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[Hurdity]

I don't usually start new threads - but thought I would try it this time...

This isn't meant to be anything definitive but I didn't want to go off topic re Taz's thread on oestrogen and brain function 

Taz you mentioned stroke risk so I looked up a few papers but it's all a bit inconclusive and you've probably seen most of it anyway - might be helpful to some though maybe?

Brain Warning - it's a long post!!!! (I'm hopeless at being brief!)


BMS and Women's Health Concern Recommendations on HRT

http://min.sagepub.com/content/19/2/59

This is the paper I often quote from and here is what it says about stroke:

Stroke
Observational studies on the use of HRT and stroke have yielded conflicting results.
The WHI study revealed an overall increased incidence of stoke in women using estrogen and progestogen therapy or estrogen alone.
Re-analysis of the combined data from the estrogen and progesterone study and that of the estrogen alone study revealed a smaller increase in incidence of stroke in women who commenced HRT between the ages of 50 and 59.
The HERS study (the Heart and Estrogen progestogen Replacement Study) found no increased incidence of stroke with HRT.
On current evidence, HRT cannot be recommended for the primary or secondary prevention of stroke.
Caution should be exercised when prescribing HRT in women over the age of 60 particularly when they have a risk factor for stroke or thromboembolism. In these groups, current evidence would suggest that the transdermal route may be advantageous.
The effects of HRT may be dose related and the lowest effective dose should be prescribed in women with significant risk factors.

International Menopause Society statement – Women's Health Initiative study 10 years on
May 2012
They re-analysed the data from the famous study and produced a paper which was summarised in the statement.

Stroke There is a modest increase in stroke risk with HRT use if started near the menopause. This risk rises considerably in women who start at older ages. There is some evidence that use of HRT patches (as opposed to pills) may not increase stroke risk, but this needs to be confirmed (Henderson and Lobo)

I haven't seen the actual paper.

Remember that the WHI study was carried out only using conjugated equine oestrogens and synthetic progestogens and was also flawed in a number of ways

There are indications that transdermal methods of oestrogen replacement are safer:

Medical News article America Sept 2013
http://www.news-medical.net/news/20130920/Hormone-replacement-therapy-formulations-may-cause-different-risks-for-stroke-heart-attack.asp

I've missed out a few paragraphs

A new observational study shows bioidentical hormones in transdermal patches may be associated with a lower risk of heart attack and FDA-approved products -- not compounded hormones -- may be associated with a slightly lower risk of stroke compared to synthetic hormones in pill form.

"If confirmed by future randomized trials, these findings may be significant because for the past decade, many women who experienced severe menopause symptoms opted not to use hormone therapy because of the reported increased risk of stroke and heart attacks,"

Shufelt said the study's findings are not conclusive and are based on observational follow-up, not a randomized clinical trial. Additionally, all types of hormone therapy had similar rates of total cardiovascular outcomes and all-cause mortality, the study showed. The similarities in results across formulations were greater than the differences

Today there are many hormone options in the form of pills, patches and creams, synthetic or bioidentical, low dose or higher dose, and we wanted to answer whether they all have the same risk. This study is important because it is the first of its kind to provide a head-to-head comparison of the different doses and delivery methods. We found low dose and the transdermal patch may carry less risk for some outcomes than traditional hormone therapy, but more research is needed," Shufelt said
.
"Our analysis of the data shows that women taking oral estradiol, the bioidentical as opposed to synthetic form of estrogen, may have a trend toward a slightly lower risk of having a stroke. Also, taking estradiol through a patch on the skin was associated with a slightly lower risk of heart disease when we compared it to taking a synthetic hormone in pill form." But the numbers of women using these newer forms of hormone therapy were small.

The researchers concluded that the FDA-approved estradiol form of estrogen, and the transdermal delivery of hormones, may not carry that same increased risk for heart attack and stroke seen with oral regimens, but stressed that the findings are inconclusive and must be confirmed by randomized trials.

