HRT in older women? What's the scientific scoop versus standard of care?

We are told there is an “estrogen window” and after this time, a woman cannot safely be given hormonal therapies anymore. That after a decade in menopause, women have missed out.

In fact this has become what we refer to as “standard of care”.

Is this accurate?

Is there an estrogen window timing set in stone where after 60 years of age, that’s it. No more safe possibility of hormone replacement therapy (HRT) for you?

I get questions like this all the time. Dr. S kindly said this when I asked if I could share her question she emailed me a few days ago?

Yes! Anything to help people feel more clear! 

Shiroko Sokitch, MD
_________________

Heart to Heart Medical Center
drshiroko@hthmc.com

Hi Lindsey
How are you? We’ve talked about getting together sometime and I would love to make plans for that. I know you’re super busy but maybe a zoom visit would be a start.

I have a serious question in light of the recent article you wrote about Dr. Mercola being wrong about estrogen replacement.

I have several female patients who are over 60 and have not been on consistently HRT.

They are being told they shouldn’t use any hormones after 60 for fear of cancer.

I have been giving some of my 60+ patients hormones and it makes them feel much better.

What is your take on the “no hormones after 60”. I’d really appreciate your input.
Wishing you a great day.
love
Shiroko
____________________
Shiroko Sokitch, MD
Heart to Heart Medical Center

Berkson:

I would love to.

I have been so busy my eye balls are twirling especially with all this lecturing, working in Florida, just quit, rebuttal to Mercola etc.

Yes you can initiate BHRT at any age even in later 90's… but very very slowly and carefully and with full cardiac workups first. Prepping receptors for a month helps as they have been senescent for a while. But receptors do reboot. They reboot and do a healthy job of receiving hormone signals.

We have done this in my medical teams safely, repeatedly, with great boost of quality of life and often able to reduce more meds, isolate less, etc.

One of my PRO members recently had a mother, 88 years old, never on HRT. She had a large stroke and was debilitated. This provider put her mom on HRT. Within days her improvement soared and she is now doing better than pre-stroke and all her support staff for the mom are amazed. I had dinner with this provider at A4M in Chicago and she shared this case report with me in detail.

lets connect next month and stay close you are amazing and I would be so honored to do so.

much love. and respect.

Berkson
Can I publish this thread it would be so helpful to so many.

Shiroko

Yes, that is fine.

Shiroko:

Hi Lindsey
Thank you again for all your work. I truly appreciate you and your research and work help me to help my patients better.

Oh, and I’ve shared your recent article rebuttal of Dr. Mercola with a bunch of my functional medicine colleagues which generated a great discussion.

And it’s going to go to some traditional OB/Gyns to help them understand more too.

Although people have a way of turning hormone theories into a religion.
Thank you
love
Shiroko

Berkson:

Their lack of knowledge is dangerous yet often arrogant.

Even more dangerous.

I hate that “sisters-of-my-heart” miss out.

Shiroko

Oh! I KNOW!!

Even my functional medicine colleagues are totally uneducated about hormones and what to do with them.

Several integrative cancer care docs say NO to hormones at anytime, and one of them is what sparked this question, that women should not take estrogen after age 60, even if they don’t have cancer.
Thank you again.

_______________________________

I will share with you today just some of the science that we share with providers at many CME symposia.

Data on hormones and older ladies.

7 Million NIH study

First off: This is the largest study ever run on estrogen replacement by the US NIH and the National Library of Congress. It’s a retrospective study. It’s still being evaluated by peer review.

Our NIH and National Library looked at the records of 7 million American women and found that 1.5 million American older women were still on estrogen replacement therapy (ERT). These women are all 65 years old or older.

These researchers then dived into the details of these women’s medical records. They had them all, as they were all on Medicare.

These findings, in this largest human estrogen study, on OLDER women, showed:

• Women on estrogen lived up to 20% longer than women not on ERT.

• ERT protected statistically (more than chance) against getting all of the 5 cancers looked at - breast, ovarian, uterine, lung and colon. Women on ERT got less of all of these cancers.

