Menopause, Women's Health

Hormone Replacement Therapy

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Hormone replacement therapy is such an important topic and so many women have questions around if using hormones is beneficial or harmful. This article will discuss everything hormone related in relation to menopause and provide information regarding if, when, how long and the benefits/risks of hormone replacement therapy.  

The natural progression of aging in women is losing follicles in the ovaries each month. Surprisingly, females have the maximum number of oocytes (follicles) at 20 weeks gestation, and they gradually decrease through the course of a women’s life until the average women transitions into menopause around age 52.

With this depletion, comes a natural decrease in the hormones, estrogen and progesterone. The course can fluctuate causing a surge of hormones and then a decline while transitioning into menopause for years precluding, which may be the cause of those pesky perimenopause symptoms. These symptoms can range from mild to severe and really impair the function of a women’s life.

The question to give hormone therapy to assist with these perimenopausal symptoms is one that should be addressed with your healthcare provider on an individual basis. The consideration is based on the individual patient and past medical history as well as family history. Just as with everything in life, there is always a risk, but there is often a benefit too. We will consider the risks and benefits of hormone replacement therapy (HRT) further in regard to cardiovascular disease, osteoporosis, and cognitive decline.

Cardiovascular Health

Estrogen is protective for the cardiovascular system. Estrogen reduces inflammation, oxidative stress in the vascular smooth muscle cells, and decreases resistance to insulin. The choice to use hormone replacement therapy for cardio-protection alone, may not be indicated as the literature shows, however, timing the hormone replacement therapy in prevention of heart disease is indicated in early menopause.

Beginning hormone replacement therapy in the perimenopausal/early menopause period promotes anti-inflammatory/vasoprotective to pro-inflammatory/vasotoxic effects. There is evidence to support this “timing theory” that cardiovascular benefits may be derived when estrogen therapy or hormone therapy is used close to the onset of menopause or within 6-10 years and the research suggests it is safe. Longer exposure to estrogen 10+ years past menopause can cause plaque erosion, rupture, thrombosis, or possibly acute coronary events (heart attacks or strokes) and should be used with caution in individuals.

There is a fine line of using hormone replacement therapy to protect patients who are at risk of cardiovascular disease and evidence supports that the duration and timing is a key variable.

Bone Health

Osteoporosis is low bone mineral density and affects approximately 10 million Americans and eight million or 80% are women. Age is a key player in increasing the risk of fractures and 1 in 3 women over age 50 will have an osteoporotic fracture. Our bones are being constantly remodeled and with relation to menopause, the normal bone turnover cycle is impaired by estrogen deficiency. This means that the bones are being resorbed faster than they are being made which can contribute to reduced bone formation and “thinner” bones.

Estrogen is beneficial for reducing bone resorption, accelerating calcium resorption, and reducing calcium excretion from the kidneys. All of these together significantly increase bone mineral density. The literature states to use HRT for osteoporosis when other therapies are unsuitable.

The other therapies are osteoporosis medications such as raloxifene and bisphosphonates, which will not be discussed in further detail in this article.  Other lifestyle interventions are imperative for prevention of osteoporosis including; a diet rich in calcium (best from plant sources), vitamin D/K2, weight-bearing and balance exercises, to name a few. Estrogen and progesterone could also be used and solid evidence suggests good benefit from using them. Click here for a more detailed discussion on osteoporosis.

Cognitive Health

Brain derived neurotrophic factor (BDNF) is a growth factor that enhances memory function. Estrogen increases BDNF levels. Researchers suggest that using HRT during initial years of menopause can increase cognitive function and improves cerebral metabolic rate and blood flow. Estradiol and progesterone reduces formation of reactive oxygen species which may be causative for neurodegenerative disorders such as Alzheimer’s disease.

Hormone therapy is approved for women with premature surgical menopause without contraindications. Clinical trials showed beneficial effects of treatment on verbal and working memory during that critical window or the “Timing Hypothesis” (within 6-10 years of menopause onset).

In addition to the time period of administering HRT, the type of hormones are also an important factor. Most of the studies and data are from the use of conjugated equine estrogens, such as Premarin. Bioidentical estrogens such as Estradiol or Bi-Est may have a different risk-benefit profile. Conjugated equine estrogens are made synthetically whereas bioidentical estrogens are as the name suggests, bioidentical.

This is the closest to our natural hormone as possible with almost identical properties. Progesterone is the name for the bioidentical sources, progestogens are those that are synthetically made. 

At Empowered Health, we discuss all of these risk and benefits with our patients. There are many reasons women seek HRT from perimenopause symptoms to protection of the heart, bones or brain. A conversation with your healthcare provider is essential in deciding if this is the best option for you. 

Haley Scellick, ARNP

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