Hormone Replacement Therapy (HRT) – Are You Still Confused? Dr. Josh Trutt Weighs in…

Well, the holidays are officially over. Many of us have spent the last week or so removing holiday decorations, and dreaming up how we can possibly lose the five-to-ten pounds we’ve accumulated thanks to a never-ending supply of eggnog and sugar cookies. (Ugghhhh….). The end of the holidays signify a new beginning, and we’re often forced to confront issues that we may have been putting off. Is hormone replacement therapy (HRT) right for you?

As if there wasn’t enough to be generally confused about leading up to and during menopause (the great hysterectomy debate, for example), there are still messy, muddled misconceptions surrounding the effectiveness and safety of hormone replacement therapy. That sucks! Feel as though you would like one, amazing doctor to sit you down and demystify the whole thing for you right here, right now? Well…you’re in luck! Dr. Josh Trutt, an expert from PhysioAge Medical Group in New York City, has been a guest on my blog before, and we love him. He’s back with some Q and A, and I for one, am a happy girl.

Ellen: Doctor, what would you say are some simple truths about hormone replacement therapy?

Dr. Trutt:

• Earlier is better. Starting HRT within ten years of menopause gives much greater benefit than starting later. In women who are younger than age 60, oral estrogens decrease the risk of both heart attack and stroke! In addition, starting HRT within eight years of menopause cuts your risk of Alzheimer’s disease in half.
• Despite the many positive studies on estrogen and memory (which can be viewed on my Hormone FAQ page, the Women’s Health Initiative reported in 2003 that HRT increased the risk of dementia in women 65 and older– as early as 12 months after starting therapy!–yet did not increase the risk of mild cognitive impairment. In other words, they seemed to say that women on HRT blew right past mild cognitive impairment and quickly became fully demented within a year of starting HRT!
• (Shumaker SA et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. The Women’s Health Initiative memory study: a randomized controlled trial. JAMA. 2003;289:2651–2662.)
• How do we explain this?
• The answer is that the study group in the WHI were older women (average age 62) who had never been on HRT and thus had spent ten years since menopause building up plaques in their vessels. Then these women were placed on two drugs (Premarin and Provera) that are known to increase the risk of clots and strokes. These women did not suddenly develop Alzheimer’s: they developed mini-strokes in that first year on those drugs, and likely developed multiple-stroke dementia. That is why it appeared to be “sudden onset” Alzheimer’s: it wasn’t Alzheimer’s, it was small strokes.
• This is completely consistent with what we know about the WHI trial: within the first year of therapy (i.e. with PremPro, not bioidentical hormones), women over age 60 in the WHI trial who had not been on HRT previously did have an increased risk of strokes– because Premarin and Provera cause increased clotting and plaque rupture early on. This is why we instead use transdermal estrogen and bio-identical progesterone, both of which do NOT increase clotting or strokes.
• Further detail for those who like to understand the fine print:
• In the Heart and Estrogen-Progestin Replacement Study (HERS), which also used PremPro and relatively older women (relative to menopause) just like the WHI: women who did NOT have a stroke or heart attack in that first year, got a progressively LOWER risk of heart attacks/ strokes each subsequent year that they stayed on hormones. So, by year 4 and 5 on hormones, even those older women, who had never been on hormones until roughly age 62, and then began taking (relatively dangerous) Premarin and Provera, were at LOWER risk of stroke and heart attack than women who had never taken hormones. The reason is that Premarin seems to cause the “reorganization” of plaques in your blood vessels (by increasing something called matrix metalloproteinase). Therefore in women who had plaque buildup for ten years since menopause (because they had no circulating estrogen/ weren’t on HRT), during that first year, this “reorganization” by Premarin increased their risk of plaque rupture and stroke/ heart attack. But if they made it past that first year, the plaque reorganization led to more stable and apparently smaller plaques that then were LESS likely to rupture every year on hormone therapy.
• Using oral non-bioidentical estrogen (such as Premarin or ethinyl estradiol), at any age, will increase the risk of blood clots. When you swallow it, it gets metabolized in the liver, and increases the formation of clotting proteins. And using it together with fake, altered progestins increases the risk of clots even more. Using it in women with other risk factors for blood clots, such as obesity or smoking, raises the risk even further.
• Transdermal estrogen (meaning through a cream or a patch) does not increase the risk of blood clots, in either older or younger women.
• Unlike horse estrogens (such as Premarin), bioidentical estrogen actually may not increase blood clots– even when taken by mouth. There are a few studies that suggest that, but the data is not fully resolved yet. To be safe, it is better to just use transdermal and not worry about it. If you want to read more about those studies, see my FAQ page under Hormone Replacement Therapy for Women.
• Oral estrogen that is started more than ten years after menopause is more likely to cause a stroke or heart attack in that first year after starting HRT. The reason is, estrogen protects women from building up plaque in their arteries. After menopause, estrogen is not being produced– so unless she goes on HRT, she will start building up plaque. Therefore, if a woman has had ten years without any estrogen, she will have built up significant plaque in her arteries. If she then starts oral estrogen, the plaque that has formed over starts to reorganize, and can become unstable in that first year, causing a heart attack or stroke.
• Oral estrogen increases something called matrix metalloproteinase, which seems to cause reorganization of plaque. Both the WHI and the HERS trial showed that if you make it past that first year without having a stroke or heart attack, then even if you stay on oral estrogen, your risk of heart attack or stroke decreases every year—and by year five, your risk is lower than someone who had never been on HRT.
  Side note #2: You can get away with using oral estrogens in women more than ten years after menopause without increasing the risk of stroke or heart attack, but only if the women are otherwise healthy: no hypertension, not obese, nonsmokers. BOTTOM LINE: This is the source of a lot of confusion as to whether HRT increases strokes or heart attacks. You can avoid this whole discussion by simply using transdermal estrogen.
• Synthetic, altered progestins like Provera (medroxyprogesterone), norethindrone, and norethisterone, all increase the risk of breast cancer slightly. Estrogen with natural, bioidentical progesterone does not increase the risk of breast cancer. Estrogen is given alone for HRT actually decreases the risk of breast cancer.[1]