• Women had less neurodegnertive diseases unless they took oral estrogens or synthetic progestins.

• Women had less adverse heart issues unless they took oral estrogen.

• Older women with established heart issues, fared the best, with ERT helping them live longer even with heart issues. Take this in. Women with established heart disease, got some of the best living younger longer benefits from ERT, than any other ladies. This is definitely not the present stance of standard-of-care.

The authors concluded:

•Menopausal hormone therapy (MHT) is indicated for menopausal symptom relief. However, MHT has also been shown to be beneficial for prevention of long-term estrogen deficiency sequelae including mortality.

•Based on a comprehensive literature review (meta-analysis of 31 observational studies) on MHT and mortality, the authors' recommendations are as follows:

•in postmenopausal women, MHT appears to confer a (significant) reduction in overall mortality; the benefit especially applies to women who initiate long-term MHT early after menopause;

•in women with prevalent cardiovascular risk factors (except for diabetes mellitus, where results are mixed), the benefit of MHT on overall mortality is even more pronounced.

Research presented and re-published by the American College of Cardiology

Another positive hormone study on ERT in older women with established heart disease was presented at an American College of Cardiology symposium in 2017, and again, still in peer review? What’s with that?

The researchers retrospectively analyzed the health records of more than 4,200 women who received a coronary calcium scan at Cedars-Sinai Medical Center between 1998 and 2012.

A coronary calcium scan is a CT scan that measures the amount of calcium in the heart's arteries. Having higher levels of calcium is a marker for the buildup of plaque, which increases the risk of having a heart attack or stroke.

41% of the women reported taking hormone replacement therapy at the time of their calcium scan. Use of hormone therapy was highest between 1998-2002

After accounting for age, coronary calcium score and cardiovascular risk factors including diabetes, high blood pressure and high cholesterol, women using hormone replacement therapy were overall 30% less likely to die than those not on hormone therapy.

Women using hormone replacement therapy were also 20% more likely to have a coronary calcium score of zero (the lowest possible score, indicating a low likelihood of heart attack) and 36% less likely to have a coronary calcium score above 399 (indicative of severe atherosclerosis and high heart attack risk).

"Hormone replacement therapy resulted in lower atherosclerosis and improved survival for all age groups and for all levels of coronary calcium," Arnson said. "From this we do think it is beneficial, but we would need prospective or randomized studies to determine which groups might not benefit or even be harmed by this therapy." Honestly, if you read the literature this mantra of we need more studies gets real old.

Estrogen is thought to be protective of heart health through its beneficial effects on cholesterol and because it increases the flexibility of blood vessels and arteries, allowing them to accommodate blood flow.

Studies show that pre-menopausal women, who produce high levels of estrogen, typically have the cardiovascular health of men 10 to 20 years younger than them, but rates of heart disease increase dramatically after menopause, when estrogen levels plummet.

By replacing the natural estrogen lost during menopause, hormone replacement therapy could be one way for women to regain the cardiovascular benefits of estrogen, Arnson said.

ERT lowers lipoprotein (a)

A genetic marker for your genetic deal of the cards for your risk of getting a stroke, is often observed by looking at a marker called Lipoprotein (a). The higher this is above reference range, the higher the genetic risk of stroke.

ERT lowers this in ladies.

Testosterone replacement lowers this in gents.

Hormones are about protection, not the opposite.

This study comes from the Department of Medicine, University of California, and Veterans Affairs Medical Center, San Francisco.

•Participants: A total of 2763 postmenopausal women younger than 80 years with coronary artery disease and an intact uterus. Mean age was 66.7 years.

•Intervention: Participants were randomly assigned to receive either conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in 1 tablet daily (n = 1380), or identical placebo (n = 1383).

•Main outcome measures: Lipoprotein(a) levels and CHD events (nonfatal myocardial infarction and CHD death).

•Results: Increased baseline Lp(a) levels were associated with subsequent CHD events among women in the placebo arm.

•Treatment with estrogen and progestin reduced mean (SD) Lp(a) levels significantly (-5.8 [15] mg/dL) (-0.20 [0.53] micromol/L) compared with placebo (0.3 [17] mg/dL) (0.01 [0.60] micromol/L) (P<.001).

