How Late is TOO Late to Start HRT for Women? New Research Study REVEALED

so bone quality declines during

menopause for women this is predictable

and ultimately preventable yet for the

past 20 years women have been denied an

accurate discussion of the risks and

benefits of horor replacement therapy as

it relates to Bone why well it all comes

down to the women's health initiative

and other studies that came out of the

same time and the impact that those had

on clinical treatment for hormones this

is especially true for women who were at

the time or over the subsequent 20 years

over 10 years out from menopause who

then had a desire to considerable

replacement therapy now I view things

very differently than doctors most

doctors do curly but especially then

because we see that women over 10 years

out from menopause or over the age of 60

depending on the study we see HRT as a

tool for these patients because the

benefits so clearly outweigh the risks

and there's a recent article that really

supports this idea this was published in

the landet uh just this last month

January 2025 so it actually stimulated

me to make this video now as usual and

this annoys me that I IED journals out

to make money but as usual this journal

article is behind the pay wall so you'd

have to pay 35 bucks to read it most

people aren't going to do that but I

want to bring it here because they make

some great points that are in addition

to the things that I usually say with

this age group around hormones so stick

around because I'm going to talk about

the tools that I think you're going to

need to have a conversation with your

healthcare provider around considering

HRT especially being over 10 years out

from menopause if you want to optimize

your bone your heart your brain your

sexual health and more this is a very

challenging conversation and and many

Physicians have really deep-seated

beliefs around the use of hormones for

these things but the more you know the

better you can prepare yourself to have

these conversations all right so this is

the story I hear all the time even in my

own mother for women who are over the

age of 60 they generally

vast majority of them in my experience

were never offered HRT because of the

timing at which they went through

menopause it wasn't really considered to

be an option for them although it

certainly should have they likely

suffered through the vasom motor

symptoms the genitor urinary symptoms of

menopause and have come out on the other

side of this hopefully not so

experiencing those things but often

times they even are now they also find

out that they have

osteoporosis sometimes they're going to

do the research and they're going to

find the tools they're going to say oh

my gosh I would love to consider hormone

replacement therapy and they asked their

doctor and their doctor said no it's too

late it's too dangerous does that sound

familiar it should because an entire

generation of women have been denied

care and are now facing declining bone

health as a result of not having

optimized hormones they're looking for

tools to improve their bones and

rightfully so they find HT but now

they're told but it's too late if this

is you and you're angry you should be

but before you switch videos to consider

something that you think might be safe

for you hear me out women over the age

of 60 in a hard practice are starting

HRT comfortably calmly because they're

armed with the right knowledge and

testing to feel secure in their decision

about using HRT to protect their bones

probably their heart probably their

brain probably their sexual health and

more so then how is it that we're able

to do this in our practice when most

patients are going to their doctors

their doctors are saying no it's too

dangerous let me explain the discrepancy

here see it all starts again with the

women's health initiative and other

studies that came out at a similar time

now if you're not familiar with this

study I'll describe it briefly but

basically the Women's Health Initiative

is the study that had the biggest impact

on hormone care in the early 2000s it

was a study that started in the 90s and

had two different groups of women who

were on hormone replacement therapy of

some kind compared to bbo and the

outcomes of these studies change the way

that we prescribed hormones probably

forever but definitely in the near term

millions and millions of women were

taken off of their HRT because of the

quote unquote risk associated with HRT

so let me explain I'm not going to go

through all the details here but let me

just explain what happened for women

over the age of 6 year over 10 years out

from menopause so if you look at this

table from this follow-up study which

actually just came out last year in 2024

so there's a couple different ways to

look at this you can look at the data

from the 2002 and 2004 Publications that

showed the increased risk of heart

attack heart disease stroke potentially

breast cancer there is a trend toward

increased risk in all these things

particularly in the combined trial now

combined even that they were both on

some form of estrogen and some form of

progestogen there was also an estrogen

only group but let me just take a quick

moment to just say the estrogen that

they were on was conjugated equi

estrogen know at that time as prevent is

the brand name of CED conjugated

estrogen this is a synthetic estrogen

that doesn't have much market share

anymore and certainly I wouldn't

recommend using it it's also oral which

has implications as well then they were

on medroxy progesterone and acetate MPA

this is a synthetic progestogen a

