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Transgender woman age 62 asks about estrogens and feminizing vaginoplasty

Dear Dr. Reed ,

Have successfully recovered by coronary bypass using 4 grafts.  Now age 62, should I resume estrogens.  Am I still a candidate for MTF vaginoplasty?

Alexis

Dear Alexis.

Over the past 10 years there has been a reformulation of opinion on estrogen usage for women over 55 as expressed by the National Health Institute.  Essntially they are saying ” no.”  Aside from the feminizing effects of estrogens the other benefits can be obtained with medications and diet devoid of estrogens per se.

Your cardiologist needs to re-evaluate you with a radio-isotope stress EKG and with knowledge you are contemplating being under general anesthesia for about 41/2 to 5 hours in the lithotomy (legs up) position.  If your by-pass was done for ischemia (reduced blood flow) but no history of actual myocardial injury or tissue loss this would put you in a more favorable category.  At any rate, you would still need to be done in a hospital and kept there for a few days post-operatively.

Here are some National Institute of Heath and other references on estrogens usage….
As you can see, as we age we have an increase likelihood of dying from a heart attack (MI) or stroke, let’s say 30% once you are 55 or older.  When someone reviews your medical records, post mortum, what doctor wants to take the credit for prescribing estrogens which are known to be coagulopathic.  In our practice, unless someone has a sterling letter of medical clearance and CABG (coronary artery bypass grafts) times 4 won’t do, at best I would recommend reduced estrogens, baby ASA daily and this becomes a shared decision (the patient knows she is at risk).

 

Harold M. Reed, M.D.
Trasngender Surgeon – Miami
1-305-865-2000

Chart ranks total deaths for the top 50 causes by age and gender. Rank is determined by official CDC final death total and certain causes such as types of heart disease and cancer are split out for age adjusted death rate rankings to give you an expanded view of what actually takes place. For this reason they will not always match rankings for top 15 causes for age adjusted death rates which use a different combination of ICD-10 Codes. You can click on any cause to highlight it to make it easy to follow as you change ages or select a different gender. To remove highlight click the cause again. Use buttons in center to select gender and Use Green Links to sort by age range. Note how the cause of death column rankings change. Scroll to the bottom of the page to see population by age range selected. Use Drop Down at top left of Page to see this chart and other data for individual states. Citation is at the bottom of page.

Click on any cause to Highlight, click again to remove Highlight
UNITED STATES

Estrogen therapy has no long-term effect on cognition in younger postmenopausal women

NIH-funded study finds neither benefit nor risk to cognitive function years after treatment



June 24, 2013

Barbara Cire | 301-496-1752 | nianews3@mail.nih.gov


A randomized clinical trial of estrogen therapy in younger postmenopausal women, aged 50–55, has found no long-term risk or benefit to cognitive function. The National Institutes of Health-supported study, reported in JAMA Internal Medicine on June 24, 2013, looked at women taking conjugated equine estrogens, the most common type of postmenopausal hormone therapy in the United States.

The earlier Women’s Health Initiative Memory Study (WHIMS) linked the same type of hormone therapy to cognitive decline and dementia in older postmenopausal women.

The new findings come from the Women’s Health Initiative Memory Study of Younger Women (WHIMSY) trial and were reported by Mark A. Espeland, Ph.D., Wake Forest School of Medicine, Winston-Salem, N.C., on behalf of the academic research centers involved in the study. The study was funded primarily by the National Institute on Aging (NIA), along with the National Heart, Lung, and Blood Institute (NHLBI), both components of the NIH.

“The WHIMS study found that estrogen-based postmenopausal hormone therapy produced deficits in cognitive function and increased risk for dementia when prescribed to women 65 and older,” said NIA Director Richard J. Hodes, M.D. “Researchers leading the WHIMSY study wanted to expand on those results by exploring the possibility of a window of opportunity whereby hormone therapy might promote or preserve brain health when given to younger women.”

“In contrast to findings in older postmenopausal women, this study tells women that taking these types of estrogen-based hormone therapies for a relatively short period of time in their early postmenopausal years may not put them at increased risk for cognitive decline over the long term,” said Susan Resnick, Ph.D., chief of the Laboratory of Behavioral Neuroscience, in NIA’s Intramural Research Program and a co-author of the study. “Further, it is important to note that we did not find any cognitive benefit after long-term follow-up.”

 

 

Estrogen and the cardiovascular system

Scientists are still learning about the actions of estrogen in the body. Studies have shown that estrogen affects almost every tissue or organ system, including the heart and blood vessels. Estrogen�s known effects on the cardiovascular system include a mix of positive and negative:

  • Increases HDL cholesterol (the good kind)
  • Decreases LDL cholesterol (the bad kind)
  • Promotes blood clot formation, and also causes some changes that have the opposite effect.
  • Relaxes, smooths and dilates blood vessels so blood flow increases
  • Soaks up free radicals, naturally occurring particles in the blood that can damage the arteries and other tissues.

