Hormone Therapy Formulations Offer Different Levels of Heart Protection – Everyday Health

In the years leading up to menopause, women go through hormonal changes that can increase their risk of heart disease, including increased body fat and high levels of bad LDL cholesterol.

New data suggests that hormone replacement therapy (HRT or HT) with oral conjugated equine estrogens may have a protective effect on heart health when compared with transdermal estradiol HT or no hormone therapy at all. The new study was published in the March issue of the journal Menopause on February 5, 2020.

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The main takeaway from this study is that all hormone therapies are not the same, and its not that one is good and another is bad, says Stephanie Faubion, MD, MBA, the director of the center for womens health at the Mayo Clinic in Rochester, Minnesota. Dr. Faubion was not involved in this research. We need to take these differences into account when we look at each individual woman, to determine what therapy is best according to her needs and what her risk factors are, she adds.

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Cardiovascular disease is the leading cause of death in women, and the risk increases after age 50, when many women officially reach menopause, a status that is diagnosed in retrospect, after a woman has not had her period for 12 consecutive months.

Estrogen is a group of hormones produced by a womans ovaries. It has heart-protective effects; as women age and approach menopause, their ovaries produce less estrogen.

To further explore how hormone therapy may impact the increase in heart risks, investigators examined data gathered from 467 menopausal women who had participated in the Kronos Early Estrogen Prevention Study (KEEPS), a randomized, placebo-controlled trial. To be included in the trial, women had to have an intact uterus, be between 42 and 58 years old, and have had their most recent menstrual period 6 to 36 months before.

To find out if estrogen might impact heart fat accumulation and atherosclerosis progression, researchers measured carotid intima-media thickness, as well as the accumulation of heart fat over a 48-month period.

Researchers divided women into three groups to see the potential effect on the progression of carotid intima-media thickness (CIMT) and heart-fat accumulation. Onegroup was given 0.45 milligram (mg) per day of oral conjugated equine estrogens (CEE), and one group was given 50 micrograms per day of transdermal 17 beta-estradiol; a third group was given a placebo.

Researchers used CAT scan to measure epicardial adipose tissue, paracardial adipose tissue and CIMT at baseline and 48 months. CEE and 17 beta-estradiol are commonly used (sometimes along with a progestin) to manage menopausal symptoms such as hot flashes, vaginitis, or insomnia.

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Carotid intima-media thickness is a measure used to diagnose the severity of carotid atherosclerotic vascular disease, which is typically caused by atherosclerosis. Atherosclerosis is a condition in which plaque builds inside the arteries, and its the underlying cause of most cardiovascular disease or events such as heart attack, stroke or even death, according to the National Heart, Lung, and Blood Institute.

Tests of CIMT measure the thickness of the inner two layers of the carotid artery, which can reveal thickening even if a person doesnt have any symptoms yet. The carotid arteries are two large blood vessels in your neck that supply your brain with blood.

Investigators found that compared with estrogen patches or placebo, oral CEE slowed the negative effects of increasing fat accumulation around the heart in atherosclerosis.

The finding is consistent with what weve seen in previous work in the SWAN study, says Dr. El Khoudary.

In the Study of Womens Health Across the Nation (SWAN), published in September 2015 in the Journal of Clinical Endocrinology & Metabolism, El Khoudary's team found that as concentrations of the sex hormone estradiol (the most potent estrogen) declined during the transition from perimenopause to post-menopause, there were greater amounts of cardiovascular fat, even after they controlled for body mass index (BMI) and physical activity.

Our new findings in KEEPS support the role of estrogen in how this fat could hurt or impact the functionality of the heart, says Dr. El Khoudary. The use of hormone therapy could modify the association depending on the formulation of the hormone therapy and the route of administration, she adds.

What isnt clear is whether the superior protective effect shown by oral CEE was because of the type of estrogen it is or because it was delivered orally; the less-effective estradiol was delivered through the skin, via patch, according to El Khoudary.

This is because these studies were originally designed before there was strong evidence that showed that hormone therapies differed from each other, she says. Further research should be designed to clarify if it is the type of estrogen or the way its administered that slows the progression of carotid intima-media thickness, El Khoudary says.

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The study emphasizes that we should not keep using the term hormone therapy for every single formula or route of administration, as there are many in the market, says El Khoudary. As we do more research, we realize that they are not all the same, and they are not all the same in how they impact cardiovascular health or risk. This study proves that, she says. The impact of hormone use really depends on the specificity of the formulation and route of delivery, she adds.

The risks and benefits of hormone therapy are altered significantly by all these factors, Faubion agrees. So, when people say hormone therapy is good or bad and make it a black or white thing, it completely misses the point, she says.

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Were just beginning to be able to really individualize therapy for each woman, which is a huge, huge step forward for us. Its important to find a healthcare provider who understands the risks and benefits of all the different types of hormone therapy, says Faubion, who is the medical director of the North American Menopause Society.

One way to do that is to visit the North American Menopause Society atMenopause.org, says Faubion. The site offers information about where to find a provider who has completed the North American Menopause Practitioner certification.

Women need to demand more from their providers, says Faubion. We need to empower women to say, 'If youre not individualizing hormone therapy for me and taking into account my cardiovascular risk and my breast cancer risk, then I need to find another provider, she says.

Faubion cautions that women shouldnt change the hormone therapy they are currently on because of the results of this study. This research identifies that there are important differences that need to be further fleshed out, but I wouldnt recommend that anyone jump off what theyre taking or switch to anything else based on these findings, says Faubion.

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Hormone Therapy Formulations Offer Different Levels of Heart Protection - Everyday Health