The Dr. Hyman Show - Exclusive Dr. Hyman+ Functional Medicine Deep Dive: Menopause And Hormone Replacement Therapy

Starting point is 00:00:00 Hey podcast community, Dr. Mark here. I'm so excited to offer you a seven-day free trial of my revolutionary new platform called Dr. Hyman Plus. For seven days you get special access to all the private content included in Dr. Hyman Plus entirely free. It's so easy to sign up. Just go to Apple Podcast on your phone and click try free button on the Doctors Pharmacy podcast. You'll get exclusive access to ad-free Doctors Pharmacy podcast episodes and functional medicine deep dives where a practitioner dives into topics like heart health, muscle health, insulin resistance, and more to help you understand the root cause of specific ailments and walk you through the steps to improve your health today. You'll also get access to all my Ask Mark Anything Q&As where

Starting point is 00:00:51 I answer the community's biggest health and wellness questions. Because I'm so sure you're going to love this platform, I am offering you free access to all of this content for seven days and a teaser of my brand new functional medicine deep dive episode diving deep into one of the most important topics in health. Head on over to the Doctors Pharmacy podcast on Apple podcast and sign up for your free trial right now. Okay, here we go. Hi there. I'm Dr. Joel Evans, and I am the Chief of Medical Affairs for the Institute for Functional Medicine. And then I'm the Director of the Center for Functional Medicine, which is my private practice

Starting point is 00:01:32 in Richfield, Connecticut. And you can reach me at email, joel at the cffm.com. And I am so happy to have been invited to speak to you, this very sophisticated audience, on the functional medicine approach to menopause and hormone replacement therapy. So you can make an educated decision about whether you want to start or not start hormones. And the real question is, do women that are in midlife need to be medicated for menopause? Yes. I'm restless, nervous, tired all the time and always nagging.

Starting point is 00:02:18 And sometimes I think I don't like being married. That was an advertisement in the 1960s. And then menopause is a hormone deficiency and totally preventable. Now, almost every woman, regardless of age, can safely live a full sex life her entire life. And that was written by the doctor that invented Premarin. And the whole reason was to have women be sexual. Or no. Combined hormone therapy in breast cancer, a single-edged sword.

Starting point is 00:02:59 Altering a menopausal woman's hormones for decades is fraught with hazard. Long-term hormone therapy for perimenopausal and postmenopausal women, a review in 2012, it's not indicated for heart protection or cognition in 2017, not indicated for preventing heart disease or dementia. The U.S. Preventative Services Task Force in November of 22 recommends against the use of combined estrogen and progestin or estrogen alone for prevention of chronic conditions in postmenopausal persons. Very strong and very clear. But don't give HRT, really? I think we should look at the IFM HRT decision tree to help us decide. And this is something that I created. I stand by it, and you'll see that it makes a lot of sense. So just reviewing some of the biology,

Starting point is 00:04:02 what happens in menopause is that women run out of eggs, right? It starts with irregular ovulation, lower progesterone, and then you end up with less estrogen and increased in LH and FSH, which are the hormones that produce estrogen. So you just run out of follicles in the ovary. Now, if you wonder about the importance of how women in your family transition to menopause, it matters. Familial menopause stories matter because there's a good correlation between menopausal age in both mothers and daughters and between sisters. And this suggests that genetic factors play a role in determining menopausal age. So we personalize by addressing each box with or without hormones.

Starting point is 00:04:52 So we look and we say, okay, you need to decide if you've got symptoms, if you are at risk for or you're just concerned about heart disease, cognitive decline, or osteoporosis. Do you have a diagnosis of heart disease, cognitive decline, or osteoporosis? Or do you just desire optimal health and aging? And that's important because women spend a third of their lives in menopause. So we are obligated to determine the degree to which declining estrogen levels mediate the age-related decline in so many health parameters. So let's start with the heart. What are the cardiovascular disease implications? So we know that this is critical because young women who have undergone early menopause or surgical menopause also have a higher risk for heart disease, independent of conventional cardiovascular disease risk factors.

Starting point is 00:05:56 So it doesn't matter if they're not overweight or they don't smoke, they're still at increased risk for heart disease. And it's the number one killer of women. And estrogen is protective. Estrogens are vasoactive, meaning they work in the blood vessels. They reduce inflammation in arteries. So it inhibits C-reactive protein, which is the marker of inflammation in injured arteries. So it inhibits C-reactive protein, which is the marker of inflammation in injured arteries. It also reduces oxidative stress. So it modulates oxidative stress in arteries and vascular smooth muscle. So we know that oxidative stress is bad, right? Free radicals. That's why we take antioxidants. So oxidative stress is bad.

