, which is up to two squirts, and there's one spray of estrogen called Evamist and it interestingly peaks the estrogen level around two or three in the morning if you apply it in the morning, and certainly sleep disturbances can occur. So it's kind of nice, nice, you get that little boost at night and each container has 60 squirts or sprays after you prime it once and so for women who don't want to rub things on their hand, the spray is a nice option. There are some research studies looking at intranasal estrogen, but that's not standardly available. And there is vaginal estrogen. Most of that's local, but there are the formulations of the femoring in two doses, 0.5 and 0.100.
Speaker 1:So, for all the reasons that we've discussed so far in this podcast, many women will continue to turn to hormone therapy as a safe, effective option. Are older women who take hormone therapy at greater risk, you may ask. Well, starting hormone therapy 10 to 20 years after the onset of menopause generally is something that we don't routinely do if you're solely taking it for prevention or just to promote general health. But that being said, women who are, say, 65 years old can take hormone therapy to relieve hot flashes, treat genital dryness, sexual dysfunction and prevent osteoporosis, particularly if they started it and they've done well on it and they just want to continue. But in order to reduce stroke risk in women over 65, I usually reduce the dose of estrogen by the time a woman is 65. And that's certainly when we assess further for heart disease risk. If the blood pressure is creeping up, that may need to be treated, and it's always the right time to talk about weight reduction, intermittent fasting, smoking cessation, improving cholesterol ratios, getting adequate sleep, maybe having a blood pressure cuff at home and checking your blood pressure more frequently, as well as diabetes prevention or treatment. As for younger women, the risks found in the WHI do not apply to them, so a 25-year-old woman who finds herself in premature menopause should not identify with the results of research that was done in 60-plus-year-old women, and that is just a devastating mistake that I see too many people make.
Speaker 1:Are low doses of hormone therapy just as effective as previous standard doses? Many times, the answer is yes. Low doses of hormone therapy are generally effective at treating hot flashes, and the hope is that lower doses will assure women that it's okay to start and continue hormone therapy, as well as give them more options and dosage ranges. But there's no pat answers that apply to all women at all phases of life, and women with severe menopausal symptoms may not benefit from a low dose as much as they would from a higher dose, which, I remind you, is not even that high a dose and it is FDA approved and safe. For example, a woman who suffers from debilitating anxiety attacks coupled with serious hot flashes and thin bones might fare better with a higher dose of hormones. So would younger women, women with faster metabolisms, women who've lost their ovaries. Furthermore, an average dose prescribed for one woman with a fast metabolism may be way too low for another woman who has a slower metabolism or who's older.
Speaker 1:Most of the studies that show impressive reductions in osteoporosis and bone breakage have not used the uber uber low doses. So if you're going to use uber low doses, you still may need to use something extra for the vagina and for the bones, and then I find that you're just, you know, increasing the time and the expense. But each woman's needs are different and the same woman can metabolize the same dose of estrogen differently. And because each woman's needs are different, you must have a health assessment to determine where you are, whether you're at risk for hormonal loss, even if you have no menopausal symptoms and what dose to begin with, and if it's beneficial to you, and we'll discuss more of this in the podcast on Chapter 11. And at least once a year this should be assessed by your physician and if you're stable, a women's health nurse practitioner can certainly examine you and give you refills if all is the same. But if you've got a new problem bleeding or a new medical diagnosis or you're approaching your 65th birthday and about to go on Medicare, where a lot of times the coverage of these hormones also change, it's good to maybe touch base again with your physician and we're going to have future podcasts on reducing the cost of medicines and what things you should look for when you're looking for secondary insurance when you become of Medicare age.
Speaker 1:Will hormone therapy protect my heart? Well, observations from studies such as the Nurses' Health Study show a lower incidence of heart disease in women who took hormone therapy. Other studies have found that hormone therapy favorably affects cholesterol ratios, improving the good HDL cholesterol with oral hormones and reducing the LDL cholesterol. But oral estrogen can increase triglycerides, so I usually avoid oral estrogen if a woman has had a triglyceride level over 400 or is diabetic without good control, or in someone who has any risk for blood clot control or in someone who has any risk for blood clot.
