Can HRT Combat CVDs in Menopausal and Postmenopausal Women?

Contrary to what many people believe, cardiovascular diseases (CVD) affect women as much as, if not more than, they affect men. Despite advances in its prevention, diagnosis, and treatment, cardiovascular disease remains the leading cause of death worldwide. One of five women in the US die of heart disease, especially as the risk of CVD increases in the years after menopause. Since menopause and estrogen loss are linked to a spike in cholesterol levels, some researchers have considered hormone replacement therapy (HRT) as a possible solution to the problem. 

So can hormone replacement therapy (HRT) really minimize the risk of cardiovascular diseases (CVDs) in a menopausal woman? Hormone replacement therapy is recommended for menopausal women to reduce their risk for CVD. Based on the current understanding that the drop in post-menopausal estrogen levels leads to a buildup of fat and cholesterol in the arteries, the likelihood of CVDs developing can be minimized by correcting hormonal imbalances through HRT. 

HRT vs CVDs: How It Works 

Hormone replacement therapy, which is also known as hormone therapy (HT) or menopausal hormone therapy (MHT) is a treatment initially designed to help women alleviate hot flashes, sweating, bone thinning, vaginal dryness, and other signs of menopause. While there are different methods of hormone delivery available, the overall goal is the same: balance oestrogen and progesterone levels during or near menopause. 

With HRT medication, patients can recover the hormones their body has stopped producing due to menopause. Estrogen, in particular, is a hormone that protects women against heart disease; it is known to combat rising lipid (fat) levels, narrowing blood vessel walls, and increasing fibrinogen production which causes blood clots. Aside from fighting CVDs, HT can also reduce the possibility of developing debilitating diseases like osteoporosis and colorectal cancer as well. 

Hormone replacement is especially encouraged for patients who are experiencing early menopause, unless there is a specific reason from them not to take it. HRT should not be taken as a form of disease prevention, as doing so could disrupt your hormone levels. 

Causes of Menopause

Before going in-depth on cardiovascular diseases and hormone therapies, it’s important to take a look at what menopause is and how it affects women’s bodies. 

Menopause is a natural event that marks the end of menstruation in a woman’s life. Much like how the first menstrual period is the beginning of puberty, menopause is the ‘last period’ that  signals the end of her reproductive years between the ages of 45 - 55. 

As a woman approaches her late 30s, her ovaries gradually begin to produce less estrogen and progesterone hormones. When the ovaries stop producing oestrogen, the female sex hormone, changes occur to the menstrual cycle. The woman stops ovulating or releasing a mature egg monthly. Menopause is officially confirmed once a woman has stopped having her period for 6 - 12 consecutive months. 

Sometimes, menopause and estrogen decline also occur under other circumstances. Carcinoma therapies, premature menopause, and surgical removal of the ovaries may all induce menopause as well:

• Chemotherapy and radiation therapy: Chemotherapy or radiation therapy can halt menstruation and fertility, causing menopause symptoms shortly after the course of treatment. However, menopause following chemotherapy is not always permanent and radiation therapy only affects ovarian function if the radiation is directed at the ovaries. 
• Primary ovarian insufficiency: Around 1% of all women actually experience menopause before they even reach the age of 40. Primary ovarian insufficiency is a result of the failure of the ovaries to produce normal levels of reproductive hormones, sometimes following genetic factors or an autoimmune disease. Patients with primary ovarian insufficiency are often prescribed hormone therapy until they reach the natural age of menopause to protect their brain, heart, and bones. 
• Oophorectomy: Oophorectomy is a surgery to remove the ovaries; they are often performed to treat ovarian cancer. As the ovaries are responsible for producing the hormones that regulate the menstrual cycle, surgical removal will cause immediate menopause. And because of the abrupt hormonal changes, patients often experience a number of severe symptoms alongside the end of their menstruation. 