progestin that also now we know over the

last 20 years of being studied has other

potential negatives it could be

responsible for some of the findings of

these studies so you're on what I would

consider crappy HRT and I'm just going

to keep calling it that it's crappy HRT

they're on crappy HRT and they found

some risk the estrogen or premate only

group also founds a rest but not of the

breast cancer side but still in the

stroke and heart disease side so it's

something to have a discussion about but

we also now have follow-up data so

there's two follow-up studies over the

course of the last 20 years and then

finally last year they published this

this I don't know it's final but a

long-term follow-up study showing

whether or not the risk that occurred

during the intervention phases in the

early 2000s whether that risk persisted

over time because they they follow these

women over time so now we have a lot of

data to actually compare what's

happening when it comes to risk and the

decision- making around hormones now

what we saw it in the early data in the

intervention data is that if you were to

extrapolate by age if you start hormone

replacement therapy even crappy therapy

within the first 10 years after

menopause you are protected specifically

from heart disease this is a big deal

this is why we should be having this

conversation with every woman who goes

to menopause talking about the potential

benefits that are known most don't have

that conversation but here's what

happens most women also were not offered

AG te during the time they didn't have

that conversation and now they're over

10 years out for menopause now what this

table clearly shows is that yes if you

start hormones within the first 10 years

after menopause you are protected from

heart disease according to this table

but if you look at the group that's 60

to 69 years old women that are over 10

years out from menopause if you look at

these numbers they're still protected

from heart disease it's just not

statistically significant so we can't

say that it's not better than Placebo

but what we can say is that it's not

worse either so yes it would have been

safer to start it within 10 years of

minute but I don't have a the time clock

that I can take us back in time and time

travel to start this 10 years early we

don't have that tool all we have is what

we have right now in this present moment

so in the moment is it riskier that

Placebo to start HRT for women in this

group age 60 to 69 so yes it's safer to

start 10 years earlier but and don't

have the ability to time travel I can't

take you back 10 years ago and start

earlier we've only have the present

moment I only have now so now is

starting HRT in this group riskier than

Placebo and the answer is no so if it's

not riskier than Placebo why are we

denying this for women over the age of

60 or 10 years out from a poost I don't

get it Somebody explain it to me I think

that it just has to do with this fear

this not this misunderstanding of the

data to say oh it's too risky cuz it's

not protective from heart disease

anymore but the risk benefit equation

needs to include all things what's

happening from a sexual health

perspective from a GSM perspective

what's happening with your bones if

you're having issues with those things

that we know are clearly going to be

benefited from HRT and there's no

increased risk of having a heart attack

heart disease for anything like that

blood clot PE whatever there's no

increased risk compared to Placebo then

what are we worried about really really

frustrating for me now if you go another

10 years and now patients are over 20

years out from menopause or over the age

of 70 you do start to see that risk go

up why that's because we know that

estrogen's protective of heart disease

so if you've been 20 years without

estrogen exposure that's a long time

your arteries are going to look

different depending on other risk

factors you may be developing plaque you

may have significant heart disease and

then starting estrogen may actually be

more dangerous than none but this really

has to come down to

individuality and individual risk

factors because in our patients I don't

see people who are I don't see women who

have a lot of cardiovascular risk over

the age of 70 of osteoporosis of course

it exists but generally my patients are

healthier they have goodlook arteries

and I'll explain how we do that but it

is not unreasonable to start HRT even

though we're 20 years out from M now how

is it that people misunderstood this and

how is it even that that risk showed up

a little bit in the first place well we

have to understand that the Women's

Health Initiative have a lot of

potential negatives and the way that it

was designed one of those negatives is

that the study group was older because

they were looking for people that didn't

have symptoms of menopause so they were

older than most women or as they go

through menopause there's a higher

percentage of obesity about a third of

the inhibtion group hypertension or

treated hypertension and about a third

and 10% of them were smokers that's a

lot of risk factors and know risk

factors for hormone replacement therapy

so if you have that group and they were

on crappy HRT do these risk factors even

apply to my population we need to

consider it but my patients are not that

population before I tell you how we risk

stratify because again my patients don't

seem to be that same population I'm also

going to talk about this new article

that was cway just last month but if you

are struggling to put together your own

