87. HRT + heart disease: 'We don't believe it's going to protect you'

BIG NEWS: Hotflash inc is the #1 Women's Health Podcast on Goodpods, and in the top 1.5 percent of podcasts according to Listen Notes. 

Thanks so much for making that happen! 

While Hotflash inc takes a break, we are replaying a popular and confounding episode here: 

With so much hype surrounding menopause hormone therapy today, it’s very hard to know what or who to believe. 

There is a big push to portray HRT not only as helpful for menopause symptoms, but also as a preventative for cardiovascular disease. But does this bear out in the research we have so far, most of which lumps bioidenticals and synthetic hormones into one basket? That was the question of the latest literature review published  American Heart Association’ journal Circulation this past Valentine’s Day – Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long? – that looked at 96 papers, articles and studies. The authors included gynecologists, women’s health internists, endocrinologists, as well as Stephanie Faubion, medical director for the North American Menopause Society, all members of the American College of Cardiology Cardiovascular Disease in Women Committee. 

Kathryn Lindley, an MD and clinical investigator in the Division of Cardiovascular Medicine at Vanderbilt University Medical Center and one of the authors of the paper is my guest on the podcast this week to break down these findings.

This episode was originally #63 and published on February 18, 2023.

Highlights: 

• why cardiologists have shied away from the topic of HRT
• why HRT isn't recommended for prevention of cardiovascular disease (even if it seems like it should be)
• the case for HRT to help symptoms
• calculating the of using HRT for symptoms ("it's not zero but...")
• why other health conditions matter
• when it comes to vaginal estrogen...
• respecting the HRT "the window of opportunity" 
• so, what can you do to prevent heart disease and stroke?
• the case for assessing reproductive risk factors (and what you need to tell your doctors about your previous reproductive life – even if she doesn't ask)
• the importance of taking in medical news in the media with "skepticism"
• the case for keeping top of your health during perimenopause and taking action early for your future health

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Transcript

0:00

you really, if you're gonna start it, you need to start it early. We still recommend using the lowest effective dose and tapering it off as soon as your symptoms you know, begin to resolve. Hi there. I'm Annemarie McQueen, a menopause in midlife journalist. I have 25 years of experience covering science health, and. And I created hot flashing to inform, inspire, and entertain people who go through pairing menopause and menopause, and the people who care about them. This podcast brings you interviews with scientists, doctors, practitioners, entrepreneurs, thought leaders, and more. In the end, our menopause experience is about so much more than ours. Symptoms. I think it's a total and complete mind, body, and soul shift. It's taking radical responsibility for every single part of our lives. It's becoming who we were born to be. It's nothing short of a hero's journey, and I am here walking the path right beside you. We're gonna have fun.

Ann Marie: 0:52

This is a topic I have to admit that I shy away from because it's so confusing and the information is all over the place so how are cardiologists feeling about this and how did this paper come to be?

kathryn: 1:07

Well, I would say in general, Cardiologists have generally shied away from the topic of h r T as a whole because, you know, obviously it's a little bit out of the wheelhouse in general of the general cardiologist and, the data, suggesting that, hormone replacement therapy could in increase cardiovascular risk.

1:26

I think just sort of, Put a level of fear amongst cardiologists and sort of the safe posture was to say, just don't take hormone replacement therapy. And so really what was driving this manuscript is not that there's been a plethora of new data that's come out, but really we wanted to gather together the data that's there and really reframe. The approach to the menopausal patient for the cardiologist to sort of help guide the cardiologists through how they should think about risk and treatment for their patients who are going through menopause.

Ann Marie: 2:01

And then is it intended also for the other practitioners who are working with women? Because we know menopause sort of falls into this gap, right?

2:07

Like there's the family practitioners and then the OB GYNs, and then if you make it to the card, Well, something's probably going on already,

kathryn: 2:16

right? Yeah, absolutely It is. I mean, I think intended to be a resource for all of those people and really to kind of specifically just think about how can we, approach hormone replacement therapy in light of, cardiovascular disease and cardiovascular risk.

Ann Marie: 2:36

Do I have this right? You have a sentence in there saying it's appropriate that no medical societies currently recommend HT for the primary or secondary prevention of cardiovascular disease. Can you explain that?

kathryn: 2:47

Yes. So, you know, when hormone replacement therapy first came out, the thought was that it was actually gonna be really beneficial for reducing cardiovascular events in women.

