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Featured topic and speakers
When does menopause start? Who should have hormone replacement therapy? Can menopause bring on heart problems? Is HRT still recommended for menopause? How to prevent heart disease after menopause?
Our guest Melissa Joy Tracy, MD, professor of medicine and systems medical director of cardiac rehabilitation, at Rush University Medical Center, discusses the latest science on how to prevent heart disease after menopause. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Melissa Joy Tracy, MD, professor of medicine; systems medical director of cardiac rehabilitation, Rush University Medical Center
Transcript
Dr. Tracy: Timing is of the essence, so we should be starting if a woman is requesting and/or if a woman has symptoms that need to be treated because of her peri- and postmenopausal.
Unger: Hello, and welcome to the AMA Update video and podcast. Today we're talking about menopause and heart health. Our guest is Dr. Melissa Joy Tracy, professor of medicine and systems medical director of cardiac rehabilitation at Rush University Medical Center in Chicago. I'm Todd Unger, AMA's chief experience officer, across town in Chicago, too. Dr. Tracy, welcome.
Dr. Tracy: Thank you, Todd. Thank you for allowing me to speak about a very important topic that's affecting over 63 million women in the U.S. alone. And statistics say that approximately 6,000 women enter menopause per day, so I think this is a really important topic.
Unger: And it's been in the news a lot, in particular around the idea or the treatment of hormone replacement therapy. And I thought just for a background here, there's been quite a bit of history around HRT. Why don't you just take us through the general timeline of how this has played out?
Dr. Tracy: It started quite a long time ago when women were having hormonal disruptions with perimenopause and postmenopause, and they first started using urine from pregnant women to give women estrogen replacement. To save costs, they then were taking it from horse urine. And the Nurses' Health Initiative really gave a boost to hormone replacement therapy, but it wasn't really being looked at in women specifically with coronary heart disease.
The HERS Study, which is the heart and estrogen progesterone replacement study, which was published in 1998, looked at women who already had established coronary heart disease and looked to see if there was any benefit for secondary prevention. So this was a secondary prevention trial. So women already who had coronary heart disease. And they did not show a significant benefit with hormone replacement therapy, and in fact, there was a trend towards worsening outcomes in women who already had established coronary heart disease.
The Women's Health Initiative was published a few years later in 2002, and this was now a primary prevention trial. And this was looking at women who did not have already established coronary heart disease and giving them hormone replacement therapy.
This study showed an increase in heart attack, an increase in the development of coronary artery disease, an increase in blood clots in both the legs and in the lungs. However, both of these studies, which I think is really imperative moving forward, really looked at women far beyond the standard or average age of peri- and postmenopausal.
So in the HERS Study, I believe the average age of the patients in that study or participants in that study were 63, and in the Women's Health Initiative were 67. Whereas most women go through perimenopause in their 50s, early 50s. Ironically, I thought that it was quite interesting that in 1973 called the Coronary Drug Project. This was, ironically, the first study that ever looked at estrogen therapy, but it was only in men.
So this was a study published in 1973 looking at men post a myocardial infarction, post a heart attack, and it showed bad outcomes. It showed that there was an increased risk of thrombosis and subsequent heart attack. But then the studies kept going forward in women until, as I said, the HERS study in 1998, and then in 2002, the Women's Health Initiative. And that's when the use of hormone replacement therapy really dropped.
Unger: All right. So that's a big point in time. Let me just pause right there, because I think what you said is really important. As a result of those particular studies that you referenced, hormone replacement therapy basically kind of came out, say lack of better words, to a little bit of a halt. And I'm curious, how has that changed now over time with maybe further understanding or refinement of the audience you mentioned.
Dr. Tracy: So as I was mentioning some of the highlighted studies, the Women's Health Initiative did then do a subanalysis. And it did identify—because, as I was stating, that the average age in both the HERS Study and the Women's Health Initiative were much older than the average age that a woman goes through menopause. So in the WHI or the Women's Health Initiative, they then did a subanalysis and noted that in younger women, age 50 to 59, those women did not have increased adverse effects that they saw in the older women.