Shufelt said that this study adds to a growing body of evidence suggesting that hormone therapy taken through a patch, in smaller doses, may have less adverse effects on a woman's risk for developing cardiovascular disease than traditional hormone therapy.

Danish Study:
http://www.ncbi.nlm.nih.gov/pubmed/23048011

Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial.

Conclusions: After 10 years of randomised treatment, women receiving hormone replacement therapy early after menopause had a significantly reduced risk of mortality, heart failure, or myocardial infarction, without any apparent increase in risk of cancer, venous thromboembolism, or stroke

The women in the study were all recently post-menopausal age 45-58 (average age 50) and were followed for 10 years then 16 years. The abstract of paper does not distinguish between results according to age

NICE Clinical Knowledge Summaries
Venous thromboembolism
http://cks.nice.org.uk/menopause#!supportingevidence1:11

Oral and not transdermal hormone replacement therapy (HRT) is associated with an increased risk of venous thromboembolism (VTE) in case-control studies.

That's it for now - all I could find and decipher without getting in too much brain fog!

Hope it's useful to someone....

Hurdity  x

[Sarah2]

The risk of heart disease and strokes in women increases after the menopause so they have the same level as men. This is something that has been known for a long time and hence the drive to try to get women to take CVD seriously once they are post meno because the stats are that more women die from CHD/CVD than cancers.

Osteoporosis kills more women than cancer- 1100 a month- through complications from broken hips and immobility ( -  raising the risk of blood clots.)

In women over 45 years of age, osteoporosis accounts for more days spent in hospital than many other diseases, including diabetes, myocardial infarction and breast cancer (11).

So...it would seem to suggest that oestrogen has a protective effect for women. It doesn't seen unrealistic to extrapolate that bioidentical transdermal oestrogen may well give protection.

On another level, even if it does increase the risk slightly, there is a lot to be said for minimising that risk by doing everything possible to offset it, by eating healthily, exercising and living a 'heart friendly' lifestyle.

My own feelings are that a woman on HRT who makes an effort to live healthily is probably at less risk of CHD /CVD and strokes than someone not on HRT who is overweight, takes no exercise, and eats all the wrong type of food.

Not a scientific analysis but my own views I must add!

Very interesting feature in The Times magazine yesterday by Dr David Agus . doctor to the late Steve Job. In his book 'A short guide to a long life ' he advocates both statins and a small mini-dose of over the counter aspirin for anyone in middle age.

I think if I was worried about strokes, I'd take HRT and a daily aspirin.

[Dancinggirl]

Bravo Hurdity and Sarah2 - all very interesting stuff and I'm sure will help to reassure those who are anxious about taking HRT.
I have to say, now I've come off systemic HRT I am really worried about osteoarthritis - I'm pretty active with gardening, lots of walking and my job involves walking and climbing lots of stairs - I hope this will protect my bones a bit.
DG x

[Sarah2]

DG- you mean osteoporosis?

You are doing all the right kinds of exercise!

[Dancinggirl]

Of course Sarah2  - I typed the wrong word - I have some osteoarthritis in my hips but it's the long term problem of osteoporosis that I'm worried about.  DG x

[Sarah2]

It's not just genetic. Genes are a factor for some women if their mothers had severe osteoporosis early. My close friend's mother was hunched with osteo at age 60- ish. My friend had osteopenia in her late 40s but not as severe as mine - yet my mum is almost 87 and has no signs of it though I suspect her bones are quite fragile now due to age.

There are a lot of risk factors some which are lifestyle attributed. see this from the National Osteoporosis Society

http://www.nos.org.uk/page.aspx?pid=263&DeliveryChannelID=23b5%253a%252f%252fw6292-0f3c-43ac-af13-7767ad9d4057&srcid=234

The only risk factor I have is low BMI- currently 19.1 which is what I've been all my life and which means I am a size 10- I am by no means 'skinny'.

