Timing is everything
A new study, presented at this year's Menopause Society meeting, posits that estrogen treatment initiated early, in perimenopause, might lower women's risks of heart attack, stroke, & breast cancer.
I was in the middle of researching a different story yesterday when I happened upon a press release of a new study that not only stopped me in my tracks, it made me decide that getting this information out there today was more important. It also made me more than a little enraged, both for myself and for every Gen-X and Boomer woman who was either taken off hormone therapy, deterred from starting, or, like me, never even told that she and her body might benefit from it.
Millennial and Gen-Z women, however? Listen up. I know many of you are not necessarily thinking about your body’s dramatic loss of estrogen in the near or far future, but if you’re in your forties right now or younger, you have a unique opportunity, if you start taking estrogen early, not only to outlive us estrogen-deprived oldsters but also to feel like yourself and have fewer symptoms while thriving. As long as your doctors—many of whom received no training in the menopause transition whatsoever—are made aware of this new data: a big caveat, I know, and one we will all have to work hard to overcome.
This new retrospective study out of Case Western Reserve School of Medicine, sorting through 120 million patient records in the TriNetX Research Network, by Ify Chidi, MPH, is called “The Timing of Estrogen Therapy: Perimenopausal Benefits and Postmenopausal Risks.” It was just presented at the Menopause Society’s annual meeting in Florida. The study’s results suggest that a much earlier timing of initiation of estrogen therapy in perimenopause—ideally ten years prior to menopause and continuing on it for that same length of time—is not only helpful in alleviating the many debilitating symptoms of the menopause transition, but that starting HRT (aka MHT) in perimenopause should now be considered standard preventative medicine. Here’s the direct quote from the Menopause Society’s initial announcement1: “The findings revealed that perimenopausal women who had used estrogen for at least 10 years prior to menopause had significantly lower odds of developing breast cancer, heart attack and stroke compared to the other two groups—approximately 60% lower.”
I read that line and teared up, wishing I could go back in time. And because I always love a good personal example of what can happen when a female body is deprived of a hormone she needs, allow me to provide my own soap operatic tale of As the Estrogen Turns.
I lost my uterus to a hysterectomy in 2012 due to adenomyosis. I was 46 years old. Right in that key window of perimenopause, but now that I no longer had a uterus shedding its lining, I also had no way of marking the natural end of menses. Nor was I provided any information about perimenopause or what it might do to me. I was simply wheeled out from my hysterectomy with a handful of flowers and instructions for recovery and wound care.
Here’s what happened over that next decade, when—we now know—I should have been treating my body with estrogen both preventatively for my heart, breasts, and circulatory system as well as to treat symptoms such as hot flashes, depression, recurring UTIs, migraines, and brain fog that are essentially the body’s way of saying, “Hey, Deb! WTF? Where’s the estrogen? We can’t operate this way…”:
2013: I was diagnosed with DCIS of the left breast. Before that, I’d already fallen into a funk so deep that I—a normally cheerful and optimistic person—leaned my head out a window and seriously considered throwing myself out of it. Yes, my marriage had just ended, and my financial situation was bleak, but it was much more than situational trauma. It was a full-bodied darkness that left me feeling as if I were drowning. 2014: I essentially stopped sleeping through the night, for years, because I kept being awoken, drenched in hot-flash sweat. 2015: I started fainting, frequently, sometimes injuring myself on the way down. I was also having heart palpitations, so I went to a cardiologist who put me on a Holter monitor for a month and diagnosed a near constant tachycardia, for which I was prescribed metoprolol, a beta blocker which made me tired, even dizzier, and even foggier. 2016: I began getting migraines so intense, I asked my neurologist, “Could this be hormone related?” She rolled her eyes and said, “No.” Not a fan of belittling contempt from those in charge of my medical care, I switched neurologists. The new one said, “Yes, I personally think this could be hormone related, but we haven’t really studied it,” and put me on a CGRP inhibitor, which worked. This was when I also started getting recurring UTIs. As in 12-15 times a year. The constant need for antibiotics wreaked havoc on my body and made it resistant to one of them. 2017: I was diagnosed with pre-cancer of the cervix and had it removed. Two weeks later, I bled out from vaginal cuff dehiscence. Why? Possibly because my vaginal tissue was now so estrogen-starved and thin, the stitches holding it and me together simply broke right through that thinning tissue and came undone, so I nearly died. 2018: I started forgetting common words, like the artichoke I was holding in my hand. 2019: The UTIs continued, unabated, until Dr. Rachel Rubin, who read a story I wrote in The Atlantic, reached out over twitter DM, and told me to get some estrogen in my body, stat. I ignored her because I was erroneously worried about the flawed WHI reporting that had stopped estrogen treatment in its track back in 2002. 2020: diagnosed with post-Covid POTS. It lasted a year. Could it also have been hormone related? Who the hell knows? 2021: Finally, fed up with the recurring UTIs, I listened to Dr. Rubin and started taking estrogen, both vaginal and systemic. But first I had to find a menopause specialist in my area who took my insurance, which took forever and was a massive hurdle to care. 2023: Diagnosed with osteoporosis.
After I started using vaginal estrogen and dabbing a small circle of systemic estrogen gel on my thigh every morning? My body stopped rebelling. Or, better put, both it and I felt as if we’d reverted back to our pre-hysterectomy self, even if my bones were now as brittle as an 80-year-old’s. No more tachycardia. No more night sweats. No more UTIs. No more dizziness, brain fog, sleeplessness, all of which are outward signs of the internal dysregulation of estrogen loss.
Life, I now realize, did not have to be that way. I did not have to lose an entire decade to medical chaos. Hopefully, once the data in this study is published, and we can get gynecologists and primary care providers not only to read it but to act on its findings, this next generation of women entering perimenopause will have it easier. Until then, if you are (or know or love) a woman who is or will soon be entering her forties, consider hopping on the estrogen bandwagon ten years prior to menopause. 120 million patient records is a substantial number of female bodies to have included in a study, even retrospectively. And a 60% reduction in breast cancer, heart attacks, and stroke is a substantial reduction in female morbidity and mortality, especially considering that heart disease is the number one killer of women.
I know we’ve all been feeling a lack of good news these days, but despite the fact that this news cannot help me and my generation personally, I see it as a welcome exception for the next generation of women as well as a boon to our understanding of our own bodies in particular, and women’s health in general.
Weirdly, the press release was changed after I published this from that declaration of a 60% decrease to the following: “The findings revealed that perimenopausal women who had used estrogen within 10 years prior to menopause had no significantly higher associated rates of breast cancer, heart attack and stroke compared to the other two groups.” But the pdf of the formerly embargoed story, which is here, remains the same. Doing a deeper dive—I’m going to try to interview the study’s author—I found this post interviewing the researcher and her professor, which is illuminating:
I would like to thank Gen X women, you and a handful of others in particular, for doggedly asking the questions and telling the stories that have normalized menopause. Almost too late for our generation, unfortunately, but we can benefit to some degree from the information and therapies. And all the generations coming after us can change their lives. It’s remarkable what one determined group of women can do.
I read this report too and felt a similar wave of relief and anger. I’m 53. In hindsight I entered peri around 39. My 40s were a decade of health-related WTF similar to yours, parallel to intense working years. Now I know that I should’ve been on estrogen then. I’m grateful my daughter won’t suffer in the same ways we did. After 3 years on HRT I’m feeling strong. Strength training helps too, which I started thanks to you Deb after your post about working with Holly. Your writing is powerful and changed my life for the better. So much gratitude for you!