San Antonio Express-News (Sunday)
Weighing the risks of hormone replacement therapy
Q: One has to wonder which is worse for longevity: living a life without sleep, the ticking time bomb of hormone replacement therapy (HRT), or prescription sleep meds?
I am a 71-year old woman who began having insomnia and sleep issues when I went through menopause in my mid-40s. Sleep has been a difficult struggle for over 30 years. I’ve been through sleep studies, worked with psychologists, listened to sleep tapes and done meditation, as well as taken all sorts of prescriptions for sleep and depression (which I don’t have), melatonin and even THC derivatives. The list goes on and on. (There is no TV in my bedroom, the mattress is good and it’s quiet. I eat healthy and exercise regularly, but I’m about 20 pounds overweight.)
I’ve always felt that hormones (lack thereof) were at the root of this problem, but my primary doctor would not prescribe them due to cancer risk and doesn’t want me to taking HRT. But I finally went to a naturopath and was prescribed compounded morning estradiol (.5 mg) and evening progesterone (200 mg). They absolutely help with my sleep. I do not notice any other differences within the female-specific body parts. I have gone on and off HRT, and whenever I’m off, sleep difficulties occur again. They disappear when I go back on HRT.
I’ve read studies that discuss the similarities and dangers whether one takes compounded HRT or prescription strength HRT. I’ve tried not taking the compounded HRT for an extended time, and I am unable to sleep.
A: The fact that your sleep disturbances reliably get better with treatment, and worse when treatment is stopped, is pretty strong evidence that the sleep disturbance is hormonerelated, although I would still recommend women be considered for other sleep disturbance causes, such as restless legs and sleep apnea, which both may occur around menopause. It
sounds like you’ve done that.
Treatment of menopausal symptoms with hormones is entirely reasonable, and I feel that many primary care doctors are so concerned about the potential harms of the treatment that they do not consider the whole woman. “The ticking time bomb” is not a fair description of HRT. It is absolutely true that HRT has risks: a roughly 20 percent increased risk of breast cancer among women taking both estrogen (the studies looked mostly at women taking equine estrogen, not the bioidentical estradiol) and a progestin (again, the studies mostly evaluated women taking medroxyprogesterone and newer formulations, such as natural micronized progesterone). Progestins definitely reduce the increased risk of endometrial cancer that occurs in women who have a uterus and take an estrogen.
Heart disease is probably a bigger concern. Women who start combination HRT in their 60s (or 10 or more years after menopause) are at increased risk for heart attack.
Both your individual breast cancer risk and your heart disease risk can be estimated with tools available to your doctor, and you can get a pretty fair idea of how much additional risk you are accepting if you choose HRT to treat your sleep disturbance. An average woman in her 60s might have about a 1 percent total increase in the combined risk of blood clot, heart disease and cancer, but some women will have higher or lower risks.
If the risk is unacceptably high, you can certainly work with a sleep medicine expert to find effective treatment.
Q: I recently got a blood transfusion, and I’ve never had the COVID vaccine. Am I going to get those blood clots that vaccinated people got?
A:
There is no evidence of risk to people receiving blood from a donor who received any COVID vaccine.
Both the Astra-Zeneca vaccine and the Janssen vaccine did have a very small number of cases of abnormal blood clots
(about four cases per million recipients). The much more commonly used mRNA vaccines made by Moderna and Pfizer-BioNTech did not cause an increase in blood clotting.
When a blood transfusion is given, the red blood cells are separated from proteins, including any antibodies made by the person who received a vaccine made, so a person does not get immunity (or the possibility of side effects) from a blood transfusion from a vaccinated person. Sometimes the proteins or antibodies are given to a recipient, such as a person who has a very poor immune system, who then gains some shortlived immunity from the antibodies provided by donors. But this is not part of a regular blood transfusion (called “packed red blood cells”).
I strongly recommend getting the vaccine. COVID infection itself is much more likely to cause blood clotting problems than the vaccine ever was.
Q: I’ve been instructed by my ophthalmologist to take AREDS2 vitamins. It says on the directions to take two vitamins daily. This would be a total of 400 IU of vitamin E daily. I’ve read that vitamin E is stored by the body. Do you think that this would be too much vitamin E daily?
A:
No, 400 IU of vitamin E has been proven to be safe in many clinical trials. Although vitamin E — along with vitamins A, D, and K — are fatsoluble and can be stored in the body, unlike vitamins A and D, the toxicity of vitamins E and K are very low. The AREDS and AREDS2 vitamins are given to people with the dry form of macular degeneration, and they have been shown to slow the progression of it.
Q: I just read your article on nitric oxide nasal spray. I don’t understand how it can be helpful when I’ve read that nitric oxide is a pollutant and toxic to humans and animals.
I read that it can cause eye and nose irritation, breathing difficulty and respiratory distress, as well as pulmonary edema and even death. Please tell me how the nasal spray is OK when breathing nitric oxide in the air is harmful.
A:
I think you may have confused nitric oxide with nitrogen dioxide. The names are very similar, but the two chemicals are vastly different. Nitrogen dioxide is a major air pollutant that can cause the symptoms you mention.
Nitric oxide is a signaling molecule (sort of like a hormone) that has a major biological effect of relaxing smooth muscles, especially in blood vessels. That’s the effect that has researchers testing the nasal spray to see if it might be helpful in COVID infection. I do not recommend this treatment, but I am waiting for additional data.
Literally every chemical can be toxic at a high enough dose. Nitric oxide only lasts in the body a few seconds, but a high enough exposure (such as a laboratory accident) can be immediately life-threatening. Of course, for medicinal use, the dose is small enough that there is little risk of toxicity.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Drive, Orlando, FL 32803.