Estrogen: Worth the risk?
Any regular reader of this blog knows that I am not a fan of hormone replacement therapy (HRT) nor the health risks associated with it. Nevertheless, although I espouse alternative strategies for dealing with menopause, I do feel that sharing news about HRT is important; accurate information leads to informed and shared decisionmaking.
So, do they (i.e. hormones) or don’t they (cause harm)? Undoubtedly, important variables come into play, including current age, how close to menopause hormones are started, current health status, whether or not a woman has had a hysterectomy, smoking history, etc. Also important is whether estrogen is used alone or in combination with progesterone. And yet despite these factors, many medical organizations continue to recommend that HRT be used for the shortest time period possible if at all.
Still, researchers continue to delve into data from the now infamous Women’s Health Initiative Study to tease out the bad, ugly and even the good.
This week, they are reporting on over 7,600 women who had taken estrogen alone for approximately 6 years, had had prior hysterectomies and were followed for an average of 10 years after the trial ended. If you recall, there has been some controversy as to whether or not estrogen alone is safer than combined HRT and actually lowers the risk for breast cancer in particular, which is why these data are particularly intriguing.
The researchers report that age at the time that hormone therapy (in this case, estrogen alone) is started is important. In fact, women who started estrogen therapy in their 50s, an increased risk for stroke and embolism, which appeared while taking estrogen, actually disappeared in the years that followed. Unfortunately, so did protection against hip fracture. Moreover, earlier reports of a decline in breast cancer risk were upheld despite body mass indices. However, the researchers say that this finding in particular, runs contrary to the preponderance of evidence from the majority of observational studies which show that estrogen use increases the risk of breast cancer, especially in lean women and after a long time period of use.
In an accompanying editorial, also in JAMA, the authors point out that more than 80% of women who took estrogen as directed only used it for an average of 3.5 years. Their point is that the results don’t directly address the “balance of risk and benefits associated with longer term estrogen use.” They also point to a larger review of data that show duration is an important factor when it comes to breast cancer risk, especially among lean women. Additionally, they say that tamoxifen, which actually antagonizes estrogen, has been shown to reduce breast cancer by 50%, which has led the International Agency for Research on Cancer to “conclude that unopposed estrogen therapy and combination HRT are carcinogenic.”
Are you confused yet?
Both set of researchers say that the decision to use estrogen or not is one that should be made between a woman and her doctor. Don’t forget: study findings continue to contradict. They add that while “there may still be a role for short-term use of unopposed estrogen for treating some women with menopausal symptoms, this role may be vanishing as existing and emerging data continue to be better understood in terms” of patients.
My thoughts? Err on the side of caution. Always.
Read MoreFlaming the fires of HRT: what influences risk?
Let’s face it. Despite my doubts about hormone replacement therapy (HRT), just like the Energizer Bunny, it’s going to keep on going. So as any responsible journalist must do, I have to share the good along with the bad and ugly. The trouble is that data rarely agree, lending confusion to the growing controversy about health risks, appropriate timing, combination and use of HRT.
Last week, several of you sent me a link to a study in the current issue of Menopause that appears to further clarify use of HRT and heart disease risk. Quite honestly, I had seen the study but was hesitant to write about it for fear of simply fueling the fires. But you’ve asked so I’ve answered.
The investigators of this particular study note that experts suspect that timing of hormone replacement, i.e. age when it’s started or time since menopause has begun when it’s started, plays a role in some of the differences between previous reports on HRT and heart disease. For example, reanalysis of data from the Nurses Health Study demonstrates that any heart benefits of HRT rely on starting therapy within 10 years of menopause, while data from the Women’s Health Initiative show that younger age plays an important role as well.
In a quest to tease this out further, they examined information on deaths from ischemic heart disease, age at first and/or current use of HRT, prior use and duration of use in 71,237 postmenopausal women in the California Teachers Study over a period of approximately 9 years. The findings?
- Overall, current age while using HRT appears to influence risk of dying from any cause. This factor appears to be much more importan than age that HRT was started or years since menopause began. Indeed, women using HRT at the time of the study who were younger than 65 years were found to have a 45% reduced risk of death from any cause compared to women who had never used HRT.
- Similar findings were seen when the researchers examined death from heart disease, with HRT providing some protection in younger current users that virtually disappeared once they reached 75 years.
The upshot is that the health consequences and risks of HRT may be influenced most by age at current use, with younger women having the most benefits to gain. Any sort of protection starts to disappear as women grow older so the window of opportunity might be small.
Still, questions remain. These researchers were only trying to determine the most important influencer(s) of death from heart disease and not examining cancer or other risks that have been definitively demonstrated. Do these data fan the controversial fires and serve to heat up the debate? I believe that they do.
As always, buyer beware. Nothing is ever as it seems. Especially when it comes to hormone replacement therapy.
Read MoreHeart disease, flashes and sweats, oh my!