2:57

And really the, the theory behind that made a lot of sense. We know that hormone replacement therapy does have positive effects on, cholesterol and weight, and we know that women really do seem to be protected against cardiovascular disease until they go through menopause. So, you know, of course it. therefore, seems like it would make sense that if you gave patients hormone replacement therapy, it would delay or prevent cardiovascular disease, and so it was just being used like crazy to help prevent cardiovascular disease. Fortunately, there have been several very large well conducted studies that have shown that that is not the case. There is actually an increased risk of cardiovascular events among patients who are taking hormone replacement therapy. And so really the way we need to think about approaching hormone replacement therapy is not using it to prevent long-term cardiovascular events, but thinking about what is that risk benefit ratio for the symptomatic patient who really could have improvement in their quality of life, by taking hormone replacement therapy, and how do we weigh that against. The potential risk of cardiovascular events, which is different, depending on who your patient is.

Ann Marie: 4:05

Okay. So if we're talking about someone who doesn't have any cardiovascular issues right now, and they're thinking, well, I think I should go on hormone therapy for other reasons, but I think it will also help protect me from cardiovascular issues.

4:24

What is your advice to.

kathryn: 4:26

There's not good data to suggest that it will prevent cardiovascular disease. However, I think we can safely say that if you are a low to moderate risk patient and you have recently gone through menopause, then it, the absolute risk to the patient is quite low.

4:45

So it is not zero, but it's quite low. And so if you're having. A lot of symptoms related to menopause, then it would be reasonable for you to be treated with hormone replacement therapy because, you know, as I always tell my patients, both quantity of life and quality of life are really important. And so it probably is worth taking a very small, absolute increased risk, if it's gonna dramatically improve your quality of life.

Ann Marie: 5:11

I keep going over this because what you're hearing, what you're saying to me and what I read in the paper is so different from what I'm hearing. When I look at social media and from practitioners on social media, you are talking about, Hey, it's probably worth going on it for your symptoms and any risk you might face will be minimal, and it's offset by the fact that it's helping your symptom.

5:32

I'm hearing over and over and over again that it's gonna help prevent cardiovascular disease that it's gonna, what did someone just say right today? The onset of menopause coincides with accelerated vascular aging. The endothelium plays a pivotal role. It's saying that progressive dysfunction of the endothelial cell layer of the vascular wall and estrogen can offset this. This is the kind of. That we're seeing all the time. And again, it's why you wrote the paper, but what, what do you make of that?

kathryn: 6:00

So most of that is accurate. We do know that, those changes do occur when patients go through menopause.

6:07

And that's exactly why we thought hormone replacement therapy would delay or prevent, cardiovascular disease. And I mean, the medical community was shocked when we did not see that, when we in fact saw the opposite. So, That thinking is exactly in line with what all of the experts in medicine were thinking when these big hormone replacement trials were initiated. Unfortunately, you know, hormone replacement therapy does have some potential, drawbacks to it, you know. Primarily related to increased risk of, blood clotting. And that is really part, a major part of the driver that contributes to heart attacks and strokes. And so, you know, if you're a low risk patient, you know that that overall risk is probably low. But if you already have a lot of other problems, like you already have atherosclerosis, you know, calcium and cholesterol plaques in your brain or your heart, then that risk, you know, risk changes a little bit. If you increase your risk of, of forming blood clots and you already have sort of unstable plaques there. Or if you have a lot of risk factors for it, like high blood pressure and diabetes and high cholesterol, and then you add this additional risk factor in. It's just these things all sort of are additive to one another. Now it is absolutely true that it does positively reflect on some of the risk factor profiles. You know, it does help with weight. It does, make your cholesterol look better. So again, it's a little paradoxical that we see this, increased risk, but it's primarily, Probably driven by that increased risk for clotting, which we also see with birth control pills. But again, you know, even with birth control pills, that risk is small. So for most patients, we say the benefit is greater than the risk. But there are some patients who have particularly high risk and we say, yeah, in your case, the risk is too high, and we would recommend an alternative me method of contraception.

Ann Marie: 8:00

When you read this paper, do you get media coverage on it?

kathryn: 8:03

Have you had a lot of media coverage on it? I've had some. Yeah, there has been some. You know, I think we're hopeful that it'll be really be a resource for the medical community to turn to, to really think about how can we incorporate all this really conflicting data about who should and shouldn't get hormone replacement therapy.