Aside from regulating the menstrual cycle, oestrogen also has an effect on almost every tissue in the body and its decreased levels manifest physically. Many women, although not all, would experience uncomfortable signs before, during, and after menopause such as: 

• Hot flushes/flashes
• Night sweats 
• Heart palpitations
• Weight gain
• Headaches
• Insomnia or sleep disturbance 
• Lower sex drive
• Dryness, due to the thinning of vaginal walls
• Aches and pains in joints and muscles 
• Pain during sexual intercourse
• Difficulty concentrating 
• Memory lapses
• Changes to the hair, skin, and nails 
• Inability to control urination (incontinence) 
• Fatigue or low energy
• Mood swings, depression, or irritability 

Most of these symptoms can be managed through lifestyle changes and hormone replacement therapy. 

Perimenopause, Menopause, and Postmenopause: What’s The Difference? 

Menopause actually arrives in phases, typically referred to as perimenopause, menopause, and postmenopause. Each stage of menopause marks a gradual transition in a woman’s life and their overall health. Physical signs could also be vastly different when comparing the early stages to the latter ones. 

• Perimenopause: Perimenopause is the period right before menopause, which can last anywhere between 4 - 10 years. Women in their 40s slowly begin to feel the physical changes due to the gradual estrogen loss, such as breast tenderness, mood changes, fatigue, trouble sleeping, and a decreased interest in sex. Although women can still become pregnant during this time, they may also experience irregular periods and intense premenstrual syndrome (PMS) symptoms. In the last 1 - 2 years of perimenopause, estrogen decline rapidly accelerates. 
• Menopause: The perimenopause period officially ends when you experience one year without your period. Menopause begins and the ovaries stop releasing eggs; menopausal women can no longer have monthly periods or get pregnant. In addition to the physical changes from perimenopause, patients may also have palpitations, weight gain, brain fog, hair loss, or unexplained aches in their body. 
• Postmenopause: Postmenopause or after-menopause are the years following a woman’s life after their periods have ceased. This final phase lasts the rest of their life; the changes and discomfort may ease or stay the same. The significantly lower estrogen levels during this time increases the risk of certain health conditions. 

What Happens When Your Hormone Levels Change

Menopause leads to drastic changes in the balance of your hormones, which are the chemicals produced by the body and released into the bloodstream. Each hormone plays a critical role in ensuring you maintain your bodily functions; they regulate processes like appetite, metabolism, body temperature, sleep cycles, reproductive cycles, sexual function, and mood. Even a slight change would have a noticeable effect on your overall health and wellbeing. 

Although hormone levels naturally fluctuate during various life stages like puberty, menopause in women completely alters the chemistry and rhythms of their body for the rest of their life. A hormonal imbalance occurs because there is too much or too little of certain hormones. Here is a look at the three major hormones involved in menopause: 

Conditions That Affect Menopausal and Postmenopausal Women 

Menopausal and postmenopausal tend to experience hormonal imbalances which increase their risk of chronic medical conditions. When estrogen supply dwindles, postmenopausal women are more likely to have osteoporosis, urinary incontinence, colorectal carcinomas, and unhealthy weight gain.

• Osteoporosis: Osteoporosis is a condition that causes the bones to become brittle and weak. It is characterized by bone density loss, increased risk of fractures, and compromised bone integrity -- all of which are linked to hormonal changes. Estrogen is a hormone that protects and defends bones strength; once women reach menopause and have lower estrogen levels, they become more likely to develop loss. Postmenopausal patients are especially susceptible to fractures in the hips, spine, and wrists. 
• Colorectal carcinomas: Colon and rectal cancers are usually grouped together; the difference between these bowel cancers depend on whether the polyps first form in the rectum or the colon. Estrogen is responsible for lowering the levels of insulin-like growth factor, a protein that prods mucosal cells into action. Without estrogen, as in the case of menopause, the extra activity of mucosal cells can lead to the development of colorectal polyps. 
• Urinary incontinence: As women undergo menopause, the lack of estrogen causes their pelvic muscles to weaken. The tissues of their vagina and urethra also lose elasticity, leading to loss of bladder control. Patients have frequent, sudden, and strong urges to urinate and an inability to “hold it in”, especially when coughing, laughing, or lifting heavy objects. This condition makes them prone to urinary tract infections as well. 
• Weight gain: Menopause and postmenopause slows down metabolism in the body. While this is sometimes related to age and a decrease in muscle tissues, hormonal changes can also cause an increase in body fat. Estrogen is responsible for fat storage and distribution, depositing fat in the thighs, hips, and buttocks during perimenopause. After menopause, however, more fat is deposited into the midsection. This surrounds the organs and leaves you more likely to develop diabetes, as an increase in visceral fat is linked to insulin resistance, heart disease, and inflammatory diseases. 

