Making the hormone replacement therapy decision

By Katherine Shagoury

Do mid-life women need to be medicated for menopause, asked Joel Evans, MD, at the 2019 Integrative Healthcare Symposium in New York City? 

Some say yes, while others say the alterations of a woman’s basic hormonal physiology over decades for long-term disease prevention could be dangerous. In fact, a 2017 and U.S. Preventive Services Task Force (USPSTF) statement published in the Journal of the American Medical Association recommended against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal women, as well as against the use of estrogen alone in postmenopausal women who have had a hysterectomy.

Still, Evans wants practitioners and patients to make informed decisions when it comes to hormone replacement therapy (HRT) and offered what he calls the HRT Decision Tree. Consider:

• Have they had their ovaries removed or started menopause before age 52?
• If menopausal symptoms are present: treat with or without HRT?
• If at-risk for or concerned about cardiovascular disease, cognitive decline, or osteoporosis: reduce risk with or without HRT?
• If diagnosis of cardiovascular disease, cognitive decline, or osteoporosis: treat with or without HRT?
• If desire for optimal health and aging: optimize the functional medicine matrix and possibly add HRT?

Women spend about one-third of their lives in menopause. Therefore, we are obligated to determine the degree to which declining estradiol levels mediate the age-related decline in so many health parameters, Evans said.

For women in the menopausal or postmenopausal stage, there are three major physiological considerations:

1. Cardiovascular disease implications
2. Osteoporosis or osteopenia
3. Cognitive decline

For the purposes of this article, we will focus on cardiovascular disease recommendations. Heart disease is the number one cause of death in women, and nearly half of all deaths in women over 50 years old are due to some form of cardiovascular disease, Evans said. Estrogen protects the cardiovascular system. Estrogens are potent vasoactive hormones, Evans says, and reduce inflammation and oxidative stress.

Menopause occurs as cardiovascular disease risk factors are increasing, including changes in body fat distribution, reduced glucose tolerance, and increased blood pressure.

“We know that menopause increases cardiovascular disease risk,” said Evans. “The question now becomes, does estrogen reduce the risk?”

But does HRT prevent cardiovascular disease in menopause? Evans says the recommendations by professional societies are contradictory and confusing. But looking closer at the literature, in 2013 an important new theme started gaining traction. A study published in Current Opinion in Cardiology stated, “the vasoprotective effects of estrogen are age-dependent and disappear with aging or estrogen deprivation.”

Evans said there is biologic plausibility that estrogen replacement therapy helps prevent cardiovascular disease. The intervention data is most supportive of estradiol, he said, and the timing hypothesis data backs starting HRT for cardiovascular disease prevention five or fewer years in to menopause.

Evans says he recommends HRT for cardiovascular disease prevention in women at high risk for cardiovascular disease and low risk of breast cancer. He says he continues it up to 10 years, but works to reduce cardiovascular disease risk at the same time to potentially stop HRT sooner.

Ultimately, the decision to utilize HRT is up to both the patient and the practitioner. Functional medicine practitioners giving HRT should always consider the functional medicine matrix first, Evans said, considering the patient’s physiology and function as a whole, as well as addressing modifiable personal lifestyle factors first:

• Nutrition
• Exercise and movement
• Stress
• Sleep and relaxation
• Relationships

From there, Evans said practitioners should consider hormone modulation, and then move on to determining in HRT is warranted. Measure levels before giving hormones, select the hormones you wish to use, select the carrier and route of administration, and decide on the dosage. Monitor levels and metabolism consistently, Evans said.

“The HRT pendulum is swinging back and forth,” Evans said. “It shouldn’t be the only course, or neglected altogether, but somewhere in between.”