8:22

And I think, you know, honestly, one really important takeaway from. Is that essentially everybody can get vaginal estrogen. The dose of that is so low, it does not have a substantial systemic effect. But, you know, many people just think you're high risk estrogen. That seems like a bad idea. We would not recommend it. But even for our higher risk patients, really they can get substantial quality of life benefit from that without having, really a significant increase in their cardiovascular.

Ann Marie: 8:53

Everyone focuses on the, the results of the Women's Health Initiative study and then the book Estrogen Matters. That came out a couple of years ago and we know that there were problems with that study and women were perhaps started on hormone therapy too late.

9:07

And you talk about that risk, how those risks increase and the window of opportunity, it's best to go on it ear earliest to menopause and all that. But there are other studies like this, the women's health in. Portion of that study that was not the only one that found this increased risk. Right? Like this is what you're saying you've looked at.

kathryn: 9:24

It was a very complete review of the literature and, You know, and, and, and in addition to that complete review of the literature really, also took in the expertise of advice in, experts in menopausal, Medicine and OB, G Y N and cardiology.

9:43

So I think it's a really nice, summary of bringing together not only like what is the literature today, but also what are the experts in all of the relevant fields. Yeah. Like what has been their experience and their guidance.

Ann Marie: 9:56

It's sometimes just portrayed as, that was the study that made it seem like there was a cardiovascular risk and that study been, has been debunked, and we just need to get to a place where we can get some new research that will show a different finding.

10:10

But what I like about what you guys did is you looked at, you've looked at everything and it's like, it's not just that study guys

kathryn: 10:15

absolutely it is. You know, it, it's not just that study, but you're absolutely right. There were some flaws with that, you know, which definitely have been incorporated into the way we think about this.

10:25

You know, we can't be starting. You know, 75 year old women on hormone replacement therapy who went through menopause at 50. You know, you really, if you're gonna start it, you need to start it early. You know, we still recommend using the lowest effective dose and tapering it off as soon as your symptoms be, you know, begin to resolve. So, you know, I think it just really takes a thoughtful approach to sort of picking the right patient for it and, using. Sort of safe methods of it. But you know, what we wanna kind of get across is that hormone replacement therapy. Doesn't need to be a no for everybody. It's, we don't believe it's gonna help protect you. But you know, for most people, if you're having really severe symptom, a very small, absolute risk increase is something that most people are willing to take in order to feel dramatically better.

Ann Marie: 11:14

Do you, do you think that we'll get new research at any point? Because you, you said there's not a lot of new research.

11:20

Do we need new research? Do we need some of those studies were done in men?

kathryn: 11:24

I do think that there's value of, ongoing research in this area and really in. You know, women in general and in the intersection of reproductive health and cardiovascular disease. In general, these are topics that are, grossly understudied.

11:38

But you know, I think. The landscape is really different now. We have, you know, different recommendations at this time for point for cholesterol management, blood pressure management. You know, we have new strategies for weight reduction. So I think that really the primary prevention landscape has changed a lot, as has the, you know, the availability of different, formulations of hormone replacement therapy. And so, you know, I think certainly, there would be value in reassessing risk in the modern era. Much is

Ann Marie: 12:14

made of the fact. And as I understand it, basically what happens in menopause as our estrogen depletes is that we are catching up to men in risk. Yes. And that's sometimes portrayed as we are having a huge surge in our risk.

12:28

And I think as you point out in your paper, the more, conditions that you have that go along with if you're diabetic, metabolics, and all this thing complicates it. But for the average woman, who is worried about this? What is your advice for her, whether she's on hormone therapy or not?

kathryn: 12:46

I mean, I would say a few things.

12:47

Number one, you know, talk to your physicians or or care team members even before you go through menopause and start thinking about how you might wanna approach it. And certainly as you be, begin to develop symptoms. You know, I think really the goal of our, you know, what our job is as. As healthcare providers is to help our patients make informed decisions not to tell them what they need to do. And so we wanna make our sure our patients have all the information that they, they need in order to make a good decision. Number two, it is absolutely true that all those cardiovascular risk factors start to increase, definitely during menopause, but even as patients begin to approach menopause. So I think that's really a good time to engage not only with your ob gyn, but with your primary care provider or your cardiologist to start really monitoring your weight, monitoring your blood pressure, monitoring your cholesterol, monitoring your blood sugars, and if you start to see negative changes on those things, there are a lot of things that we can do to sort of, you know, temper those changes and keep. Cardiovascular risk, kind of healthy trajectory. And obviously that includes dietary changes and exercise, but of course there are also lots of, medication options that are available as well. So we really wanna be proactive, particularly around that time of life when we see a lot of changes in that metabolic risk.