Speaker 1:But in the heart and estrogen progestin HERS trial women who already had existing coronary heart disease did not have a lower rate of cardiac events when taking PremPro, and the American Heart Association has issued various guidelines and they basically state you shouldn't use it to treat or prevent heart disease. But you can certainly take it for other indications, and the most recent American Heart Association guidelines actually acknowledge menopause and estrogen deficiency as a risk for cardiovascular disease, and we'll go into that in much more details in a future podcast. So a 30-year-old woman who smokes and is overweight is not at immediate risk for heart attack, but her lifetime risk is very high and it should be addressed then. And even a 50 year old woman who only has one risk factor for heart disease still has an increased absolute lifetime risk for heart disease and a shorter duration of life. So that needs to be addressed. So we don't use hormone therapy specifically to prevent heart disease. Cirms, which are selective estrogen receptor modulators, such as avista, raloxifin and antioxidant vitamins, are also not specifically recommended for the prevention of heart disease. So women at the very highest risk for heart disease should certainly aim to reduce their LDL cholesterol under 70, to stop all forms of nicotine, to control blood pressure and blood sugar and also be assessed for depression, which is a risk for heart disease.
Speaker 1:Whi findings did discourage the use of just broad spectrum hormone therapy as just a broad spectrum heart protection. But hormone therapy is not damaging to the heart per se and if you take it for five to 10 years within 10 years of menopause, starting under age 65, generally there's actually less cardiovascular disease and less diabetes. So this is so much information to process and consider and I think that the biggest risk with hormone therapy is the rare risk of blood clot, particularly with oral estrogen, and oral estrogen with progestins further increase that risk. So knowing your family history and your personal history is important and if you're someone who's had blood clots or has genetic risk for blood clots, such as prothrombin G mutation, factor V, leiden, we generally don't use oral estrogen In the menopausal state. We use transdermal. So don't plan on solely taking hormone therapy for anti-aging, even though there are probably some anti-aging benefits, but certainly in younger women with premature menopause. Definitely consider it strongly and you're probably going to have some benefit in cardiovascular risk and anti-aging if you start hormone therapy and you already start with healthy arteries Because estrogen has so many complex effects on nitric oxide it's a calcium channel blocker.
Speaker 1:It improves blood flow. It has effects on cholesterol, some antioxidant effects and certainly in diseased arteries it can promote clot disruption. So it's got a lot of complex effects. Do take hormone therapy for therapeutic effects if you need it and you're being monitored, and stay tuned for further research. And how will hormone therapy affect by blood pressure, you might ask. Hormone therapy generally does not have a negative effect on blood pressure. In fact, sometimes the blood pressure actually increases less over time in women who take hormone therapy than in those who don't. It generally increases with all people with age. Certainly, higher doses of synthetic pharmacologic doses of estrogen, such as in birth control pills or hormonal contraception, can increase blood pressure and affect the run in angiotensin system.
Speaker 1:Does hormone therapy improve depression, feel-good neurotransmitters in the brain, serotonin, dopamine or epinephrine? Because the replacement of lost estrogen and occasionally progesterone or androgens can improve a woman's self-image and comfort level and sleep. And so it's reasonable to conclude that hormone therapy can positively affect the mood in many, but certainly not all, women, and some progestogens negatively affect women's mood. But many medications, whether they're mood medicines, blood pressure medicines, cholesterol medicines, actually seem to work better when there's adequate estrogen. Hormone therapy might exert benefits beyond helping women regain their even mood by eliminating the unpleasant symptoms of menopause. When women who've been prescribed estradiol stop their therapy, their hot flashes can return, but sometimes the depression does not. The jury's out regarding why estrogen has exact antidepressant effects in some women. We know it's effective in keeping depression at bay in some women, while also reducing severe menopausal symptoms. But estrogen in general is not repeat, is not a standalone treatment for major depression, and women who've never had depression, anxiety or panic but who all of a sudden develop these symptoms during menopause certainly needs to see a women's health specialist who understands the connection in the brain between hormones and neurotransmitters.
Speaker 1:Does hormone therapy improve cognitive function, both memory and thought processes? The answer to this controversial question seems to depend on the timing. Some studies show long-term users of hormone therapy who started hormone therapy at the beginning of menopause show better memory function later in life than women who began it much later. Other studies show that starting hormone therapy long after menopause actually may cause some cognitive decline, and that might be in women, because over age 65, oral estrogen can increase the risk of stroke. Clearly more research is needed before we can better define the role of hormone therapy in cognitive functioning.