Being overweight has pros and cons- it used to be thought that heavier women did not have thinner bones but new research has cast some doubts on this.

http://www.livescience.com/9017-women-belly-fat-lead-osteoporosis.html

[Trey]

I have been on estrogen 33 years.  I had surgery for varicose veins so I am careful about blood flow and wear support hose on long trips.  I take 81 mg. of aspirin daily and daily fish oil as it has anti platelet effect on blood.  I am extremely active and have no evidence of stroke issues, although I do get occasional visual migraines.  My mother is 98 and had a stroke at 97.  She also had carcinoma in situ at 84, and she has been on equine tabs her entire adult life including the present. I switched to the patch at 60 and felt so much better than when on the equine tabs.  I had a hyst at 32, thus the ERT only.  Don't know why I'm posting this.  Maybe I'm a long term statistic.  I, too, have researched HRT and ERT very carefully and am comfortable with my choices.  I was scared to death with my recent biopsy and relieved it was totally benign.  My biggest fear, after the obvious, was having to give up ERT.

[CLKD]

   will read all this at a later date …….. it's interesting!

[Sarah2]

Trey pleased you have had such a good outcome.
It's worth mentioning though that risks are not accrued until a woman is on HRT over the age of the natural menopause- so around 51. So not sure how old you are now, but take it's only the years after age 51-52 that 'count' towards your total. And oestrogen-only HRT has a very good safe profile for risks ( cancer at least) compared with combined HRT.

[Trey]

I'm 74.  I play high level tennis almost daily......etc.  I feel estrogen supplementation is making up for the fact we are living longer and the human body has not yet adapted to our longer time in post child bearing years.  There are many, many common drugs with horrible safety risks.  I think of estrogen as far more natural than synthetic chemicals that are unusual for the body.  Sorry, in a rush and not being too clear here.

[Hurdity]

The problem with post-child-bearing years is that we probably cannot adapt! Any potential adaptation - eg having a higher post-menopausal oestrogen level, cannot be passed on to the next generation, because we are past child-bearing - unless it is linked to another advantageous change that is expressed while we are still fertile, if you see what I mean... I think we will have to continue taking it for a long time - unless of course the maximum child-bearing age evolves to be later - which perhaps it now should?

For many conditions there is a known genetic susceptibility, but whether or not the genes are expressed can be modified by the lifestyle factors mentioned - eg diet and exercise. In some cases we know the likelihood of the genetic link through our relatives - but not always - so it is always best to make sure lifestyle factors - diet, exercise etc are beneficial to good health. Then we are giving ourselves the best possible chance!

I totally agree Trey re oestrogen. If only the research world would wake up to this and conduct more trials so that the risk factors are quantified for the different HRT types at different ages and then we would all know where we stand. I would have thought the big pharmas would be wanting to fund it because they stand to make more profit if it turns out that eg low dose transdermal oestrogen could be routinely prescribed until say age 70 with minimal risk.

Hurdity x

[Ju Ju]

Interesting. My grandmother had a heart attack at 63, after the death of my grandfather and a difficult life and my mum had a stroke at age 66. She collapsed at a funeral, the 4th in 2 weeks, including that of her brother. She did not cope well and I think she would have had a break down if she hadn't of had a stroke. She is now 86, frail but still here. I am not convinced this is genetic, but I did avoid HRT up to recently in desperation. ( the other reason is that my sister had breast cancer, but there is no other close family history, so not considered a risk). Difficult choices we have to make sometimes.

[Sarah2]

I think it's better to look at it as a predisposition rather than a direct genetic link.
I think the stats are that a third of us will die from cancer, another third from CHD and another third from everything else. Very few people die from old age.

I suppose what everyone wants is to avoid premature death or disability. Having a stroke at 90 is very different from having one at 60 and the older you are the more quality of life over longevity seems to matter to many people.

[KatieLiz]

With regard to risks and medication - I've got an ear infection and have been prescribed antibiotic and steriod ear drops.  The side effects are: super infection, hearing loss!  My GP didn't highlight this to me - unlike when I started HRT!

[Trey]

Amen! KatieLiz