Over the last 20 years, we have sadly gone back and forth on therapy recommendations for menopause, confusing both physicians and the general public. During the 1980’s and 1990’s we told women to protect their hearts with estrogen therapy when they reached menopause. Then sadly, results from the HERS (Heart and Estrogen/Progestin Replacement Study) and the WHI (Women’s Health Initiative) showed more cardiac harm than benefit. Because of these results, most women stopped using hormone therapy during menopause (despite the fact that hormone therapy showed to have other benefits).
So what’s new now? Emerging findings reveal that there is a window in time when estrogen therapy appears beneficial and another when it has more risk. Two studies[i],[ii] published in the prestigious New England Journal of Medicine in March 2016 show that during the first 6-10 years of menopause, estrogen decreases the risk for heart attacks and strokes. However, 10-12 years after menopause, estrogen use shows an increase in cardiovascular events.
The details are critical, so let me share a few important points:
Progesterone versus progestins
First, estrogen is commonly used with progesterone, especially if women still have a uterus. The type of progesterone therapy makes a huge difference in clinical outcomes, regardless of age. A synthetic form of progesterone, called medroxy progesterone (MPA) increases the risk for heart disease and for breast cancer. I can’t understand why any physician would recommend medroxy progesterone during menopause, but it is still in use.
Progestins are a common class of progesterone-like drugs that pharmaceutical companies structurally modify from bio-identical progesterone into a different compound so that they can have a patent on the product they create (as natural hormones provide no patent protection). Nearly all progestins increase the risk for adverse health events, such as heart disease, when compared to natural progesterone.
Micronized progesterone has not been shown to have these adverse effects, so clearly if you are taking progesterone, I recommend you talk to your physician about taking the micronized form of bio-identical progesterone. Due to limited topical absorption, I usually prescribe oral progesterone.
Topical versus oral estrogen therapy
Second, estradiol is the natural, bio-identical form of estrogen most commonly used to treat menopause symptoms. Yet whether a woman uses it orally or topically has a significant impact on inflammation and clinical outcomes. Oral estradiol, compared to topical estrogen, increases inflammation levels (hs-CRP) by 192% and increases the risk for a blood clot by 400%[iii]. So when a woman is using estrogen, I nearly always recommend using a patch or an estrogen cream applied topically. If you happen to be using oral estrogen, check with your physician if you might be a good candidate to use a topical alternative. Many physicians might not be aware that there are now several FDA approved forms of topical estrogen.
When is the best time to use estrogen:
Third, the timing as to when you use estrogen is critical. During the first 6 years of menopause, evidence shows that there is more benefit than risk to estrogen therapy, especially if you use a topical form of estrogen and it is used with micronized progesterone. After 10 years of menopause, a woman and her physician need to balance the risks and benefits of estrogen therapy carefully, in particular look at risk for a future heart attack or stroke, and make the best decision in light of the severity of menopause symptoms present.
Lastly, there are some other aspects of menopause therapy that are less controversial. Everyone agrees that using estrogen during menopause helps menopause symptoms and improves bone density. It is also well established that estrogen increase the risk for a blood clot to form (although much less with topical than oral therapy). Another side effect of estrogen use is that it increases the risk for gall bladder disease and gallstones. In the end, you and your physician always need to balance the benefits versus the risk with hormonal therapy.
I hope this blog has helped you understand the benefits and risks of estrogen therapy.
I wish you the best of Health!
Steven Masley, MD, FAHA, FACN, FAAFP
[i] Manson JE, Kaunitz AM. Menopause Management—Getting Clinical Care Back on Track. N Eng J Med 2016; 374: 803-6.
[ii] Hodis HN et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. N Eng J Med 2016;374:1221-1231.
[iii] Circulation 2007;20:340-5.
DR MASLEY RECOMMENDS:
“In his new book, The Estrogen Window, Mache Seibel, MD, has created a breakthrough guide to coach women through menopause. He clarifies how to manage menopause symptoms, balance the risks and benefits of hormone therapy and when might be the best time to consider treatment, and how to communicate effectively with your doctor. I Highly recommended this for anyone dealing with menopause issues.”―Steven Masley, MD, FAHA, FACN, FAAFP, CNS, bestselling author of Smart Fat and The 30-Day Heart Tune-Up and creator of top public television programs: 30 Days to a Younger Heart and Smart Fats to Outsmart Aging.
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