bone health program and you have some

questions please consider coming to our

free master class we talk about the

common myths and misconceptions that we

see in our community and our patients

and they answer questions for about 20

minutes at the end it's a really

valuable tool that hundreds of people

are doing every other week so if you

haven't done it please do it this is

something that I'm doing for you I would

encourage you to check it out the link

is in the description on YouTube all

right so this study that was published

last month is an in-depth review of the

literature over the last 25 years and I

think they do a really good job of

pointing out the shifts and car that

occurred obviously as a result of the

Whi but also the discrepancies in the

care that has gotten bigger and bigger

because the care that women are

receiving is not the same is not

supported by the current literature now

they start off by talking about these

consensus statements that started in the

early 2000s as a results of Whi one of

the things I want to point out here is

that these consensus statements just

simply recommend that doctors look at

the the risk benefit equation and they

say this they say the risks only

outweigh the benefits for symptomatic

otherwise healthy women within 10 years

of menopause what does that mean

symptomatic means vasom motor for the

most part most do aren't actually asking

about genit urinary symptoms so

generally we're talking of vasom motor

symptoms for otherwise healthy women

within 10 years I think that's an

interesting statement because sometimes

the otherwise unhealthy barle

osteoprosis would hos get influence here

anyway they go on to say that outside of

that individual risk factors need to be

considered but they're saying with that

is if you're over 10 years out for

menopause or you're not an otherwise

healthy woman you need to individually

consider risk factors but that's it they

never said don't use it for women who

are over 10 years out from minapa that

was never the recommendation but doctors

took data to say the only women who

should be offered HRT if any are healthy

women within 10 years of vopos and

that's what's happened over the last 20

plus years so this article goes on to

discuss three main topics perivascular

risk which is the biggest part dementia

risk which is really interesting and

then they touch on fracture risk a

little bit now the thing that they

didn't t talking about that you might be

wondering is cancer risk I hear this all

the time well my doctor doesn't want me

to start HRT I'm over 60 because it

increases my risk of cancer that is

absolutely not true the cancer risk

associated with for replacement therapy

if it exists at all which is a whole

another video but if that cancer risk is

present it is not age dependent meaning

that there's no difference in cancer

risk if you start after the age of 60 or

70 or even 80 or 90 it more has to do

with heart disease than anything else

and there's a discussion around dementia

here as well so let's break this down

now this article is actually kind of

hard to read because they talk about all

the specific things that are broken down

so you're talking about VTE which is

vomo embolism you're talking about CHD

quary heart disease am I am my cardio of

Arin heart attack so it's pretty

Technical and it can be hard to read but

let me break down some of these things

because it makes some very clear points

that would be easy to miss if they

weren't explained in a different way so

when it comes down to coronary heart

disease this is actually the development

of plaque within the arteries that lead

that give blood to the heart there is an

increased risk for women age 70 to 79 or

over 20 years off from menopause in the

intervention phase of the women's health

initiative but if you look at the

follow-up studies that risk does not

persist what does that mean it means

that it occurred early on but if you

follow these patients over time it's not

different than PLO and arguably at the

time it wasn't statistically signicant

anyway so now if I were to use all of

this data to educate my patients I would

say that there is no increased risk for

women 70 to 79 that doesn't mean I'm

going to prescribe for all those women

just means that as a group we don't need

to consider them actually at higher risk

now for heart attack specifically there

was a marginally higher uh risk in women

who are over 20 years out from menopause

but remember that that group also had

additional risk factors smokers obesity

hypertension and they werey H te it's

going to keep calling that the stroke

risk that was present in the initial

studies also went away with long-term

followup so again if you follow people

long enough if the groups aren't

actually different it's going to level

out over time this is why long studies

are important now what's interesting is

that PE or pulmonary embolism was

actually higher in the combined group

even in older women even a younger women

actually but this is one of the reasons

why we don't use mroy progesterone

acetate and if you look at the CE only

group to estrogen only group there was

not an increased RIS of stroke over time

so I think we can actually blame

probably the NPA the preest in for this

increased risk initially seem

impersistent over time now if you look

at all these risks together they end up

coming in somewhere around between 8 and

26 additional events per 10,000 women

per year now that risk of side effect is

rare by definition now this is really

important because rare side effects

happen with drugs and other treatments

and surgeries all the time and we don't

