Effects of HRT: Alone, in Combination or Sequencing

Or simply interview the doctor and ask about their education, expertise and length of time in treating patients with those needs. It's like a job interview....what qualifies you to treat my _____fill in the blank.

Unfortunately, the Women’s Health Initiative back in the early 2000’s influenced physicians to not use HRT for post menopausal women. I believe many women suffered after this flawed study and there are still physicians out there that have not updated their knowledge base. Very frustrating for women and my hope is that my daughter and granddaughter will have better care than I do as they age. I feel like I am fighting with my rheumatologist and gynecologist. Have an appointment with an endocrinologist a few counties away, but it isn’t until 2026 he is so busy. Hoping I can stay stable until then.

Any functional medicine providers in your area?
Curious to know what your docs give as their rationale for denying bhrt.

I have not found anyone in a two county area who believes in bhrt. Granted, I have not had appointments with everyone. But I have talked to many women in my area who are in the same pickle and running into this brick wall. The rational I have received from all of them is cardiovascular risks. My father suffered from heart disease and had a heart attack at age 51. He was an athlete. My mother had deep vein thrombosis in her mid forties and then suffered mini strokes as she aged. I believe they see me as high risk for a cardiac event; specifically based on that flawed study. To that point; to date I have no heart issues. I’ve always been active; no high blood pressure. So in conclusion, I think they fear liability.

@gravity3
One last thing, I believe my current physicians are pressured by the insurance companies as well.

I've come to similar conclusions.

Wow, you've done a fair amount of work for an informed and shared decision.

I've only done LPa for ASCVD genetic testing, and thought APO-E is for neurodegenerative risk. My understanding is LPa and APO-B are most atherogenic where high LPa is not treatable. But since LDL-c is routinely tested it became the "proxy" for atherogenic burden although for some people the two may not correlate to each other. Please correct any misunderstanding here from your knowledge base.

Which calculation method do you use for your 10 year cvd risk? I've used MESA which takes cac score into account. The calculated risk is below 2%. But this calculated risk is based on the LDL-c level that was controlled below target value by a statin and heart healthy diet. I have a feeling cardiologists know this very well based on labs/tests, medical history and family history.

You are at a unique position to use HRT for your osteopenia to prevent/stop bone loss. I wonder how often you get dexa scan and if you monitor bone markers. I'm keen to see how testosterone in the mix would affect bone markers. If you test them and could share, it will be great to to observe testosterone effect, even at the very low dose you are getting,

I’ve watched many of Menopause Taylor’s videos, and she offers in-depth information, especially for younger women, focusing on prevention. She provides an excellent service for healthy younger women. However, at 74 years old with cardiovascular disease (CVD), my situation requires a more individualized approach. It seems I am a borderline case, which is why I keep being referred to a cardiologist.

There’s a lot here to unpack. Apo-E (Apolipoprotein E) is involved in the metabolism of fats. Every human inherits one copy of the gene. There are three variants of the ApoE protein: e2, e3, and e4. The combination of these variants determines your ApoE genotype. For example, you could have a 2/2, 2/3, 3/3, or 3/4 genotype, among others. Some combinations can be protective, neutral, or harmful. I have the ApoE 3/4 genotype, which is associated with an increased risk of both Alzheimer's disease AND cardiovascular diseases. The most feared one is 4/4 genotype.

Apo-E binds to lipids to form lipoproteins. To simplify things, because of my APOE 3/4 allele, my body struggles to clear LDL efficiently. This causes LDL to linger longer, leading to oxidation and increased inflammation.

My understanding of Lp(a) and APOB is the same as yours except
Lp(a) is treatable with three medications available today. However, these medications cannot fully address Lp(a) in a way that is highly effective for those with high levels of it. They are approved for lowering LDL and not specifically for Lp(a). Despite this, I believe they should still be used. Statins, for example, can increase Lp(a) by 8-24%.

Repatha can reduce Lp(a) by an average of 27%, Praluent can reduce it by about 25%, and Leqvio can also lower it by around 25%. Both oral and transdermal estradiol can reduce Lp(a) by up to 22% in postmenopausal women, but as we know, both estradiol and Lp(a) can also contribute to plaque instability in postmenopausal women who have heart disease.