Ann Marie: 14:06

And maybe this is going a little bit too far away from your area of expertise, but you mentioned, feminine forever and, and the whole, you know, estrogen deficiency narrative in your paper. And I do feel we're returning to that in a strange way, it seems in the culture. I sort of wondered what you thought of that from your area of expertise and if this sort of deficiency narrative exists in cardiology.

kathryn: 14:31

As a field of cardiology, again, sort of the whole intersection of reproductive hormones and, and cardiovascular disease has been grossly understudied and, undervalued. So I think it's actually an area right now that has a huge amount of interest, which I think is very exciting for women because, Pregnancy hormones, reproductive hormones around the time of menopause very strongly interact with both short and long-term cardiovascular risk.

14:57

So, I hope to see increased funding through the, you know, n i h and other institutes to help us better understand this. And definitely the conversation is picking up within cardiology to. Really trying to better understand how these things interact with your long-term risk and you know how we need to be thinking about them and, and incorporating them into our care of patients.

Ann Marie: 15:20

And one thing I'm seeing a lot more lately is they're talking about hot flashes as if you have really bad hot flashes and night sweats as that being sort of a biomarker for future cardiovascular problems. And if that is really bad, I mean it always used to be like, haha, I have hot flashes and you know, it takes some hormone therapy. But it seems like there's a, a link there. So can you sort of explain where, where that, your understanding of that is?

kathryn: 15:43

Yeah, I mean there does seem to be some, length area that may be some, physiological marker of, you know, the hormone changes and,

15:52

associated

kathryn: 15:53

risk. So I think it's, it's not well, uh, studied and well understood, but certainly there does seem to be a relationship there.

16:02

And so, you know, I definitely think that's an area. Ongoing evaluation. You know, we honestly, when we do our cardiovascular studies, oftentimes, you know, we don't even ask about these reproductive factors better yet, severity of them. And so it's a real missed opportunity to, you know, when we, we take patients with premature, you know, cardiovascular events. We don't even ask them when they went through menopause or if they had, you know, pre-eclampsia during pregnancy. So it's a real opportunity for us to start gather that information where we're doing these many thousands of people trials to start to tease out how those symptoms, how those risk factors really relate to the long-term events.

Ann Marie: 16:41

Do you have any advice for people who are going through this who may read medical studies in the paper? Because I know the media are notorious for getting this stuff wrong. Yeah. I mean, that's what happened with the Women's Health Initiative and It's happened over and over and over. But do you have any advice for people when they're reading stories about it,

17:00

how it's portrayed how to, how to. Read it with a certain amount of skepticism.

kathryn: 17:05

I think it's very valuable to, you know, be invested in understanding the issue, particularly when, you know, when it, it, you know, personally pertains to you and to obtain the information you can so that you have kind of a framework for having the discussion with your healthcare team.

17:23

I think it's really important to remember though, that, you know, Things that are published in the lay media can have extreme amounts of bias or, or bent just depending on what the source is of the publication. Can definitely, you know, bend not, not bend the truth, but sort of, portray, data in, in different lights, just sort of depending on what the bias of the writer is. So I think it's important to gather that information to kind of build your framework and then have an honest conversation with a healthcare provider that you trust, because they're going to have the experience. Really reading all of the medical literature and knowing how to sort of incorporate that in hopefully a less biased manner and be able to kind of help distill that down, that you can use that information to build off of the framework that you have.

Ann Marie: 18:14

And since I have you on a call, I'm 52, turning 53. I'm pretty healthy. Got a few little things that I'm working out, but what's your best advice and not on hormone therapy? What's your best advice for me to keep my heart going?

kathryn: 18:28

Absolutely. So, you know, obviously if you smoke, stop smoking and if you don't smoke, don't start.

18:35

That's the most important thing you can do.