•In a randomized subgroup comparison, women with low baseline Lp(a) levels had less benefit from estrogen and progestin than women with high Lp(a) levels.

•Conclusions: Our data suggest that Lp(a) is an independent risk factor for recurrent CHD in postmenopausal (older women, Berkson’s wording) women and that treatment with estrogen and progestin lowers Lp(a) levels. Estrogen and progestin therapy appears to have a more favorable effect (relative to placebo) in women with high initial Lp(a) levels than in women with low levels. (I am not a fan of MPA, a synthetic progestin, but still this was a very demonstrative study on older women with established heart disease benefiting from ERT).

From Texas.

University of Texas Health Science Center and Hermann Hospital, and the Texas Heart Institute, Houston, USA did another study.

Estrogen replacement therapy (ERT) in women after menopause is associated with prevention of clinical coronary artery disease.

However, few studies have investigated possible benefits from ERT in postmenopausal women undergoing treatment for established coronary disease.

We therefore retrospectively reviewed the clinical outcomes of 428 postmenopausal women undergoing percutaneous transluminal coronary balloon angioplasty (PTCA) to test the hypothesis that ERT has a beneficial effect in this setting.

Meaning, how did ERT help older women with established heart disease in procedures where they could look inside the women’s blood vessels? Berkson’s words.

The women were divided into 2 groups based on ERT status at the time of the procedure. Estrogen users were younger (60 +/- 10 vs 68 +/- 9 years, p <0.001), more commonly had family histories of coronary heart disease (54% vs 41%, p = 0.04), had less incidence of hypertension (63% vs 76%, p = 0.02), and had slightly fewer diseased vessels per patient (1.3 +/- 0.5 vs 1.5 +/- 0.7, p = 0.03) compared with nonusers.

No in-hospital deaths occurred in estrogen users compared with 5% hospital mortality in nonusers (p = 0.01).

The combined outcome of death or myocardial infarction (MI) also was lower in estrogen users (4% vs 12%, p = 0.04).

Of 348 women discharged after successful PTCA, 336 (97%) were able to be contacted at an average follow-up interval of 22 +/- 17 months (range 5 to 82).

Estrogen users had superior event-free survival both for death as well as for death or nonfatal MI.

Repeat revascularizations were similar in both groups (32% vs 24%, p = 0.15).

In a Cox proportional-hazards model, nonusers had 4 times the likelihood of death after angioplasty compared with estrogen users (OR = 4.025, 95% CI = 1.3 to 13.4, p = 0.02).

We conclude that estrogen replacement may offer protection against clinical coronary events in postmenopausal women who already have established coronary disease and are undergoing balloon angioplasty.

The benefit was independent of age, smoking, presence of diabetes mellitus, or the number of diseased coronary vessels.

Yet heart docs often tell women and somehow it’s become standard of care, if you are on ERT, and you get an adverse event (like a heart attack or stroke) that you are no longer a candidate for ERT.

But the science does not support this view.

I am only sharing peer review science here, not just my personal experience or opinion.

From Brown-Dartmouth

Brown-Dartmouth Medical Program, Providence, Rhode Island, USA looked at ERT and restenosis “after” percutaneous coronary interventions.

Background: Although estrogen replacement therapy in women has been associated with a reduction in cardiovascular events and improvement in endothelial function, no study has examined whether estrogen reduces restenosis rates after percutaneous coronary interventions.

Methods: A total of 204 women enrolled in the Coronary Angioplasty Versus Excisional Atherectomy Trial with angiographic follow-up were contacted, and their menopausal and estrogen replacement status was determined. Late loss in minimal lumen diameter, late loss index, minimal lumen diameter, rate of restenosis > 50% and actual percent of stenosis were compared in estrogen users and nonusers by quantitative coronary angiography at 6-month follow-up.

