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

Cold Facts About Hot Flashes

By Lauren Streicher, MD

Published May 27, 2014, Everyday Health

The number one reason most women start systemic estrogen is to treat hot flashes once they realize that yoga, carrying a portable fan, and dressing in layers are not real solutions. Hot flashes occur in 75 percent of menopausal women and typically begin as a sudden sensation of heat on the face and upper chest that becomes generalized. A severe flash can be pretty intense (I call it the furnace inside you) lasting between two and four minutes with profuse sweating, followed by chills and shivering. Physiologically, a hot flash happens for the same reason that you sweat in a sauna… the body is trying to cool down. The difference is, you don’t really need to cool down, but your menopausal brain thinks you do. While most last 2-4 years, some women will experience flashes for up to 10 years. About 10 percent…forever.

Toughing it out works out for some women, but other’s who have severe hot flashes though out the day and nights are totally blind sided by just how debilitating hot flashes can be. Estrogen therapy will eliminate or dramatically reduce flashes, but many women choose not to take estrogen, or have been advised by their doctors to steer clear. In fact only 7 percent of women with hot flashes ultimately accept a prescription for estrogen. As an estrogen alternative, menopause experts, including myself, often prescribe one of the antidepressants which years ago were serendipitiously found to reduce hot flashes in menopausal women. This of course is the rationale for Brisdelle; the FDA approved option of low dose paroxetine, one of the selective serotonin reuptake inhibitor (SSRI) antidepressants.

While numerous scientific studies have shown that many antidepressants are effective at reducing hot flashes, no studies have compared antidepressants, estrogen and placebo in the same study.

In the May 27 issue of JAMA, a new research study is published looking specifically at this issue. 339 peri and postmenopausal women in the study took estrogen, venlafaxine (an antidepressant), or a placebo for 8 weeks. Women that took the venlafaxine had a reduction in hot flashes that was essentially as good as women that took low dose estrogen.

In addition to flash frequency, this study also looked at “treatment satisfaction” and interference of symptoms with daily life and found that treatment satisfaction was highest for estradiol, intermediate for venlafaxine, and lowest for placebo.

The study is somewhat limited in that it was short (only 2 months) and did not evaluate libido or weight gain, both of which have been shown to be affected by antidepressants used in typical doses used to treat depression. That evaluation would require a longer study and more women. But, be that as it may, this is still important information and confirms that venlafaxine, like other SSRI’s and SNRI’s, at least in the short term, not only reduces hot flashes, but does it almost as well as estrogen.

Every once in awhile someone will say, my grandmother didn’t take anything for hot flashes, why should I? Well grandma was more likely to be home baking cookies than doing a job that required a good night’s sleep and the ability to think clearly. Grandma may have been having occasional sex with Grampa, (there’s a visual I didn’t need to give you!) but was unlikely to be starting a second marriage or a new relationship in her 50’s. Grandma likely did not live nearly as long as you will. So whether you chose to take hormone therapy or an alternative, if your flashes are getting in the way of your sleep, your sexual health or your quality of life, know that you have options.