Ann Marie: 18:36

What about vaping? What about vaping?

kathryn: 18:38

No, we would definitely recommend staying away from vaping as well. There's a lot of people who think

Ann Marie: 18:42

vaping is, is fine.

kathryn: 18:44

We were real, I think we're really hopeful that it would be a much safer alternative to smoking, but it doesn't really seem to be the case.

18:50

And then, you know, right around this time you are. Tend to see your metabolism slow down, your weights start to go up. That can be really frustrating for patients who have never had a problem with their weight and all of a sudden it's really hard. So I think watching your diet can be really helpful for that. I usually recommend a Mediterranean diet with lots of fruits and vegetables, whole grains, lean meats like fish and chicken. And you really have to think about portion control because unfortunately it's really hard to exercise off weight. It really comes down to portion control. And I also usually recommend to really pay attention to what, what calories you're drinking. So it's really easy to drink a lot of calories through soda, sweet tea, Gatorade, sweetened coffees, things like that. And you don't really calculate those in your brain when you're thinking about what you ate for the day. but those are calories that can really sneak in. Definitely stay active with exercise. If you can exercise most days of the week that you know, not only helps prevent weight gain, but it also helps your blood pressure, helps your cholesterol, it helps your blood sugars, it helps your overall cardiovascular risk. And then I would say, you should definitely be speaking with your healthcare provider, really on an annual basis. Really around the time of menopause, I tend to do a little more, intensive screening for diabetes and cholesterol. And blood pressure because those are times when those risk factors start to go up and we can, you know, really assess your long-term risk of cardiovascular events and kind of determine whether or not there's any indications we're starting cholesterol medicines or if we just need to keep working on diet and exercise. And, you know, even if patients begin to develop pre-diabetes, there are some interventions we have that can help, prevent or delay the onset of diabetes. So I think it's a time to really engage with your healthcare provider, stay active, and really be proactive about treating all those risk factors as they may begin to accumulate. I was talking to my friend who's

Ann Marie: 20:44

the same age as me. She said, I think this is a time where everything is in flux and your body's kind of like really trying to balance, right? And so this is the time when things can. And get worse. Yeah, but they don't Maybe, maybe they can start and you can nip it. Is that, is that, am I reading?

21:02

Is that, that's how we feel?

kathryn: 21:04

I think that's absolutely true. I mean, you know, as you go through menopause, you can start to develop high blood pressure or high cholesterol, and you feel fine with those things. You have no idea that those issues are even going on. And it's important to recognize and treat them early.

21:16

because if we treat them, it's really gonna help keep your heart and your brain healthy over the long term. If they go unchecked for a long time, that's where you're really gonna start to get into trouble. So, you know, we wanna identify those right away and so we can really kind of keep you on a healthy trajectory over the long term.

Ann Marie: 21:32

So menopause isn't a direct line to heart disease and hormone therapy isn't the cure

kathryn: 21:39

I think that is a good summary.

Ann Marie: 21:42

Thank you. I'm really glad I talked to you today. That's great. Is there anything that I, I'm, I mean your whole career and everything you've ever done, but is there anything in this part that you think I should have asked or you'd like to say?

kathryn: 21:53

No, I think that that was great. It really summarized our work really well.

Ann Marie: 21:56

Thank you so much for joining me. If you like this conversation, I hope you'll check out some of my other interviews on the Hot Flashing Podcast, subscribe, give a rating, maybe a review, and come back for more next week. Hot Flash Inc. Was created and is hosted by Annemarie McQueen, produced and edited by Sonya Mac. The information contained in this podcast is intended for informational purposes only, and is not intended for the purpose of diagnosing, treating, curing, or preventing any disease. Before using any products referenced on the podcast, consult with your healthcare provider, read all labels, and he all directions and cautions that accompany the products. Information received through the podcast should not be used in place of a consultation or advice. Care provider. If you suspect you have a medical problem, ie. Menopause or anything else or any healthcare questions, please promptly see your healthcare provider. This podcast, including Annemarie McQueen and any producers or editors disclaim any responsibility from any possible adverse effects from the use of any information. Contains herein opinions of guests on this podcast. Are their own, and the podcast does not endorse or accept responsibility for statements made by guests. This podcast does not make any representations or warranties about a guest's qualifications or credibility. This podcast may contain paid endorsements and advertisements for products or services. Individuals on this podcast may have direct or indirect financial interest in products or services. Referred to here in this podcast is owned by Hot Flash, Inc. Media.