So then there's been subsequent studies. There was the Danish osteoporosis prevention trial, DOPS, or study, and that was published in 1999. And the important part of this study is that it really looked at a population that really is the framework of the average woman going through menopause. The average age was approximately 50 years of age.
Most of the women were only about seven months post going into menopause, and they were not obese. And this study actually showed that it may be the timing of when we start hormone replacement therapy. There was then the ELITE trial. The ELITE stands for early versus late intervention trial with estradiol. ELITE trial. And that was published in 2015. So both the DOPS trial and the ELITE trial, what those have now coined are two things.
The timing hypothesis and the endovascular or healthy endothelium hypothesis, meaning that there have been a lot of studies to show, including the Women's Health Initiative trial, that, well, wait a second, why does it show that hormone replacement therapy in younger women can actually be preventive, but in older women, they have increasing negative effects?
Unger: Very, very interesting. When you look at those studies, one has to question, in that first set of studies, why would they look at people in that more advanced age group that are well out of the onset of menopause?
Dr. Tracy: At that time, again, we didn't have a lot of data looking at timing. So it was a broad spectrum in evaluation, looking at women. All those women were obviously postmenopausal, but of varying durations out of postmenopausal state. So we didn't have a lot of that data.
And when that data came out, the first one, like I said, was secondary prevention, because we wanted—we started noticing that—we used to think that heart disease was a disease of men. But then we realized that women were catching up 10 years, roughly 10 years after menopause. So we wanted to look to see, OK, what if we gave these women, who already have developed heart disease, estrogen back? Because we noticed that it's mostly a postmenopausal or post-surgical menopausal issue. So the ideas were right, but the timing was not.
Unger: Interesting. And I want to delve a little bit deeper into the benefits side of this, because we talked about what the study showed and possible negative outcomes, especially about depending on what age it was started. But how about the benefit side? Can you talk to us a little bit more about that, particularly in that age group, the younger age group?
Dr. Tracy: So we have data, both in humans, primates, mice, that if estrogen is given at an early stage peri or postmenopausal, it actually can protect the endothelium of our vessels, of our vessels in our heart and our vessels in our brain. Interestingly also, estrogen actually reduces the risk of diabetes. It actually can increase our protective estrogen, our HDL, and lower our LDL. And it has been shown to help with obesity, helping women to maintain their lean body mass and to decrease adiposity.
However, based on the Women's Health Initiative and the HERS study, there are no medical societies, rightly so, that are promoting hormone replacement therapy for specifically primary or secondary prevention for coronary heart disease. Most women are seeking the use of hormone replacement therapy, primarily for those vasomotor symptoms that they get that really affect their quality of life.
That's the hot flashing. That's the sweats, both during the day and at night. So when a woman approaches their physician, it's mostly due to the fact that they are having quality of life issues based on those vasomotor symptoms. Affects their quality of life. It's affecting their mood, relationships. So that's why women are now currently and more robustly approaching their physicians.
Unger: So two questions coming out of that. Number one, you can imagine why there's confusion probably among physicians, probably certainly among patients as to whether this is an appropriate treatment for them. And so I want to talk a little bit about that. And then you mentioned that there's not currently the movement toward recommending this for heart health. And so let's just start with the former one. How should physicians be using HRT to treat menopause symptoms now?
Dr. Tracy: So this is a really important issue. You have to break down the patient, the female patient, into low, moderate and high risk. You also have to have very open shared decision making with your patient. So if she is low risk, low risk is typically 50 years of age. Low risk is someone who either is peri- or early postmenopausal, healthy weight, healthy blood pressure, healthy cholesterol, a really neutral family history for cardiovascular disease, and very low risk for breast cancer.
Those are our women who are low risk, and those are women who you can pretty confidently treat their vasomotor symptoms. Again, vasomotor symptoms. Not cholesterol. Not weight. Specifically, their vasomotor symptoms related to peri- and postmenopausal.
The 180 of that is our high-risk patient. So that's somebody who is over 60 years of age, who is well out of menopause, and who has the direct opposite risk factor profile from our low risk. Obese, hypertension, and hypertension, really in the more extreme ends of hypertension. High cholesterol, sugar, diabetes, those women who have already had a stroke or a heart attack, or those women who have had a history of breast cancer.