Estrogen Loss: A Risk Factor for CVDs 

Although scientists are still learning about how estrogen fluctuation affects the body, it’s clear that estrogen is active in every tissue and organ system. This includes the heart and blood vessels, where estrogen can:

• Increase HDL cholesterol (good kind)
• Decrease LDL cholesterol (bad kind)
• Relaxes, smooths, and dilates blood vessels for increased blood flow
• Promotes blood clot formation or causes changes to have the opposite effects
• Absorbs free radicals, the naturally-occurring particles in the blood that can damage arteries and other tissues 

Traditionally, estrogen has been defined as the protector of the heart. When estrogen levels drop, doctors observe a jump in heart disease risk as LDL cholesterol increases and HDL cholesterol decreases. This leads to a buildup of fat and cholesterol in the arteries, which develop as heart or circulatory system disorders like heart attack (myocardial infarction), stroke, high blood pressure, high cholesterol, and high triglyceride levels. Poor vasomotor symptoms also include changes in blood pressure, night sweat, hot flushes, and heart palpitations. 

From this point-of-view, it makes sense to replace estrogen through hormone replacement therapy. Doctors prescribed HRT to a number of women in order to improve their heart health and keep the inner linings of their blood vessels flexible. However, recent studies on the long-term use of HRT are challenging the traditional way of thinking. 

After large-scale trials were conducted, researchers discovered mixed results: the risk for heart attack, stroke, and breast carcinoma increases the longer HRT is used. According to the largest randomized, controlled trial to date, there is a small increase in heart disease for postmenopausal women using combined estrogen and progestin hormone therapy. On the other hand, some clinical studies also suggest that oestrogen replacement alone won’t increase the risk of heart disease, but may not provide the protective benefit against coronary heart disease.

As study outcomes are affected by a number of factors, it’s hard to determine what exactly is the most accurate finding. The current recommendations from the CDC are as follows:

1. HRT should not be used as prevention for myocardial infarction or stroke. 
2. Using HRT for addressing osteoporosis and other conditions should be carefully considered; the risks should be weighed against other benefits. Women who have existing coronary artery diseases should consider other treatment options.
3. HRT may be used for short-term to treat the effects of menopause, but long-term use is discouraged. 

If you’re suffering from menopausal or postmenopausal symptoms but are worried about the negative side effects of hormone replacement therapy, you should consider: 

1. The actual risk of an individual getting heart disease due to hormone therapy is very low. For patients who experienced menopause early on and have moderate to severe menopause complaints, but are otherwise healthy, the benefits likely outweigh potential risks. 
2. Individual cardiovascular risk depends on many factors like personal medical history, family medical history, and lifestyle practices. If you’re a patient with low risk factors and significant complaints, hormone therapy should be considered. 
3. The health risks for women who have had early natural menopause or primary ovarian insufficiency before the age of 40 are different from women who reach menopause in their 50s. Premature menopause leads to a higher risk of coronary heart disease, and HRT in this case can protect you.

Other Risk Factors of Cardiovascular Diseases

Risk factors are conditions or lifestyle factors which make a person more likely to develop a certain disease or increase the chances that an existing condition will get worse. When it comes to CVDs, most doctors look at the risk factors that can be managed as some risk factors, like age and family medical history, cannot be changed. However, they do make your physicians aware of what you could be at risk for. Coronary heart disease risk factors for women include: 