Estrogen probably affects the cardiovascular system in other ways that are as yet undiscovered. New research continues to give scientists and physicians more information � and raise more questions about this important and controversial hormone.

Over the years, evidence was accumulating that suggested estrogen also helped protect women against heart disease. With heart disease is the number one killer among women over age 65, this is an important issue. Women develop heart disease 10 years later than men, but by age 65, their risk is equal to that of men.

The accepted thinking was that the drop in estrogen levels associated with menopause accounted for this jump in heart disease risk in women. When estrogen levels decline, levels of LDL cholesterol (the harmful kind) increase, and levels of HDL cholesterol (the positive kind) decrease, leading to the build up of fat and cholesterol in the arteries that contributes to heart attack and stroke. It made sense that replacing estrogen through HRT would potentially improve heart health. This thinking contributed to a huge rise in the number of women being prescribed estrogen.

Rethinking old ideas

Recent studies on the long-term use of HRT are changing that way of thinking. With scientific data potentially linking HRT to higher risks of heart attack, stroke and other serious health problems, many women are reconsidering HRT.

The buzz about estrogen started in the late 1990s when a report from the Heart and Estrogen-Progestin Replacement Study (HERS) was published in the Journal of the American Medical Association (JAMA). This study of more than 2,700 women with existing coronary heart disease was designed to test whether estrogen plus progestin would prevent a second heart attack.

During the first year of HRT, women in the study had a 50 percent increase in heart attack and stroke. But, after two years of treatment, women on HRT actually had less heart disease and fewer heart attacks and strokes compared with women not taking HRT.

The study left many unanswered questions, leading researchers to take another look at these same women. They published their results in 2002. This time around, after nearly three more years of followup, the researchers concluded that there was no lasting decrease in heart disease or heart attack/stroke risk from HRT, and HRT increased the risk of blood clots.

Evidence adding up

Meanwhile, an even larger study, the Women�s Health Initiative (WHI), was raising more questions about the potential risks associated with HRT. Involving more than 160,000 women, WHI is the world�s largest clinical trial of health interventions for midlife women, studying the effects HRT, diet changes and calcium and vitamin D supplements on heart disease, osteoporotic fractures and breast and colorectal cancer risk.

In 2002, scientists at the National Institutes of Health (NIH) National Heart, Lung and Blood Institute halted the arm of the WHI study in which women were taking combination estrogen and progestin. Early data from this group of women showed that HRT significantly increased the risk of breast cancer, heart attack, stroke and blood clots in the legs and lungs.

Then, in 2004, the NIH stopped the estrogen-only study arm, in which women who had undergone hysterectomy were taking estrogen. Data showed that estrogen increased their risk of blood clots and stroke and did not reduce the risk of heart attack. (Estrogen�s effect on breast cancer risk was unclear.)

A change in recommendations

These studies were the first large-scale trials that looked for cause and effect with heart disease and HRT. HRT does offer some benefits, such as preventing osteoporosis and reducing the risk of colon cancer. But the data on heart-related risks from these studies were very compelling. As a result, the American Heart Association and the U.S. Food and Drug Administration developed new guidelines for the use of HRT:

  1. HRT should not be used for prevention of heart attack or stroke.
  2. Use of HRT for other problems such as preventing osteoporosis should be carefully considered and the risks weighed against the benefits. Women who have existing coronary artery disease should consider other options.
  3. HRT may be used short-term to treat menopausal symptoms.
  4. Long-term use is discouraged because the risk for heart attack, stroke and breast cancer increases the longer HRT is used.

The bottom line, say physicians at the Miller Family Heart & Vascular Institute at Cleveland Clinic: weigh the benefits of HRT against the risks and discuss the whole subject of HRT with your physician to be able to make an informed decision.

Additional Information

For more information about HRT and your heart, call the Miller Family Heart & Vascular Institute Resource and Information Center Nurse at 216.445.9288 or toll-free 866.289.6911.

To make an appointment with a Preventive Cardiology specialist, call 216.444.9353, or toll-free 800.223.2273, ext. 49353. Preventive Cardiology can assess your heart and circulatory system health and help you set up a plan to reduce your risk for heart attack and stroke if needed.

To discuss hormone replacement therapy with a Cleveland Clinic expert, call 216.444.4HER to schedule an appointment with a gynecologist or nurse practitioner.

References

  • Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, Vittinghoff E. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA1998; 280(7):605-13
  • Grady D, Herrington D, Bittner V, Blumenthal R, Davidson M, Hlatky M, Hsia J, Hulley S, Herd A, Khan S, Newby LK, Waters D, Vittinghoff E, Wenger N; HERS Research Group. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA 2002; 288(1):49-57
  • Manson J, Hsia J, Johnson K et al. Estrogen plus progestin and risk of coronary heart disease. New Engl J of Med 2003; 349:523-534.
  • U.S. Department of Health and Human Services and the National Institutes of Health. Facts on Menopausal Hormone Therapy, June 2005.
  • Women�s Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomies. JAMA2004; 291:1701-12.
  • The American Heart Association*
  • Heart Truth for Women, NHLBI*

 

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