Estradiol delivered transdermally is likely to be the safest route and type of estrogen to give for maintaining brain function in middle age and beyond.
“What we have learned the past decade is that not all estrogens are the same,” said Sarah Berga, MD, of Women’s Health at Wake Forrest Baptist Medical Center, “and that the differences can be critical.”
While it would be ideal for researchers to offer a one-size-fits-all approach to hormone therapy for menopausal and post-menopausal women, Berga said, treatment is complicated by factors such as patient health status and age, timing of therapeutic initiation, differences in types of estrogen, and differences in progestins.
“Hormones can [elicit] one set of effects from an unhealthy person and a totally different set of effects from a healthy person,” Berga said. “So the healthy user effect is not so much of a confounding of the study design as it is real. A healthy person responds in a beneficial way to hormones where an unhealthy person might actually have harm from hormones.”
These nuances require a customized approach to therapy, and an understanding of how hormones affect the brain.
Berga’s research finds that not all micronized progestins are the same, and that further research is required to determine how they differ.
“Some of the 19 nortestosterone progestins look to be a little bit safer than the 21 carbon progestins. But the jury is still very much out on how progestins differ from one another and these are very much the early days [of research].”
Berga said the importance of physician education and patient education are key to talking intelligently about which hormones to take and why, and stresses that it may take time for insurance companies and advisory boards to make adjustments to care practices as new findings emerge.
Recent studies challenge scientific statements that hormone therapy is risky after age 65. These statements influence insurance company policies, posing road blocks for physicians who may have justified reasons for continuing some form of hormone replacement therapy after age 65.
Berga advises physicians to not only review ACOG guidelines, but to familiarize themselves with scientific statements on post menopausal hormone therapy by the Endocrine Society statements on hormone replacement therapy, especially regarding treatment after age 65.