Heart disease is a major issue in women, especially as they age. In fact, more women die of heart disease than all forms of cancer, including breast cancer. During the time right before and up to five years after menopause starts, cholesterol and low-density lipoprotein (LDL) levels soar, placing women at even greater risk.
I’ve written previously about the link between waning estrogen levels and heart disease risk and steps you can take to address specific risk factors. But what about vasmotor symptoms like hot flashes and night sweats? Unfortunately, in addition to being linked to elevated cholesterol and LDL, researchers are discovering that vasomotor symptoms like hot flashes and night sweats actually cause calcium deposits to build up in the arteries and aorta, negatively blood pressure and increase body mass index compared to women without these symptoms.
In the latest bit of news from the research front (published in February issue of Menopause), it appears that night sweats might be the larger culprit. In fact, when researchers examined data culled from 10,787 Dutch women (mean age 53) participating in another study who were free of heart disease at the start, they discovered that over a period of approximately 10 years, women reporting night sweats had a 33% increased risk for heart disease compared to women who were asymptomatic. In comparison, hot flashes did not appear to increase risk in any significant way. What’s more, risk remained even after the researchers accounted for factors that might influence risk, such as BMI, blood pressure and total cholesterol. Additionally, elevated risk was even seen among women both who had used hormone replacement and had never used hormone therapy or oral contraceptives.
Before you become anxious about these findings, it is important to note that when the researchers did a second analysis that adjusted for sleep and mood (both of which have been linked to vasomotor symptoms and heart disease), and found that while risk was still elevated, it was no longer significant. This implies that factors other than night sweats might also be contributing to heart disease risk, and that the sympathetic nervous system, which is responsible for increases in nervous system activity and blood vessel abnormalities, may also play a role.
Meanwhile, prevention recommendations continue to be fairly straightforward:
- Don’t smoke or quit if you do.
- Exercise…at least an hour daily if you can.
- Eat a health diet, rich in whole grains, fruits and vegetables, healthy fats, fish oils and low fat proteins.
- Maintain a healthy weight.
- Drink in moderation.
Ladies, we are in control of our destinies when it comes to altering how we age in that we can influence certain factors. There are no guarantees. But you can bet that we can change the odds in our favour.
Please, please care for your heart. It matters. A lot.
Read MoreWednesday Bubble: Get up and…
move? You bet!
According to a newly published study in the advanced online edition of European Heart Journal, taking breaks from long stints at your desk or even while you’re playing couch potato can go a long way towards preventing heart disease and losing some of that waistline bulge. In fact, the researchers say that prolonged periods of being sedentary, even if you regularly participate in moderate to vigorous physical activity, can increase the risk of heart disease. The bottom line? It’s not only the length of time you’re spending at your desk or on your derriere but how often you interrupt that time that counts.
This is the first time that a large, multiethnic population of varying ages has been evaluated to determine how a lack of activity affects certain markers of heart disease, including inflammation, waist circumference, cholesterol and blood fats. Researchers studied 4,757 participants over a period of three years who wore a small device (an accelerometer) that measures both the amount and intensity of activity; this allowed them to collect data on inactivity and breaks in inactivity.
The findings? Irrespective of factors like exercise time, diet and smoking, people who took the most breaks from inactivity (~179 breaks a day) had, on average, a 1.6 inch smaller waist circumference than people who took the least amount of breaks (~14 breaks per day) and remained inactive for the longest period of time. Moreover, taking breaks from being sedentary appeared to improve blood fats and blood glucose levels as well as C-reactive protein level (CRP, a blood protein that many experts believe, increases heart disease risk because of its role in promoting inflammation). Another interesting finding was gender-based; even though women tended to be more sedentary overall, they did take more breaks, thereby improving their heart disease risk. This is especially notable since research has shown that not only is heart disease the number one killer of women, but it tends to increase as estrogen levels wane.
Dr. Healy, the study’s lead researcher, suggests that even small changes, standing for as little as one minute at various intervals throughout the day, may help lower heart disease risk and counter the danger of being sedentary for too long. In a work environment, this means, standing up when talking on the phone, walking over to a colleague, using the restroom, and of course, taking the stairs. If you work at home, some of these recommendations are adaptable, such as making a point to take out the garbage, walk outside for a minute or put in a load of laundry.
Truly, get up and move as often as possible. It may save your life as well as your waistline!
Read MoreWednesday Bubble: all juiced up and ready to go
Did you catch last week’s news about pomegranate juice and kidney disease? It seems that pomegranate juice just might be the next best thing… or not. The same holds true for orange juice, weight loss and heart disease. So before you get too excited about the wonders of the orange, let’s take a look at what research is telling us.