Speaker 1:Can breast cancer survivors use hormone therapy? If you're a breast cancer survivor or receiving treatments for cancer, you would have to definitely discuss hormone therapy with an expert. Generally it's not prescribed for women in active treatment, since some breast cancers may grow when exposed to estrogen. But there's lots of alternatives and survivors who have debilitating symptoms of menopause may want to explore low-dose hormone therapy. The HABITS trial Hormone Replacement After Breast Cancer Is it Safe? Study showed an increased risk of breast cancer recurrence if hormone therapy was used, particularly with high doses of progestins, but other studies have shown no increased risk and perhaps survival benefit, and this could be due to the bias of patient selection and or for different effects, as the trials that used more progestins did seem to have worse outcomes.
Speaker 1:Certainly, most breast cancer survivors can use the vaginal string, vaginal local estrogen creams or vaginal DHEA to restore the integrity of the vagina, and many women who are receiving therapies that wipe out estrogen need bone agents like zolendronic acid, known as Reclast, or denosumab, also known as the brand name Prolia. And certainly, if a young woman undergoes breast cancer and is done with her breast cancer treatment, we we do not. We no longer prevent that person from deciding about whether she wants to become pregnant naturally or through assisted techniques, and women who have had breast cancer and have a pregnancy which is very high levels of hormones afterwards have the same or, in some cases better, outcomes than women who have not been pregnant after their breast cancer diagnosis. So, as you can see, it's very complicated. Can we predict who will benefit from hormone therapy and who are the small portion of people who might be harmed from hormone therapy? And who are the small portion of people who might be harmed?
Speaker 1:I think genetic testing and evolving research will probably allow us to further determine in the future, more fine tuning, who are the people that are the best candidates for long-term therapy, as well as those few women who are predisposed to clots or could be potentially harmed. But what we do know now is that short-term therapy is safe and effective for the vast majority of women within 10 years of menopause and it's not a high-risk proposition for those who have discussed the option with their physician and found to be suitable candidates. But individualization, monitoring and re-evaluation are critical and while there's no time limit to feeling well and no specific time limit to hormone therapy contrary to the urban myth that it's only five years periodic reassessment is needed and some people erroneously tell women oh, after five years you have to stop flashes and you've been on hormone therapy and your hormone therapies are stopped and you're under the age of 60, even 65, you have a higher risk of stroke and heart attack because of the resultant hot flashes than someone who continues on therapy. So there are risks in stopping therapy. Hormone therapy it works. The WHI study found that 77% of the women in the study who complained to hot flashes said their hot flashes significantly diminished when they were on hormone therapy. Bear in mind that women with severe hot flashes were not included in the study because they would have known right away if they were taking the drug or placebo, although we do know that the brain is powerful and placebos have about a 30% effect. There are other options for treating hot flashes. You can go back and listen to podcast chapter seven, as well as the medical CME free podcast that talk about the candy neuron inhibitors and non-hormonal options for hot flashes, but none is as effective and broad as hormone therapy. Weighing the risk and benefits, again, I stress that hormone therapy is still the best therapy for treating symptoms and menopause. All women should determine their risk profile with a knowledgeable clinician before starting any prescription treatment. Having said that, let's look at a summary of the risk and benefits.
Speaker 1:Hormone therapy benefits Treats hot flashes. Helps prevent and treat osteoporosis. Prevents vaginal changes from thinning tissue. May improve the skin appearance and hair. Reduces the risk of diabetes. Might reduce the risk for colon cancer. We need further studies. Now. What are the risks? The biggest risk is the rare risk of blood clot, dvt, especially with oral hormone therapy. Oral hormone therapy is also associated with some increase in gallbladder disease, a need for gallbladder removal. There is an increased risk of stroke, primarily in older women with higher oral doses.