• Age: Around 82% of people who die from coronary heart disease are 65 years and older, although this age tends to be lower for women. Menopausal or postmenopausal women who are 55 years old at least should pay close attention to their cardiovascular health, as risks begin to triple with each decade of life. Women who have had early menopause are also twice as likely to develop CVDs than women of the same age who have not yet reached menopause. 
• Family history: Cardiovascular disorders are, to some extent, genetic. It’s important to let your doctor know if you have any immediate relatives with a history of heart surgery, high blood pressure, myocardial infarction, or stroke. 
• Blood pressure: High blood pressure or hypertension is defined when the systolic and diastolic pressure levels climb to 130/80 mm Hg or higher. As women age, hypertension becomes more common, although high BP rarely causes noticeable physical changes. 
• Cholesterol levels: High levels of cholesterol in the blood, especially of low-density lipoprotein cholesterol (LDL-C), can cause a buildup of plaque in the inner walls of the arteries. Plaque slows blood flow or blocks blood flow entirely. If the blood vessel in the heart gets blocked, it causes a heart attack; if a blood vessel in the brain is blocked; it causes a stroke. 
• Diabetes: Diabetes is a disease where levels of blood glucose are too high due to a poor regulation of insulin in the body. Women with diabetes are more likely to develop CVDs as diabetes can affect blood circulation over time. 
• Weight: A healthy body weight is necessary for optimal cardiovascular health. Overweight women can reduce health risks greatly by losing just 10% of their weight through a low-fat, high-fiber diet and regular exercise. 
• Poor diet: A high intake of fatty, sugary, processed foods are linked to a number of conditions like cardiovascular risk, obesity, and diabetes. A high intake of fat, sugar, and sodium combined with a low intake of fruits, vegetables, and fish can raise blood pressure and blood cholesterol drastically. 
• Smoking: Smoking is the most preventable risk factor for cardiovascular disease; women who smoke are two to six times more likely to have a heart attack than nonsmokers. Aside from directly inhaling tobacco, exposure to secondhand smoke may also increase health risks. Patients who quit smoking drop a number of health risks quickly, regardless of how long and how much they have smoked.
• Excessive alcohol consumption: Some studies suggest that low levels of alcohol consumption are actually protective against vascular disease, but the cardiovascular risk increases when consuming alcohol in moderate or high amounts. 
• Physical inactivity: Insufficient physical activity (or less than 30 minutes of moderate activity daily per week) is a leading cause of ischemic heart disease and diabetes. Participating in 150 minutes of exercise weekly can help with weight loss, improve blood glucose control and blood pressure, raise good cholesterol, and lower triglyceride levels in menopausal and postmenopausal women. 

What Is Hormone Replacement Therapy? 

Menopausal and post menopausal women face a lot of potential risks and medical complications as they age. Fortunately, hormone replacement therapies can address some of the complaints of menopause and manage certain risk factors as well, especially for women who experienced menopause too early. 

Hormone replacement therapy is medication that contains female hormones, usually taken to replace estrogen that the body has stopped producing during menopause. Hormone therapy is most often used to treat common menopausal symptoms, but is sometimes utilized to minimize bone loss and reduce fractures in postmenopausal patients as well. 

Although there are some risks associated with estrogen replacement therapy, it largely depends on the type of hormone therapy administered, the dosage prescribed, how long the medication was taken, and personal health risks of the patient. In order to achieve the best results, hormone replacement therapies should be tailored to the specific patient and reevaluated frequently to see if the benefits continue to outweigh the risks. 

How HRT Helps Menopausal and Postmenopausal Women

Currently, there is still a debate on whether hormone replacement therapies can provide cardiovascular benefits. There are a number of studies investigating the long-term effects of hormone therapy on postmenopausal women who receive it closer to menopause versus later in life. Based on existing research, HRT is recommended only as a tool for managing physical manifestations of menopause rather than a preventative solution, and should only be administered under close medical supervision. 

There are also a number of risks depending on your current age and stage of menopause, hormone dosage, the type of hormones you take, the method of delivery, and whether or not you’re taking unopposed estrogen or estrogen combined with progestin (the synthetic form of progesterone). Other factors like family medical history and cancer risk should be taken into account as well. 

