If you've been following the menopause movement, you've likely encountered discussions about the "critical window" for starting hormone therapy. Experts often cite a timeframe of "within 10 years of the final menstrual period or until age 60, whichever comes first."
Reflecting on the Women’s Health Initiative (WHI) trial, as discussed in a previous blog post, the study aimed to address whether hormone therapy should be universally administered to menopausal women for disease prevention. The resounding answer was no. However, there are significant caveats to consider. Firstly, the study employed oral premarin and synthetic progestin, whereas current practice leans towards "bioidentical" hormones such as transdermal estradiol and oral progesterone. Secondly, crucially, the study excluded symptomatic women, assuming hormone therapy was a given for them and focusing instead on its potential benefits for asymptomatic women.
A key finding of the WHI study highlighted an increased risk of cardiovascular disease and thromboembolic events like heart attacks and strokes associated with the hormone regimen used. Yet, recent research indicates that when initiated early in menopausal transition and administered in contemporary ways (estradiol transdermal and oral progesterone), hormone therapy can be protective against heart disease.
During menopause, our vascular system undergoes irreversible changes. LDL cholesterol levels rise, contributing to atherosclerosis, while blood pressure increases, placing added strain on vessels and plaques. A loss of collagen and elastin occurs and arterial walls become less flexible. These changes, though inevitable with age, accelerate during menopause and worsen over time. Administering oral estrogen, which increases clotting factors, and synthetic progestin, linked to cardiovascular issues, to individuals with advanced disease escalates their risk of adverse events.
However, there's no definitive age at which hormone therapy becomes unsafe. Individualized care is paramount. If a 65-year-old patient seeks hormones solely to improve overall health, I would not recommend initiating therapy. But if the same individual reports struggling with hot flashes for a decade, I'd be open to discussing hormone therapy, evaluating their heart disease risk factors, including lipid profile, family history, exercise habits, metabolic health, and smoking status. Additionally, a coronary calcium score (CAC), a CT scan assessing arterial calcifications indicative of plaque, can provide valuable insight. With a thorough understanding of risks and benefits, hormone therapy could be a viable option.
In essence, while risks may slightly increase post-60, hormone therapy isn't categorically ruled out. For suitable candidates, it can be life-changing.
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