Ellen: The majority of women fear that HRT will cause breast cancer. Does it?

Dr. Trutt: The Danish Osteoporosis Prevention Study is a large, prospective, placebo-controlled trial on HRT, and included over 1000 women who were within a few years of menopause.

These women were on HRT for ten years and were followed for 16 years total. None of the women had an increased incidence of breast cancer, and in fact, there was a decreased incidence in breast cancer for the women who used estrogen-only HRT. So, it would appear that there was no increased risk of breast cancer, or any other type of cancer.[2]

For more information about HRT and breast cancer, please visit Hormone Therapy and Breast Cancer: Clearing the Confusion and Fear by Marina Johnson, MD.

Ellen: The 2002 Women’s Health Initiative was a huge prospective trial of HRT. What were some general conclusions coming out of this study?

Dr. Trutt:

• For women who took oral estrogens but did NOT take Provera, the risk of breast cancer– in all age groups– went DOWN. That’s right: contrary to what you hear in the news, taking estrogen alone without Provera actually DECREASED the risk of breast cancer. In the WHI trial, and in many other trials like it, the fake, non-bioidentical altered version of progesterone (called “progestins”) is what caused a small increase in breast cancer. Estrogen does not. Estrogen with bioidentical progesterone also does not increase breast cancer risk.
• In the women who were younger than age 60, the risk of heart attack and stroke went down and their risk of “total death,” meaning death from any cause, went down.[3]

Ellen: Do “mainstream” docs agree with what you are saying?

Dr. Trutt: The Endocrine Society did a review of HRT in 2010. They were a very “mainstream” group of endocrinologists. Not all types of HRT are appropriate for all women, and they said that. But very importantly, they also pointed out that Menopausal Hormone Therapy was associated with a 40% reduction in mortality in women in trials in which participants had a mean age below 60 yr or were within 10 years of menopause onset,[4] and that is exactly what they found in the Danish Osteoporosis study which was just released. Imagine finding a medication that lowers your risk of death by 40% for as long as you take it! That is what HRT offers when taken appropriately.

So, despite all of the misleading information out there regarding HRT, the conclusion that I have come to with Dr. Trutt is this:  hormone replacement therapy is not a necessary evil; it is necessary and not evil. It is extremely important, however, to discuss exactly what type of HRT is right for you. That means you need to find a doctor who cares. 

For additional resources on hormone replacement therapy, see my other blogs on the topic at:

Menopause Mondays: Testosterone Therapy & Prostate Cancer with Dr. Josh Trutt

Menopause Mondays: Does HRT Cause Cancer?

Menopause Mondays: Take the ‘Bite’ Out of HRT

Menopause Mondays: Understanding Hormone Replacement Therapy

Remember: Reaching out is IN! Suffering in silence is OUT!

What steps are YOU going to take to determine whether or not HRT is right for you?

Ellen is the author of Shmirshky: The Pursuit of Hormone Happiness — a cut-to-the-chase book on perimenopause

and menopause that’s filled with crucial information, helpful guides, and hilarious and heartfelt stories.

Visit her at Ellen Dolgen and subscribe to her Menopause Mondays newsletter. Like Ellen on Facebook, follow Ellen Dolgen on Twitter, Pinterest, Klout, Google + and watch her videos on You Tube.