If you’re relatively healthy, you may want to consider the benefits of HRT:

1. Among all other treatments, HRT remains the most effective medication to relieve hot flashes and night sweats. 
2. Patients who need to prevent bone loss or fractures but cannot tolerate bisphosphonates could utilize postmenopausal HRT. Estrogen therapy also works where most other treatments may not be effective. 
3. Hormone therapy can ease vaginal complaints of menopause, including dryness, itchiness, burning, and discomfort during intercourse. It can also address other issues like thinning vaginal walls, vaginal or bladder infections, mood disturbances, abnormal sensations, poor sleep patterns, and hair loss. 
4. Patients who experienced menopause in their 40s or have some form of estrogen deficiency should undergo estrogen therapy to decrease the possibility of early onset heart disease, stroke, dementia, osteoporosis, or mood changes. 

What To Expect From An HRT Procedure

Patients are often confused or afraid when they hear about hormone therapy because they don’t really know what to expect. Here are a few common questions women ask prior to undergoing HRT: 

Q: Are hormone replacement therapies safe?

A: Yes, as long as you take the appropriate amount of medication that’s right for you. There are different types of menopausal and postmenopausal hormone therapy, delivered in various ways. Even the length of time it takes for symptom relief varies from person to person, so be sure to visit a provider who can customize the procedure for you.

Q: What are the different types of products?

A: Estrogen and progestin are available in a number of forms. If your uterus hasn’t been removed, most providers prescribe progestin to balance the effects of estrogen in the uterus. There are two major kinds of hormone therapies which can replace what you lose after menopause:

• Synthetic hormone therapies contain a higher dose of estrogen which is absorbed throughout the body. They are available as pills, skin patches, gels, spray foams, vaginal creams, and slow-releasing suppositories or rings which have to be placed in the vagina. 
• Low-dose vaginal estrogen can treat symptoms with minimal absorption into the body. Usually, these creams, rings, and tablets are only good for vaginal and urinary complaints of menopause. Conjugated equine estrogen is one form of medication that is better applied to the vagina than taken orally, in order to minimize potential side effects. 

Q: How long will it take for the body to adjust to the new hormones?

A: Side-effects usually improve over time, so talk to your doctor if they are still severe and persist after three months. It’s also good to check back with your provider after six months to see if the hormones are making a difference, if there should be changes to the dose, and if the side effects are still “normal”. Some doctors prescribe cyclical HRT with estrogen and progestin to align with the normal menstrual cycle, so the body is more receptive to the new flow of hormones. 

Q: How long until results can be felt?

A: Results tend to differ from person to person. Depending on the dosage and hormone type (estrogen, progestin, or combined), most patients observe changes within the first few weeks or months after treatment. For bioidentical progestin or estrogen, results can be experienced in as little as two weeks because bioidentical hormones are formulated to mimic the body’s natural hormones. This allows for a quicker adjustment period. 

Potential Risks and Side Effects of HRT During Menopause

Hormone replacement therapies are not for everyone. The basic rule of thumb doctors follow before prescribing HRT is whether or not the benefits of hormone therapy outweigh the risks. Even though hormone therapy can treat menopausal symptoms and reduce the risk of some debilitating diseases, it also has the potential to increase the risk of other diseases -- albeit minimally. These small risks and side effects must be balanced against the actual benefits of HRT for each individual patient. 

Hormone replacement therapies are not recommended for patients who have had a myocardial infarction, heart diseases, or history with blood clots. Some common side effects of oestrogen or progestin therapies include:

• Acne
• Bloating
• Cramps
• Headaches
• Bodily swelling
• Breast tenderness
• Nausea
• Vaginal bleeding

HRT has also been studied to increase the likelihood of developing breast cancer, endometrial carcinoma, venous thromboembolism, and cholecystitis. 