Middle-age is associated with a slow down of metabolism, distribution of weight and of course, an increase in risk for certain diseases, in particular heart disease. For women specifically, hormonal changes – namely a steeply progressive increase in testosterone, can contribute to a risk of developing metabolic syndrome (i.e. the cluster of risk factors — abdominal fat, high blood pressure and cholesterol levels and insulin resistance –that increases the likelihood of developing heart disease and diabetes). In fact, data from the Study of Women’s Health Across the Nation has shown that women have a a 1.45 times increased risk of developing the metabolic syndrome in perimenopause and a 1.25 increased risk after menopause. So, the cards are automatically stacked against us. Let’s add overweight and obesity, poor eating habits and sedentary behavior to the mix and we have a veritable “heart condition in the making” cocktail.
Wondering where this is going?
Across the board, the key ways to improve one’s risk of developing disease include a balanced diet rich in fruits, vegetables, whole grains and good fats and regular physical activity. The formula isn’t a magic one and but it’s been shown time and again to improve the odds. However, we are a society of instant gratification so it’s easy to fall into the trap of a quick fix, whether that entails botox, diet pills, diet plans, sweating or the like without paying much attention. Hence, when I saw a study setting the stage for the latest and greatest answer to our problems, i.e. orange juice, I had to take a closer look.
Like pomegranate juice, orange juice is rich in flavonoids, naturally-occurring plant and vegetable compounds that have both antioxidant and anti-inflammatory properties. Orange juice is also an important source of vitamin C, folate and potassium, which have been shown to help protect cells from bad, LDL cholesterol, reduce the risk of atherosclerosis and possibly help lower blood pressure. But, can drinking orange juice help prevent heart disease in middle-aged women who are already at risk?
When researchers compared 26 premenopausal women between the ages of 30 and 48 who were considered overweight or obese, and asked them to engage in a 1-hour aerobic exercise (running) 3 times a week and either drink 2 glasses (16 oz) of orange juice daily or not, they observed the following:
- Regular aerobic exercise led to an average loss of 11% to 15% of fat and 1.2% to 2.5% of BMI depending on the group that women were assigned to.
- Women who drank orange juice along with their thrice-weekly exercise had as much as a 15% decline in LDL-cholesterol and an 18% increase in HDL (good) cholesterol.
- Daily orange juice intake also led to less muscle fatigue and better overall responses to aerobic training.
- Although drinking orange juice added to daily caloric intake, it actually led to a decreased consumption of other foods.
Should you start drinking orange juice to lose weight and save your heart? Not so fast. This study simply shows an potential associated benefit and does not prove that drinking orange juice causes a reduced risk in heart disease,; mind you, these women were only studied for three months. Moreover, the study was small and a much larger group is needed to demonstrate proof of a benefit. Additionally, the results did not show which components in orange juice are specifically linked to a potential risk reduction, or if there are components in the juice that are shared by other juices. On a more positive side, it did demonstrate the benefit of a balanced diet, regular physical activity and improvements in performance, perhaps as a result of extra nutrients and energy provided by the juice.
Time to juice up? Nope, just time to start opening your eyes a bit wider when you see headlines touting the amazing benefits of a quick fix. Rule number 1? There are no quick fixes.
Read MoreWednesday Bubble: the crystal menopause ball
Can you predict the age you will start menopause?
Most women and many experts say that there is a link between when their mothers started menopause and when they will likely start menopause. In fact, the ‘mother’ hypothesis has been explored in numerous studies, with explanations ranging from hormones to genetics to evolutionary selection. However, are there any other determinants or factors that also may come into play? Indeed, it appears that there are. And why is it important? Studies have shown both early (<age 45) and late (>age 56) menopause to be associated with increased health risks, such as heart disease.
Recent data from a study of over 1,000 women, almost of half of which were postmenopausal, show that weight gain and weight loss in the perimenopausal years may play an important role in determining the age that you start menopause.
After evaluating body mass index and height, and the women’s history of weight loss and gain in body mass index from age 25 to menopause, the researchers found that women with a history of losing 11 pounds or more between age 25 (excluding weight gain or losses due to pregnancy) and menopause or gaining roughly 1 pound or more per year during the same time period were more likely to start menopause later than the average age of 50 or 51. The greater the loss or gain, the later menopause began. Other factors that also appeared to influence a later menopause included the number of bleeding days between ages 20 and 30 (with “more” associated with “later”), use of an IUD, a later year of birth and how a woman perceived her economic status. On the other hand, women who smoked or had type 2 diabetes before transitioning to menopause and who had a mother who started menopause earlier than age 50, were more likely to start menopause earl
Wondering why this is important?
Clearly, the more information we have about when menopause might start, the greater our ability to start instituting effective strategies, such as exercise, relaxation, diet, etc, to stave off the numerous health issues that arise as our hormones decline. Some of these strategies might also serve a dual purpose of ameliorating vasomotor symptoms like flashes and night sweats.
Is the crystal ball accurate? Only time will tell. But knowledge is power. Always.
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