Speaker 1:For women with a uterus who have not had a complete hysterectomy of removal of their uterus, estrogen alone can increase the risk of uterine hyperplasia and uterine cancer. But if you take estrogen with progestogen, you reduce this risk lower to the risk of placebo, but you still can get uterine cancer even being on hormone therapy. Hormone therapy has no apparent effect on the risk of ovarian cancer. So don't forget to put these risks and benefits into context, because there is a risk in not treating your symptoms. A lot of women can't function and go to work, they have multiple doctor visits, their personal relationships fall apart and they are not as active because they don't feel as well, which then promotes further weight gain, which promotes further medical problems. So you have to look at the whole picture.
Speaker 1:So you ask is hormone therapy right for me? First of all, if you don't feel comfortable about taking hormone therapy, remember, throughout this podcast we have so many descriptions of alternative therapies lifestyle changes, food, vitamins, stress reduction, exercise, other non-hormonal pharmacologic agents. Some are proven, others are not. As we've seen for women with severe menopausal symptoms, sometimes alternatives are not enough, and you certainly don't have to suffer before you consider hormone therapy. I mean, every day I see someone who's just suffered so long and they thought that they had to have the worst symptoms ever, which is not the case. So you should be asked these questions, though, before being prescribed hormone therapy Do you have abnormal vaginal bleeding, heavy periods, postmenopausal bleeding, spotting after intercourse or when wiping yourself?
Speaker 1:Is there a history of cancer in your family? Early heart disease, blood clots? Have you personally had any endometrial or uterine cancer? Have you personally had blood clots in the veins, superficial or deep, especially during pregnancy or when taking birth control pills? If you've never had blood clots and you've had pregnancies, perhaps a C-section, or taken oral birth control pills or hormonal contraception, because there is a hormonal birth control patch and a couple vaginal rings NuvaRing and the one-year Anavera ring. If you've used these agents and haven't had a blood clot, chances are you're probably not a clotter.
Speaker 1:Do you have chronic liver disease, because oral hormone therapy does go through the liver. Do you smoke? Certainly, women who are over the age of 35 who smoke even one cigarette a week cannot take hormonal contraception and we don't want our menopausal patients and postmenopausal patients to smoke. But if you do smoke, that is not an absolute contraindication to menopausal hormone therapy like it is for hormonal contraception. There's a big difference. Do you have any active gallbladder disease? So if you answer yes to any of these questions, you might need to further individuate your therapy and you might not be the best candidate for hormone therapy or it may need to be adjusted. So for women with liver disease or increased risk of blood clots, high triglycerides, gallbladder problems in those women, it's probably more prudent to use a low-dose hormone therapy or go the transdermal route.
Speaker 1:Now, remember this podcast is not medical advice and it's just a form of some information to help arm you to be ready to discuss these issues with your personal physician. If your answer to every question, though, is no, then you're probably a good candidate for hormone therapy, and you have to just try it for at least three months and see how you feel. The lower the dose, the longer it takes to feel better. So if you go with some uber low dose, it may take up to six months. If you go with a standard dose, some women feel better within a few weeks, certainly within 12 weeks. Am I better off with an alternative?
Speaker 1:Some women choose not to start hormone therapy for personal reasons. Maybe they don't have hot flashes, their bone density is normal. They don't want to take any pharmaceutical agent. If you're a breast cancer with hot flashes, certainly look into the candineuron inhibitors if they've hit the market Venlafaxine or desvenlafaxine, which is a Fexor, or Pristique. We discussed those options in prior podcasts and we'll be talking about them also in customizing therapy for more details. And don't forget to get your bone density checked and get periodic vaginal and vulvar exams to see if there's any signs of thinning. If you're a current breast cancer patient and you're taking tamoxifen or an aromatase inhibitor, in general those women are completely discouraged from using any systemic estrogen use, and that also includes oral DHEA, which I have seen some integrative and functional medicine doctors prescribe. The vaginal DHEA is fine, but not oral.
Speaker 1:What about if you're a woman who doesn't have breast cancer, but you just have an increased risk? If you don't have hot flashes but are at risk for spine fractures thin bones in the spine you may really want to consider the prescription medicine raloxifin, also known as Avista for five years because it's FDA approved to reduce the diagnosis of invasive estrogen-positive breast cancer as well as reduce fracture risk. Similar to menopausal hormone therapy, avista has a slight increased risk of blood clots, particularly if you're immobilized, but does not increase the risk of stroke in older women like oral estrogen does. However, older women with heart disease who have a stroke while they're on raloxifin may have a slightly higher risk of stroke death. So, as with any medicine, there's benefits and risks and it has to be individuated.