• Breast cancer: Based on research, women over the age of 50 who use combined oestrogen and progestogen (progesterone) replacement for less than 5 years have little to no increased breast cancer risk. However, patients who use HRT with progestin for over 5 years may have a slightly increased chance of getting breast carcinomas -- depending on the type of progestogen used. For patients using oestrogen without progestin, there is no increased risk for up to 15 years of usage. 
• Venous thrombosis: Venous thromboembolism is a condition wherein blood clots from inside the veins. Findings suggest that there is an increased risk of developing venous thrombosis among postmenopausal women who are genetically predisposed to blood clots. Risks are also at their highest during the first year or two of therapy, but lower with non-oral HRT delivery like patches, implants, and gels or tibolone. 
• Endometrial cancer: The endometrium is the lining of the uterus and the risk of polyps forming in this area is increased with the use of oestrogen-only HRT. There is zero risk if the uterus was removed through a hysterectomy, nor with the use of combined progestin treatment. 
• Cholecystitis: Cholecystitis is a disease in which the gallstones in the gallbladder cause infection and inflammation by blocking the ducts; the only treatment for this problem is to surgically remove the gallbladder. Researchers have observed that the risk for cholecystitis is slightly higher with oral HRT, but lower with patch HRT. 

Do’s and Don’ts for Minimizing Menopausal Complications

As mentioned earlier, a healthy lifestyle should not be underestimated for its role in preventing heart disease among menopausal and postmenopausal women. Take cardiovascular risk seriously by following these do’s and don’ts to reduce the risk of cardiovascular disease during and after menopause: 

1) Do quit smoking. 

Smokers are at a much higher risk for heart disease compared to nonsmokers. Preserve your cardiovascular health by saying goodbye to your cigarettes and staying away from secondhand smoke as much as possible. Ask your physician for tips on how to best break your smoking habit.

2) Don’t exceed your recommended body weight. 

Growing overweight leads to an early onset of heart disease. When you go over your ideal weight, your heart has to work harder to pump blood and replenish nutrients throughout your body. A healthy diet, regular exercise, and sufficient sleep are the most effective methods of weight loss available. 

3) Do exercise weekly. 

Your heart is just like any other muscle: it needs to undergo regular workouts to keep it strong and healthy. Being active and exercising regularly -- at least 150 minutes per week -- improves the ability of your heart to pump blood and reduces stress. Be sure to incorporate aerobic exercises for additional cardiovascular conditioning. 

4) Don’t eat and drink junk. 

While it is tempting to open up a bag of chips or drink a few cans of beer to unwind after each long, stressful day, it’s best to eat junk food occasionally and in moderation. Your diet is a major lifestyle factor that affects everything else in your body, so your cardiovascular health will definitely benefit from a high-quality diet that’s low in saturated fat and trans fat. 

A diet that is high in fiber, whole grains, nuts and legumes, fruits, vegetables, fish, soy products, and folate-rich foods can reduce blood pressure, lower cholesterol, and maintain healthy weight. It’s best to avoid sweets, red meat, fatty and processed foods as well. As for drinks, you can indulge in 1 - 2 alcoholic beverages per day to keep the heart healthy, but no more than that. 

5) Do treat, manage, and control your medical conditions. 

Diabetes, high cholesterol, and high blood pressure are all known risk factors for heart disease. Have regular checkups and health screenings so you can detect and treat these conditions as early as possible. Some doctors recommend:

• Getting cholesterol levels checked every 5 years
• Getting blood pressure checked at least every 2 years
• Getting blood glucose levels checked every 3 years
• Checking waist circumference and body mass index during every regular healthcare visit 

6) Don’t stress out. 

Psychosocial and mental stress are associated with an increased risk of heart problems. Menopausal and postmenopausal women are also more prone to suffer from depression, which is linked to a doubled risk of stroke among middle-aged women. While the transition from perimenopause to menopausal and postmenopausal stages can be an emotionally difficult time, it’s important to stay positive and stress-free. Practicing good habits and engaging in socialization can greatly improve mood and relieve stress in older women. 

Consult With Us At Revitalize You MD 

At Revitalize You MD, we aim to provide the best care for you and your health. Aside from bioidentical hormone replacement therapy, we also offer a number of medical and aesthetic procedures which can be tailored to suit your personal needs and goals. You don’t have to suffer through discomfort and low self-esteem; bring back wellness to your body with help from our certified and licensed medical staff. Schedule an appointment with Revitalize You MD today.