not offer them as a result of rare side

effects it's good to discuss them for

informed consent but we don't

necessarily not offer them consider oral

contraceptives so birth control pills

have a known increased risk of blood

clot for example and other things some

studies show up to 6X increase in blood

clot with synthetic apogen and progest

oral contraceptive pill does that stop

us from prescribing it to millions of

women no it's one of the most commonly

prescribed drugs out there we know that

it has this increased risk and women

should be told about it they probably

aren't they should be told about it but

even then they're going to decide to use

it because of the risk benefit equ we

don't prevent women from being presaged

we just try to educate them about the

potential risks now I personally

wouldn't use them but lots of doctors

are and to have a difference in the way

that we would recommend or not recommend

HRT because of a known rare risk 6X is

not rare but a known rare risk I think

is just not fair we're not offering to

an older population of women the same

potential benefits as we are to a

younger population but something that's

actually less risky if that makes sense

now you can also look at this from a

testosterone perspective so I recently

listened to an interview with Dr Kelly

casperson so she's a urologist so she

deals with with hormones on both sexes

and she compared the recommendation

actually out of this Lancet article the

Traverse study so the Traverse study is

a study on testosterone and men that are

highrisk of heart attack because there's

some concern that testosterone

replacement can cause an increased risk

of heart attack and what was cool about

this study even though I wish it were

done differently but what's cool about

the study is that it did not show an

increased risk of heart attack great but

it did show an increased risk of

pulmonary embolism acute kidney injury

and a f what were the recommendations

from the authors and did the consensus

statements actually change as a result

of this so

they didn't really say much about it

they reported it but then it didn't

really talk about it the consensus St

was didn't change and I don't really

think prescribing patterns changed I'm

not sure if those risks are real was

that by chance it's a whole different

conversation but ultimately they are

rare and there an accepted risk of using

exogenous testosterone does the benefit

outweigh the risk and for most men the

answer was yes and I agreed so I treat

men same way I use testosterone and I

recognized that this potential risk is

there but it's extremely rare and not

all studies work that so what can we say

rare events are going to occur we want

to mention them we want to talk about

them but just like other drugs we should

just add them into the risk benefit

equation we have to also then stratify

other diseases into that equation like

say osteoporosis so if someone has

osteoporosis Are we more worried about

their hip fracture their loss of

Independence their pain their change in

spinal alignment as a result of fracture

is that a bigger risk or is it this rare

sub increased risk of pulmonary and

blowman stroke which again was only due

to crappy hormones in the first place

how's that going to balance out in your

head I know what my answer is let's talk

about dementia so dementia is

interesting because first of all Cog

decline is hard to measure so there are

not great tools to measure cognitive

function in high function individuals

mild cognitive impairment is actually

hard to catch early on there really are

great instruments so out of the date

when you're looking at you know is

hormone replacement going to have a

negative impact on cognitive function

this is a hard study to do now the

Women's Health Initiative tried to do it

so the Women's Health Initiative memory

study lims tried to find whether or not

there was an increase or decrease risk

of of dementia associated with AJ to use

what they found though in reported is

that there is a two times increased in

probable old dementia in women over the

age of 65 that were assigned to the HRT

group now that risk comes out to again

around 23 per 10,000 women per year so

again this is rare but what's

interesting here is that if you look at

the estrogen only group there was no

increased risk so same thing was it the

progestin or was it really relevant at

all so to understand that we need to

look a little bit deeper there's some

follow-up studies on this with the that

this wind study and what they found is

that if you follow these womit over time

you would expect if they were developing

dementia at a higher rate that they

would die from dementia at a higher rate

and they did not in fact that estrogen

only group was actually protected from a

diagnosis of all time versus other

dementias so it kind of sounds like the

same argument around breast cancer where

it looked like maybe there was an

increased risk but it doesn't play out

over time and in the estrogen group they

were protected of it now also in the

combined group what's interesting if you

look at the study details is that only

40 % of the participants actually filled

out the follow-up data so that clearly

is going to represent a significant

amount of bias when you only when you

have less than a 50% followup it's

really hard to draw conclusions from

that in addition the instrument that

they Ed to measure this I mention we

don't have great tools so they used one

I'd never heard of it's called the

California verbal learning testos for

and of that test only one subdomain

actually showed a reduction in