Then you have the moderate risk group, which is a blend, as you can imagine. And that's really the group that really a lot of discussion—and that's where the shared decision making really needs to come into play.
I think with your high risk group, it's clear cut. Those women should not be on hormone replacement therapy. The women who are low risk, shared decision making is still important, but the benefits in those patients definitely the data shows that the benefits outweigh the risks. And that moderate risk group are those women who have established coronary disease but haven't had a cardiovascular event.
So an elevated coronary calcium score, sugar, diabetes which is well controlled, possibly a moderate level of their obesity, hypertension, but not the severely hypertensive population, risk factors, but not a woman who has had breast cancer already. So looking at those patients in a spectrum of low, moderate and high risk is really paramount.
Unger: That is a really, really helpful framework to think about, so thank you so much for clarifying that. When you talk to patients or you hear about other physicians, your colleagues, what are the kinds of questions that patients have about heart health during menopause?
Dr. Tracy: So a lot of it is frustration, because as a woman progresses from perimenopause to menopause, unfortunately, their weight goes up, their blood pressure goes up, their cholesterol goes up. They are seeking the magic pill, the magic cure. So there's nothing that beats a healthy lifestyle. So I think we should always start there.
As systems medical director of cardiac rehab, exercise and healthy lifestyle are part of my backbone. I've been an athlete my whole life, so I really feel confident and able to discuss with my patients what is a healthy lifestyle. So I discuss with them exercise, healthy diet, healthy sleep, which is now becoming our next vital sign that we discuss with our patients. So we should always start with a healthy lifestyle.
Thereafter, we want to make sure that any of those risk factors which need optimization are addressed. So if they do have an elevated coronary calcium score, an elevated cholesterol, to treat their lipids or to treat their blood sugar. But again, looking at those women in that low, moderate and high risk categories really helps. And even having—there's a very nice chart published in one of our journals called Circulation.
With that, it has a green light, a yellow light and a red light, and I'm happy to send it to you. You can possibly attach it to this webinar. But it gives a clear cut picture of women who are going to fall into one of those groups, or a blend of one of those groups. But I think that's a great visual to share with your patients so that they can see where you're coming from when you're having these discussions with them.
Unger: Do you have any other advice for physicians out there about how to talk to their patients about the issues we've covered today?
Dr. Tracy: I think understanding that timing is of the essence. So we should be starting, if a woman is requesting and/or if a woman has symptoms that need to be treated because of her peri- and postmenopausal. The guidelines right now are to treat 50 years or older, but less than 60, and definitely as soon as there's symptoms of peri- or postmenopause start. So 50 years is sort of that cutoff.
That's when a lot of women are going through peri- and menopausal symptoms, but to not really continue if the symptoms can be treated with less or no hormone replacement therapy, not beyond 60 or 65 years of age. Again, if the symptoms come back, what doctors can do is start a lower dose of the therapy for the shortest duration. So timing is of the essence. Dose is of the essence. Try the lowest dose, whether it's estrogen combined with progesterone or estrogen alone, depending if the woman has a uterus or not.
But what is also very important is the route of how the hormone replacement therapy is delivered. The transdermal hormone replacement therapy does appear to be safer than oral hormone replacement therapy, because when estrogen has to go through the liver and go through its first pass of metabolism, that's when it can affect a lot of the procoagulants, which cause our blood to be thicker and could cause heart attacks, stroke and blood clots.
So the transdermal hormone replacement therapy actually appears to be a safer option for women than the oral. So timing of when to start it. Duration. How long to start it. The dose of the hormone replacement therapy. The route of how we're giving it, whether it be oral or transdermal.
Unger: Dr. Tracy, that was just a terrific answer and so helpful. I really appreciate you joining us today. There's clearly a lot more education that's needed on this topic. Thanks for sharing your insights with us. If you found this discussion valuable, you can support more programming like it by becoming an AMA member at ama-assn.org/join. That wraps up today's episode. We'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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