Starting point is 00:06:47 Estrogen is an antioxidant. And in the heart, it increases dilation in those blood vessels, which is good. And it decreases proliferation, which is good. and it decreases oxidation of LDL which is the bad cholesterol and it's not really LDL that's a problem it's oxidized LDL it's those free radicals that attack the LDL it decreases insulin resistance and it normalizes heart muscle cells. And here you see how estrogen reduces oxidative stress through many different mechanisms. And what it does is it is helpful, all these diseases on the left, atherosclerosis, arrhythmias, hypertrophy, which is enlarged heart, heart failure, ischemia, which is lack of oxygen, elevated blood pressure. Estrogen is helpful because it blocks the oxidative stress, which is the cause of all

Starting point is 00:07:58 of these particular issues. So estrogen blocks this from happening so you don't get these particular problems. And this is the mechanisms by which estrogen inhibits oxidative stress. And I don't expect you to know all of these things, but it's here if in fact you want to go through them or you just want to know, yeah, estrogen reduces oxidative stress. It's an antioxidant. It's a good thing. And menopause happens at the same time in a woman's life that the cardiovascular risk factors are increasing. So this is when body fat changes. This is when you get that weight around the middle, which is the visceral adipose tissue, which is the body fat that is pro-inflammatory. You have reduced glucose tolerance, abnormal lipids,

Starting point is 00:08:52 increased blood pressure, increased sympathetic tone, which is the stress part of the nervous system. The blood vessels don't work well and the vessels get inflamed. So all of these things happen just as menopause is happening. So the question now is, since we know that menopause increases both cardiovascular risk and cardiovascular disease, the question is now, does estrogen replacement reduce cardiovascular risk? And if estrogen replacement reduce cardiovascular risk? And if it does reduce cardiovascular risk, is the risk benefit a net positive? So does HRT prevent cardiovascular disease and menopause? Look at what the U.S. Preventative Services Task Force said.

Starting point is 00:09:40 Remember, it said we shouldn't take it for anything. And now they say that there might be a protective effect on heart disease. However, there are certain trials that have not demonstrated such an effect. But now it says there might be a protective effect. But we need to look more closely. So let's look at the new recommendation from the U.S. Preventative Service Task Force that says there's no difference in the risk of heart disease if you're given estrogen and a progesterone. But what about estrogen alone? Let's look at the new recommendation statement.

Starting point is 00:10:19 Similarly, no difference between persons taking estrogen alone and not. What about ACOG, American College of OBGYN? ACOG opinion says that menopausal hormone therapy should not be used for prevention of heart disease. Now, remember, what's supposed to be going on in your mind is you're thinking, wow, Dr. Evans just showed me all of these good things that estrogen does. It's an antioxidant. It prevents oxidative stress. It's anti-inflammatory, like all these good things. And all of the professional societies are saying, don't take it. That means something. What about the 2022 position statement for North American Menopause Society? For healthy women that are within 10 years of menopause that have symptoms, benefits outweigh the risks with fewer heart

Starting point is 00:11:21 events in younger versus older women. But initiating hormone therapy in women aged 60 years or older, or after 10 years of menopause, no effect, but is associated with a higher risk of stroke. So that's interesting. This is the first time we're hearing about this. But it's still not approved for primary or secondary cardio protection. But as you see, that the benefits outweigh the risks if you have symptoms. Yet, the data shows a reduced risk of coronary heart disease in women who did this, who started when they were younger than 60 or within 10 years of menopause.

Starting point is 00:12:12 This is what I want you to remember. Very important. So, the risk of breast cancer related to hormone therapy is low. Less than one additional case per thousand women, or three cases per 1,000 women when used for five years. So it's very low. But different types of estrogen or progesterone, as well as different formulations and the timing, the duration and patient characteristics, all play a role on the effect of hormone therapy on the breast. And we're going to go through this in detail so you really understand if it's going to be right for you. What about hormone replacement therapy in diabetes?

Starting point is 00:12:59 Well, estrogen and progesterone actually reduces the incidence of metabolic syndrome, which is pre-diabetes. And the incidence of type 2 diabetes was decreased by one-third. And a smaller analysis confirmed these findings and said that women that have type 2 diabetes using hormones actually had better glucose control. And that benefit stops when hormones stop. So hormone therapy can be considered for symptomatic menopausal women that have diabetes. And this is from North American Menopause Society. So my conclusion of the professional society recommendations, they're contradictory, they're confusing, and they're not very helpful because they're so contradictory and so confusing. So in order to safely and effectively utilize HRT, we have to look closer at the nuances of the research.