Results: Late loss in minimal lumen diameter was significantly less in women using estrogen than in nonusers (-0.13 vs. -0.46 mm, p = 0.01). A regression analysis of the determinants of late loss in minimal lumen diameter revealed that estrogen use was the single most important predictor of subsequent late loss (F = 13.38, p = 0.0006). Formal testing revealed a highly significant interaction between the use of estrogen and intervention (angioplasty or atherectomy). Women undergoing atherectomy who received estrogen had a significantly lower late loss index (0.06 vs. -0.63, p = 0.002), less late loss (0.06 vs. -0.61 mm, p = 0.0006), larger minimal lumen diameter (p = 0.044) and lower restenosis rates (p = 0.038 for > 50% stenosis) than those not using estrogen. In contrast, estrogen had minimal effects on restenosis end points after angioplasty.

Conclusions: This study demonstrates the potential for estrogen replacement therapy to reduce angiographic measures of restenosis in postmenopausal women after coronary intervention, particularly in those undergoing atherectomy.

BTW: I interviewed that Harvard OBGYN who wrote that estrogen window book. Never published that podcast.

Why? This guy quoted a study that he claimed, when I interviewed him, proved that natural hormone therapies, bioidentical hormone replacement therapies (BHRT), had been shown in this study to be harmful. I was stunned. I asked please give me that citation. He haughtily waved me away, it’s in my book. Read my book. In other words, look for it myself.

Calling my mentors, none of them had heard of this.

I scoured this dude’s book for several days and found it. A survey. Not a study. On gyneologists’ opinions, roughly 125+ of them. It was just a survey. A set of opinions. Not a study.

I did not publish this interview that would, of course in my opinion, scare ladies needlessly and pass wrong info forward. This guy has, btw, won awards for this book. This book did a lot to promote his “theory” of an estrogen window. Which, the science does not support.

You gotta be careful who you listen to.

In my opinion.

I have had women in their 90’s, on many meds, sometimes up to 14 to 20 meds, isolated, in pain, overweight, osteoporotic. Once on HRT, very slowly, very individualized, they can reduce meds, lose weight, start to socialize, it’s like a dried up plant being given water and sunlight.

Big credentials! Harvard. OBGYN. Hard-earned yes. But does not mean they are always right?

If our mantra is look at the science, then yes, let’s do so. I invite you to digest the above science along with your Sunday brunch.

I gotta go get my morning cup of Joe.

Did YOU find this post helpful?

Also, PS, look at the dynamic ladies on HRT.

Dr. Pam Smith is a icon in teaching BHRT. She is on BHRT, getting up there, and going strong. Look at myself.

We are aging slower because of BHRT. But it’s BHRT combined with consistent, healthier choices. Such as Dr. Smith shares how she always has 2 ounces of pomegranate juice a day.

What we eat, how we live, matters.

I am soon gonna tackle testosterone replacement in ladies. Good, bad or wrong?

Dr. B.

References:

Effects of Hormone Therapy on survival, cancer, cardiovascular and dementia risks in 7 million menopausal women over age 65: a retrospective observational study doi: https://doi.org/10.1101/2022.05.25.22275595 This article is a preprint and has not been peer-reviewed [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice. Yale BMJ Preprints

The impact of menopausal hormone therapy on overall mortality - a comprehensive review. Climacteric. 2020 Oct;23(5):447-459. doi: 10.1080/13697137.2020.1767568. Epub 2020 Jun 18. PMID: 32552066.

Hormone Replacement Therapy Is Associated With Less Coronary Atherosclerosis and Lower Mortality," on Friday, March 17, at 3:45 p.m. ET at the Non Invasive Imaging Moderated Poster Theater, Poster Hall C at the American College of Cardiology's 66^th Annual Scientific Session in Washington. The meeting runs March 17-19. 2017

Estrogen and progestin, lipoprotein(a), and the risk of recurrent coronary heart disease events after menopause. JAMA. 2000 Apr 12;283(14):1845-52

Estrogen replacement therapy and outcome of coronary balloon angioplasty in postmenopausal women. Am J Cardiol. 1998 Aug 15;82(4):409-13

Relation between estrogen replacement therapy and restenosis after percutaneous coronary interventions. J Am Coll Cardiol. 1996 Nov 1;28(5):1111-8