A Question about Blood Clots and HRT
Through his practice, Dr. Goodman receives many questions from patients regarding menopause and bioidentical hormone replacement therapy. Below is a recent question from a patient and what follows is Dr. Goodman’s response:
I started menopause at about 49 years of age and am now 56. Two years ago I had a blood clot in my lung, which was attributed to my HRT (hormone replacement therapy) medication and was told to quit it cold turkey. My doctor at that time advised “natural” medicine—none of which have really worked. Amberen required a double dose. iCool works to a point but cannot be doubled up. My gyno, with whom I had an appointment in January, told me no matter what I took to diminish my hot flashes, the result would have the same problematic impact on my hormones, creating a tendency for blood clots. Is this true or not? If this is the case, what can be done to lessen or stop my hot flashes OR am I doomed to have them the rest of my life? My mother is 82 and has been off HRT for years and as soon as she stopped using it the hot flashes came back. I’d love to know your opinion on this.
Dr. Goodman’s Response:
The blood clot you got may or may not have been related to your hormone therapy. A large volume of evidence-based literature in major respected medical journals over the past several years has clarified the possible role of hormone replacement therapy in the genesis of “blood clots.” It turns out that it is not the estrogen itself that may generate an increase in clotting potential. It is, rather, the oral form of the estrogen, especially if combined with the potent progestin (synthetic progesterone- like medication), medroxyprogesterone(Provera ™) and other progestins found in oral contraceptives.
Evidence collected over the past 5-10 years is showing with increasing certainty that transdermal delivery of estrogen (via patch, spray, gel, etc) is safer than oral. Orals, however, are cheaper, so your insurance company, in an effort to improve their profits by providing the cheapest medications, may seek to charge you a higher co-pay when you seek the safer delivery system.
What to do? First, have your PCP or gynecologist (if they’re savvy enough) test you for any genetic predisposition to form blood clots. If they do not know what tests to conduct, ask for a referral to a “Hematologist.” In the absence of increased genetic risk, there is no reason why you cannot re-start hormone therapy, with the following provisos:
1) Use low dose and transdermal.
2) If you still have your uterus and need a progesterone-like substance to “balance” the estrogen, it should only be micronized progesterone (one brand name is Prometrium™) given either daily or (better) given at a dose of 200mg for 14 days every 3-4 months.
3) Avoid situations that may be conducive to blood clots, like long periods of sitting in a cramped space; make sure you are able to get up every hour or two and walk around.
4) Also, remember that obese people get more blood clots than their thinner sisters. Exercise a lot and focus on good nutrition.
That said, if you or your doc decide against hormones for whatever reason, there is still hope. Consider these options for managing symptoms without hormones:
· The medication Gabepentin taken once/twice per day and at bedtime, especially if combined with the antidepressant meds fluoxitine (Prozac™), sertraline (Zoloft™),
citralopram (Celexa™), venlafaxine (Effexor™), and others, can help with hot flashes and mood.
· For vaginal dryness, whether or not you decide to use the low dose transdermal estrogen, you are totally safe using a microdose vaginal estrogen product like estradiol cream (Vagifem™) with absolutely no increased risk of thromboembolism.
· Most importantly, do your best to avoid hot flash triggers, which include stress, heat (e.g. hair dryer, hot places, etc), and spicy foods. Everyone has their own unique triggers, so identify yours and work to reduce or avoid them.
There’s always hope when it comes to your menopausal symptoms. Don’t be afraid to ask questions to get the information you need to make your life as comfortable, enjoyable and vibrant as it can be.
Learn more about menopausal symptoms, menopausal medicine and bio identical hormone replacement therapy at https://www.drmichaelgoodman.com/.