Starting point is 00:14:00 Enter the timing hypothesis. So looking back to this American College of OBGYN statement, what they said was don't use menopausal hormone therapy for prevention of heart disease. However, the timing hypothesis, which states that cardiovascular benefit may in fact exist when estrogen therapy or hormone therapy is However, in the text, they say, however, age and time since menopause are critical modifiers of the effect of hormones on the heart disease with favorable effects observed for women age 50 to 59 and within 10 years of menopause when you start treatment. So the question, does timing of

Starting point is 00:15:15 HRT matter in the prevention of heart disease? I think so. We've got the timing hypothesis. And now here's some extra information that estrogen signaling, meaning estrogen functions differently in older women. And it goes from anti-inflammatory and vasoprotective to pro-inflammatory and vasotoxic. So estrogen goes from a good guy to a bad guy in the transition from being younger to older. And we know that that transition is 10 years. So early menopause, as I said earlier, is associated with adverse cardiovascular disease. And so starting hormones in the perimenopausal or early menopausal period reduces those bad outcomes. So in summary, as women age and or there's an estrogen deficiency, the vasoprotective effects of estrogen diminish over time. And there's biologic plausibility for this.

Starting point is 00:16:24 Biologic plausibility means it makes sense. How does it make sense? Because early in the atherosclerotic disease process, so that's early in the production of plaque, estrogen is protective and retards plaque formation. But later in the process, estrogen causes plaque erosion or rupture, and that's what kills people with thrombosis and acute coronary events. That's when the plaque breaks free and breaks. And there's further support for the timing hypothesis from a trial called the ELITE trial, where they looked over six years, and that was women who did it for less than six years for menopausal onset. And women that were taking it starting 10 years from menopause didn't show this effect, and the effect was slower progression. So slower progression is if you start it less than six years. So when HRT initiated at menopause or within six years, there's a significant reduction in heart disease, and there's no effect when initiated more than 10

Starting point is 00:17:42 years after menopause onset. Now remember here, it says no effect, but I told you how estrogen becomes pro-inflammatory and starts damaging vessels after 10 years. So I don't like estrogen being used more than 10 years after menopause. The latest on the timing hypothesis from March of 22 about the elite trial about timing of hormone therapy initiation where they say it possibly has a benefit depending on the timing of initiation and that the overall risk benefit is such

Starting point is 00:18:23 that it's not indicated for heart health alone. Interesting. Benefit, but we're not promoting it. And then the type of estrogen matters. So if it's estradiol, which is the natural form of estrogen, the bioidentical, and you can get this from a pharmacy, it does not have to be compounded, estradiol may have a different risk benefit than Premarin. So estradiol was not associated with heart disease risk, but actually reduced the prevalence of heart disease. And this is looking at almost 500,000 women that all cause of death, what they call all cause mortality. So death from any reason was reduced by 12% to 38%. Stroke death reduced by 18%. Heart death reduced by 18%. However, no difference in risk reduction if you started before or after age 60.

Starting point is 00:19:26 So this is one study that says the timing hypothesis doesn't work, but that's okay with me because it shows that hormone therapy is really beneficial. And I still believe in the timing hypothesis because of what happens biologically. So my takeaways, there's biologic plausibility, meaning it makes scientific sense that ERT, estrogen therapy, helps prevent cardiovascular disease and type 2 diabetes. Remember that 30% reduction of diabetes. The intervention data is most supportive for estradiol, not premarin. You want it to be five or fewer, certainly less than 10 years into menopause. So start it five or fewer years. And I recommend it in women that are at high risk for heart disease and low risk of breast cancer. I continue it up to 10 years, but I want to reduce cardiovascular

Starting point is 00:20:31 risk at the same time so I can consider stopping HRT sooner. Or by the time I stop it at that 10 year window, I've reduced their heart disease risk. Well, I hope you enjoyed that teaser of exclusive content that you get every single month with Dr. Hyman Plus. If you want to listen to the full episode and get access to ad-free podcast episodes, plus Ask Mark Anything episodes, plus monthly functional deep dive episodes, I guess that's why we call it Dr. Hyman Plus, then head on over to the doctor's pharmacy on Apple Podcasts and sign up for your seven-day free trial.

Starting point is 00:21:11 Hi, everyone. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It's important that you have someone in your corner who's trained, who's a licensed

Starting point is 00:21:42 healthcare practitioner, and can help you make changes, especially when it comes to your health.

The Dr. Hyman Show - Exclusive Dr. Hyman+ Functional Medicine Deep Dive: Menopause And Hormone Replacement Therapy

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