Speaker 1:What if you're a woman with a history of stroke or heart attack? Well, certainly you need the standard cardiovascular evaluation and treatment lowering the LDL cholesterol, treating the blood pressure, stopping smoking, treating diabetes, discussing whether you need to be on aspirin or a blood thinner as well as a statin in the evening, discussions on whether baby aspirin is appropriate, doing cardiac rehab with appropriate exercise, being on a Mediterranean diet. So we don't use hormone therapy or roloxifin or antioxidants to prevent a heart attack or stroke in someone who's had the disease. But if your cardiac status is stable and you have other indications for hormone therapy, you certainly can be continued on these hormone therapy and many women function better. So if you are a heart attack survivor and having menopausal symptoms, just like if you're a cancer survivor or you've had blood clots, those special groups of women do benefit from seeking out a menopause specialist as opposed to just a women's health doctor, and you may want to go on our website, speakingofwomenshealthcom, or on menopauseorg. So if you have had a heart attack or stroke or even a carotid dissection, which may be more common in pregnancy or in some women on hormone therapy, once you're medically stable and if your symptoms are severe, you still may consider hormone therapy. But it's critical first to stabilize your status, work with your cardiologist or women's health specialist and evaluate all the risks before beginning any treatment. Paradoxically, though, women who do have a heart attack while on hormone therapy actually tend to respond better to treatment than women who've had a heart attack and who are not on hormone therapy the California teacher study showed this Less ventricular arrhythmias. For someone experiencing moderate to severe hot flashes, hormone therapy is truly the best option for your hot flashes. Though women may try over-the-counter products such as black cohosh remifemin, they're generally not that much more effective than a placebo and may help more with sweats than with flashes. For preventing osteoporosis, many women, when they stop, rapidly lose bone, typical of perimenopause and early postmenopause. So if the only reason you're using hormone therapy is to help your bones, you can certainly use other bone agents, but estrogen is the only option shown to reduce all types of fracture in women who have a normal bone density as well as it reduces fractures in women with osteopenia and women with osteoporosis. Please tune in to our podcast, chapter 12, to go into bone detail, and we're also going to have an upcoming CME podcast on bone health. A final word on hormone therapy and choice.
Speaker 1:I'm often discouraged by the media warnings that continue about hormone therapy, although 20 years post-WHI the tides turned a little bit. I had so many women recently send me links to a New York Times article about how you know they had gotten it so wrong 20 years ago. I'm like, yeah, tell me about it. I've known about this since the beginning, but it's so bad that the media has really affected so many women's psyche because it's really dealt a direct blow to symptomatic, suffering women. Of course, all therapies, including hormone therapy, should be scrutinized for effectiveness and risk, and all women should be listened to and no one should disregard their concerns or symptoms. Just like with any biologic pharmaceutical agent, understanding risk associated with any therapy is critical before the woman and her healthcare clinician can make educated decisions together.
Speaker 1:The problem occurs when scientific studies are just misrepresented for clicks and blown up into national headlines that don't address the full picture, don't address the facts underlying a particular study. This happens too often and these mixed messages confuse women who are very busy, and it does a great disservice to them. So we feel as if our choices are limited and that our safety is at risk. And if you want to control someone, you make them fearful. So anytime you become fearful, your antenna should go up that someone's trying to control you. So if you're suffering from severe menopausal symptoms, don't be a martyr. Please Don't allow yourself to live each day feeling like less of a person because of your discomfort and distress. There are so many options and hormone therapy is one of them. It's not the only one, but it's an important one, and it's a solution that is FDA approved, has been used for over 70 years and certainly has benefited millions of women and has been shown to be safe and effective in numerous well-designed studies.
Speaker 1:So thank you for joining me back in the Sunflower House. This is your host and author. Sunflower House. This is your host and author, dr Holly Thacker. I'm the executive director of National Speaking of Women's Health and you can catch us on anywhere you get your podcast Apple Podcasts, google Podcasts, amazon Music, podcast, addict, iheartradio, cashbox, overcast, spotify. Please give us a five-star rating Helps us move up in the rankings, and please join me back in the Sunflower House for Chapter 11, customizing Hormone Therapy.