Most doctors want to increase statin dosages to lower LDL to very low levels with people that have heart disease and not address Lp(a). But why not use one of these three medications to treat both high LDL and Lp(a) until newer Lp(a) drugs are released? The main obstacle is the complex approval process and insurance challenges. Repatha and Praluent are covered under Medicare Part D, while Leqvio is covered under Medicare Part B and is generally easier to get approved. I have been approved for Leqvio but still waiting to start it.

I’m not sure if calculators are always helpful. You can have a CAC score of 0 and still experience a heart attack. My MESA score with CAC is 4.5%.

I had a hysterectomy (uterus and cervix removed) when I was 44, 1994. Afterward, a coworker gave me a book about bioidentical hormones, and I became aware of the potential for bone loss, even with intact ovaries. Around 1995, there was some news about testosterone helping women with bone health and libido.

I used the compounded bioidentical hormone doctor my coworker recommended for estradiol for about a year and also a had a Dexa scan for a baseline. Then I added testosterone cream a year later after hearing about it in the news. After a year of testosterone I had another Dexa scan (I was paranoid about osteoporosis). The results showed improvement with the testosterone. Two years later, the doctor moved to a different state, and when I tried to find another doctor to prescribe testosterone, many of them were horrified and I couldn't find anyone who would prescribe it.

I became overconfident and went for about 12 years without a DEXA scan. In 2022, I had one and found out I have osteopenia. I had another scan June 2024, and the results showed minimal change. The last June scan, I had only been on the Estradiol 0.025 patch for about 2-3 months, so I don’t think it had any effect on my DEXA results. I do believe that adding testosterone and increasing my estradiol patch to 0.05 will make a difference, but I won’t know for sure until June 2026.

I’ve seen two endocrinologists that don't believe in bone markers. I would like to have them done, but I’d have to find a doctor who would actually perform them. There isn't any facility here doing TBA scoring for cortical bone. Both doctors said they wish there were but it was about $.

When I found out about my osteopenia, I was very focused on preventing osteoporosis. I joined Mayo osteoporosis forum to learn more. After reading people’s experiences with osteoporosis and medications, I became scared. That fear kicked off my journey with hrt, which ultimately led me to discover I have cardiovascular disease. It’s been quite a journey.

Teb, thank you for taking the time to respond and include the helpful links. I’m familiar with NAMS and have used their directory in the past, but I was surprised to find there are no NAMS providers in my area.

I don’t live in California, though I am familiar with Dr. Felice Gersh. I’ve watched many of her videos and appreciate her work. Have you watched Dr. Louise Newson and Dr. Kelly Casperson's videos they seem to offer more material that’s specifically relevant to older women like myself, which is rare to come by.
I’m also familiar with Alloy Health and have used one of the prescription products they offer.

Regarding your comment "I can understand your concerns about your cardiologist prescribing hormones". I’m sorry if there was any misunderstanding. He is not prescribing my hormones. I’m currently using a 0.05 patch and a 4 mg testosterone/DHA cream for osteopenia, from a different provider.
To answer your question, I do not have a uterus.
After recently discovering that I have heart disease (I had a CAC scan as part of my HRT risk assessment), I consulted a cardiologist to ensure my late introduction to HRT would be safe, considering my heart condition.

I have a long convoluted history in my search for an HRT provider as I am sure others do. I have two health insurances, and my husband has one, which together costs us $8,500 per year. Out of options and desperation to find a doctor who would prescribe estrogen for osteopenia (incomprehensible why they wouldn't, even off-label. This was before I knew I had heart disease) I ended up spending more money on a very expensive telehealth consultation with Dr. Shawn Tassone. He was the one to prescribe my present hormones for my osteopenia. Unfortunately, due to his price increase, I cannot continue with him and am back to square one.

I’m aware of Midi, but they don’t accept either of my insurances. I’m hoping my primary care doctor will continue prescribing my hormone medications, especially since they’ve already been prescribed by another doctor.

While I might not be able to use the information and links you provided, I think it's important that others know this valuable information is available, and they might be able to benefit from it.