Has your doctor told you that taking estrogen could cause a heart attack? This is one of the reasons hormone treatment fell out of favor back in 2002 when a landmark study, called the WHI (Women’s Health Initiative), published its findings. Newspapers across the world announced taking HRT increased a woman’s risk of heart disease by 28%! This was shocking news at the time since earlier studies had indicated that taking estrogen decreased a woman’s risk of a heart attack – in some studies by as much as 50%.
Because the WHI was such a large and scientifically-sound study, its results have been the basis for the guidelines for over a decade and doctors have been obligated to tell their patients that taking hormones will not protect them from heart disease.
Fast forward to today. What is now becoming apparent is that the WHI study was a situation of good science being inappropriately applied. It turns out the majority of women in the WHI were much older than the typical woman going through menopause. The average age of the women in the study was 63 and some were up to 20 years beyond their last menstrual period. So, they were put on hormones many years after when most women would normally start taking them. In addition, only two types of hormones were used in this study – Premarin and medroxyprogesterone, which is the generic name for Provera.
So, while no one really disputes the conclusions of the study, the problem is that the findings should only apply to older women on these particular hormones. But instead, the policy makers have broadly applied the findings to all women and for all types of HRT. This is what many menopause experts feel is inappropriate.
If you look at studies that enroll women around the typical age of menopause, they show taking hormones decreases a woman’s future risk of heart disease. This holds true even when you look at the small subset of women in the WHI who were younger than age 59. Furthermore, studies looking at women who take estrogen alone, without a synthetic progestogen, show an even greater benefit.
Why HRT may be detrimental to older women, but beneficial for younger women, has spurred much interest. A relatively new theory, called the Timing Hypothesis, has been proposed and explains why this may be occurring. In future blogs, I will discuss this in more detail and go into the research and studies supporting this concept.
The bottom line is that, if you are just entering menopause, the preponderance of evidence indicates taking HRT will not be harmful to your heart and may very well help prevent a heart attack in the long run. So, as you tally the benefits and risks in your decision about whether to take HRT, this is one area you should think about – especially since heart attacks account for more deaths in women than all types of cancer combined!
can anyone offer advice? Been on much needed vagifem for 18 months. Started hrt everol 50 patch 6 months ago, no side effects helped with brain fog, anxiety and bloating. Progressed to 75 patch after 3 months. No noticeable side effects. No noticeable difference. Started on everol 100 two weeks ago hoping one more step up may help with joint problems (possible arthritis now think) and residual vaginal atrophy symptoms such as urinary issues. Had various side effects from day 2 so pretty sure too high for me. Gave up yesterday feeling bit poisoned! Just leaving off for 24 hours to give my system a small chance to recover. Doctor advised by text to cut patch down to 75. All fine but forgot to advise on progesterone which goes up to 3 tablets with the 100 patch. The 14 days of tablets started last night so i took 3. Wondering if i should take 3 for 7 days total and then go down to 2 (normal dose for other patches) or stick with the normal 2 because i will now be using 75 patch for rest of the 4 week cycle. Spoke to a different doctor and they seemed a bit vague and said do whichever i want. Spoke to two pharmacists – one said they really didn’t know and the other went down more on the side of take 2 mainly just in case you get more side effects to the extra progesterone you are not used to. Bit confused – don’t want to risk a build up in womb – if that is even a possibility? Am i worrying over nothing?
Hello Jane. There are two ways to take progesterone along with the patch – either a lower dose progesterone pill every day or a higher dose of progesterone 12 to 14 days each month. The dose of progesterone is adjusted based on the dose of estrogen. Typically if a woman is on a 50 mcg patch she would take 100 mg progesterone daily continuously, or 200 mg for 12 to 14 days each month. If a woman takes a higher dose estrogen, she would need to take more progesterone. If a woman is taking the 75 mcg patch it would be advisable to take either 200 mg progesterone every day or 300-400 mg progesterone 12 to 14 days each month.
Having said that, there has not been a lot of research on the optimal doses of progesterone for women on the higher doses of estrogen. If there is concern that a woman is not getting adequate progesterone, doing an endometrial ultrasound is one way to make sure the lining of the uterus is not getting too thick. If a woman is getting the right balance of estrogen and progesterone, the lining should remain very thin.
There has not been a lot of research on whether taking higher doses of estrogen helps joint pain and generally this is not a reason to take higher doses of estrogen.
Most women find that a 50 mcg patch is sufficient for helping most menopausal symptoms. The younger the woman is, the higher the amount of estrogen may be needed – so women just entering menopause may require more, but then find that a lower dose down the line works as well. If a woman simply is not getting relief of symptoms with her patch, it is possible she is not absorbing the estrogen well and a different patch may work better. Some doctors also check estrogen levels to get an idea if the estrogen in the patch is being absorbed.
If a woman finds that her vaginal symptoms are not helped that much by her patch, it is best to add vaginal estrogen to her regimen rather than increasing the strength of the patch. There are many types of vaginal estrogen products.
The link below from the British Menopause Society outlines the advice of how much progesterone should be taken with estrogen. One comment that I do have is that from my research, Evorel patches appear to deliver more estrogen than other brands of patches of an equivalent dose, so erring on the side of taking a higher dose of progesterone may be advisable when women use Evorel patches.
Link to BMS guidelines BMS guidelines.
Thanks very much for your reply. It was very informative. I took 3 progesterone tablets for two nights but the second night i had itchy skin in the night especially around breast area and sides of chest so reduced to my usual 2 tablets last night. Did not get the itchyness last night. But obviously not sure if it was the extra progesterone or the effects of the extra estrogen! Sorry to ask another question but the last doctor i spoke to told me to put a 75 patch back on which i did yesterday 3pm. But still got bit of vaginal/bladder burning and the capacity to hold on to wee getting up in nighttime is worse than normal for last 3 nights. have had a white discharge over last say 10 days which is lessening – seemed ok type. For this reason i reduced patch to 50 this morning. Is this ok until i speak to doctor again or is it perfectly safe to just take patch off again completely for another day? or do i put a 75 back on? I normally have very little discharge and am still quite dry even on the vagifem but when i started vagifem initially about 18 months ago, the two weeks of intense treatment at the start did produce a similar effect of creamy white discharge so the extra estrogen in the 100 patch must have cranked something up – am surprised it aggravated my vaginal/bladder area though – i thought it was supposed to help?
Hi Jane, estrogen tends to stimulate the cells in the vagina and so many women do notice a little more discharge with treatment. Progesterone does not seem to have much effect in the vagina, so we usually attribute vaginal discharge to the estrogen component. It is advisable to consult with a health care provider to make sure there is not an infection or other explanation for any new vaginal or urinary symptoms.
When a patch is removed, the estrogen level gradually goes down over a number of hours. It is not dangerous to remove a patch and replace it with a different patch even if it is not the same dose. It is also not dangerous to remove a patch for a day or two. However, symptoms such as hot flashes, night sweats, sleep disturbance, or mood swings may arise.
Breast tenderness usually is due to higher estrogen levels, although progesterone can also cause some breast symptoms.
Hopefully your doctor can help sort things out for you and make sure there is no other explanation for your symptoms. Sometimes it takes a few weeks for any change in HRT dosing to stabilize.