performance but the question is is that

even clinically relevant like what does

that even mean what is that test

actually used for what is it actually

sensitive to maybe it's relevant but

should we not offer

HRT because of this one thing I think

clearly not maybe we need to know more

information but it's not going to stop

me from prescribing additionally my

clinical experience says cognitive

Improvement is profound with HRT for

some women maybe not all but I find that

women are thinking better they have less

brain fog they have better energy better

Vitality their brain just seems to work

better and it makes sense because we

have estrogen and progesterone receptors

on our nervous system so it's likely

going to have a big a big impact so I

don't think that this study is a reason

not to prescribe it now could I say you

should use HRT to prevent dementia I

don't think we could really say that

either I think it's poly true but I

don't think we have a good enough study

to show that but I'm here more for

health optimization and if a woman's

going to use HRT for a specific reason

but also potentially get the benefit

that are a little less known like is it

going to benefit a woman over the age of

60 with heart disease is it going to

help to prevent dementia I can't Clearly

say that those things are true I think

they're likely true and we've already

decided based off of other factors the

risk and benefit equation around using

HRT so why not so then finally they get

to bone health and I kind of like what

they say which is like nobody's arguing

whether or not hormones are good for

bone health they're just not using it

people aren't also saying how profound

it can be for bone health and again I

have studies that I talk about that show

up to 10% Improvement of boneo density

in the course of 12 months massive right

it's better than really any any drunk

because you can use it long term so what

do we do well ultimately we have the

conversation I know I would never want

to deny care without the conversation

about risk benefit from the perspective

of understanding both the risk and the

benefit and if your doctor is doing that

I hate saying this but you might need to

find a second opinion or a new doctor

because they're just not open to having

this conversation with you and helping

you go down the path that you think that

you need to be on you have to advocate

for yourself remember even in the early

guidelines no one said don't use it for

women over the age of 60 or 10 years off

of menopause they just said consider the

individual risk factors also remember

that in the Whi a third obese a third

hypertension 10% smokers what would

those data points look like if they

didn't have those pre-existing risk

factors what if they were using

different forms of hormone replacement

therapy what if they were using

bioidentical estradi cream micro

progesterone capsules and plus or minus

testosterone lastly if you have

osteoprosis your risk equation is

different than if you don't what is the

risk of fracture what is the risk of

loss of Independence or even death as a

result of a hip fracture loss of

function from a spine fracture the pain

P treat treatment Etc you have to look

at this through that lens if you have

poor bone health and you're trying to

improve your bone health HRT can be

profoundly impactful but it has to be

done right and individual risk factors

really do need to be considered I do not

treat all patients with osteoprosis with

hormones because some people do have

risk factors the risk factors we look at

are chronic inflammation metabolic

dysfunction insulin resistance

hypertension genetics family history

modifiable risk factors like smoking

vaping other bad lifestyle choices we

can also look at Advanced markers like

apob LP little a lpa2 CRP and more to

identify what's happening in the blood

to help identify risk we can also image

the arteries there's so much we can do

to help identify what kind of risk we

have for our patients that are over the

age of 60 or over the age of 70 so do

the risk factors for my patients match

those of the studies that were used to

make these recommendations in the first

place no we have patients that are over

the age of 70 who have been they've gone

through the testing they've looked at

the blood we've looked at the Imaging

and their arteries look better than mine

so if coronary heart disease is all I'm

worried about when it comes to starting

HRT it's not but if that's the primary

thing why would I prevent them from

going on it if that's their go their

goal and desire why would I prevent them

from going on it I think that at should

be considered for all women almost

regardless of age if a woman who is

within 10 years of menopause there's no

question unless there's a clear

contraindications that she would benefit

from HRT for a woman 10 to 20 years out

I rarely have an objection but we might

going to do a little more research for

women over 20 years out it gets a little

tougher but I still think that it is an

option for some women it's just a

smaller group and remember that a

diagnosis of osteoprosis actually

changes the equation there's much more

risk with those pre-existing factors

those pre-existing diagnosis then

understand that these risks from the

Women's Health Initiative are rare and

that in men or in younger women they

would be ignored and that's a good frame

to consider for older women as well so

that's it that's my rant on when to

start HRT remember that a diagnosis of

osteoprosis isn't the end but deciding

to reverse it is a beginning I'll see

you in the next video