Hormone Replacement May Be Heart-Safe During Menopause

While most women perceive breast cancer as their greatest health threat, in the United States, heart disease is the No.1 killer of women, as well as of men. An American woman is 10 times more likely to die from heart disease than from breast cancer. Because many women take statins, a class of drugs that lower cholesterol, how well these drugs work for women who are also taking hormone replacement therapy is an important question.

One of the main purposes of the Women’s Health Initiative (WHI), a large U.S. study of 161,000 women that was initiated in 1991, was to determine whether long-term hormone therapy could prevent heart disease in women and prolong life in addition to controlling postmenopausal symptoms.

The end result, released in 2002, was not the expected result.

The WHI showed that for every 10,000 women per year who used estrogen and progestogen (compared to the women who were not taking any hormones or were taking estrogen alone), there were actually seven additional myocardial infarctions (heart attacks) and eight additional strokes. Overall, hormone replacement was associated with higher heart-health risk in this study.

But what we now appreciate is that, in many ways, the study design was flawed. For one, the average age of women in WHI was 63, and more than 70 percent of the women enrolled were over the age of 60.

Age Matters for Heart Disease Risk During Menopause

A re-evaluation of the study results showed that estrogen users between ages 50 and 60 did not increase their risk of cardiovascular disease. They actually decreased their risk of coronary heart disease and overall mortality. This is an important finding because menopausal women in this age group are the ones who are the most symptomatic — and the most likely to take hormone therapy.

Other studies have confirmed that it is not only the age at which women take hormone therapy, but also the type of estrogen that matters. Beta estradiol and transdermal estrogens seem to have cardiovascular advantages over the conjugated equine estrogen that was used in WHI.

There was another important issue. WHI did not identify who was taking statin drugs, and who was not.

New Data on the Difference Statins Can Make

A new Swedish study, published in the journal Menopause, attempts to answer the question of statins’ effects on heart disease risks for women taking hormone replacement therapy.

In this study, 40,000 women took statins along with beta estradiol, compared to 38,000 who did not. Over four years, the number of deaths and cardiovascular events, such as heart attack and stroke, were recorded. The rate of death from any cause was 33 per 10,000 person-years for women who used hormone therapy with statins compared with 87 per 10,000 person years for women who used statins alone — a significant difference.

The bottom line? If a woman chooses to take hormone therapy, it appears the best time to start is at the onset of menopause. The type and route of estrogen make a difference. In addition, for women at risk for cardiovascular disease, taking a statin may decrease the risk of coronary heart events that may occur early on in hormone therapy.

In spite of this information, at this point, hormone therapy is not recommended to treat or prevent cardiovascular disease. But, as we continue to gather data, the estrogen pendulum is swinging again. Many women can feel a lot more comfortable about taking systemic estrogen — not only relieve menopause symptoms but maybe even to prolong life.

Everyday Health March 25, 2015

Everyday Health March 25, 2015

Busting 5 Hormone Replacement Therapy Myths

By Lauren Streicher, MD

Published May 9, 2014, Everyday Health

Between the “expert” at Whole Foods, your hairdresser, and your most savvy friend, it’s hard to know who or what to believe when it comes to hormone replacement therapy (HRT). Even your gynecologist and internist may give conflicting recommendations! My new book, Love Sex Again, is your go-to guide for comprehensive, medically accurate information on hormone therapy risks and benefits. Here’s the scoop on some common hormone replacement therapy myths.

Myth No. 1:  Local vaginal estrogen carries the same risks as oral estrogen.

The facts: FDA class labeling requires all products with the same ingredient to have the same warning, even if the problem indicated by the warning has never been demonstrated in that product. That’s why risks associated with oral estrogens are listed on vaginal estrogen rings, tablets and creams even though not one single complication, warning or risk listed on the package insert (dementia, blood clots, breast cancer, oh my!) has ever been shown to result from using a local vaginal estrogen product. There is a movement among scientists to get these dire warnings off the label, since there is no evidence of truth, and many women who would benefit are too frightened to use vaginal estrogen products.

Myth No. 2: Bioidentical hormones are ‘natural.’

The facts: The only way to really get a natural bioidentical hormone is to drink the horse urineor eat the soy plant. All plant-derived hormone preparations, whether they come from a compounding pharmacy or a commercial pharmacy, require a chemical process to synthesize the final product, which can then be put into a cream, a spray, a patch, or a pill.

Promoters of compounded, plant-derived hormones use the terms “natural” and “bioidentical ” because they are appealing to consumers and imply an advantage over manufactured pharmaceutical products. FDA approved plant-derived products from your corner drugstore are just as “natural” as the products you get from a compounding pharmacy.

Myth No. 3: Saliva levels are a useful way to determine hormone therapy dosage.

The facts: No one argues that estrogen and progesterone levels are detectable in saliva, and it would be great if a drop of spit could actually unravel the mysteries of menopause. Unfortunately, salivary hormone levels, which are used to create the illusion of individualized therapy, are not biologically meaningful; do not correlate with blood levels; vary depending on diet, time of day, and other variables; and have not been proven useful in any scientific studies in determining the appropriate dosage for hormone replacement.

Likewise, blood tests, while more accurate, are not routinely used to determine the appropriate dosage of hormone therapy since there is a wide range of “normal” blood levels. What matters is not a target number, but how someone feels.

Myth No. 4: Estrogen therapy is a leading cause of breast cancer.

The facts: This is the one that will have a lot of you shaking your heads and thinking, “Is she kidding?” But the facts speak for themselves. Over 80 percent of women who have breast cancer have never taken hormones. In addition, the risk of developing breast cancer from hormone therapy is lower than the risk associated with daily alcohol use or obesity. According to the 2002 WHI study (the one that made women across the nation flush their estrogen down the toilet) only the women who took estrogen and progestin together had a slight increase in breast cancer.

The news flash that didn’t make it to the news is that in the estrogen only group there was an 18 percent decrease in breast cancer. It is now clear that the modest increase in breast cancer in women who take hormone therapy is due to the progestin, not the estrogen.

Myth No. 5: Orgasms require estrogen.

Rejoice! Even if your estrogen tank is on empty most women can still experience the big O. Appropriate local or systemic estrogen therapy goes a long way to make intercourse more comfortable if pain or dryness is an issue, but it does not appear that addition of hormone therapy is necessary for most women to have an orgasm. Having said that, there is data that suggests that supplemental estrogen alone or with testosterone in some post-menopausal woman will facilitate orgasm by increasing blood flow and sensitivity to the clitoris.