Hormone Replacement Therapy

By Wayne Persky

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A large-scale Swedish study analyzed data for over 900,000 women aged 50-58, including 77,000 hormone therapy users, to compare cardiovascular risks associated with different types of hormone therapy (Johansson, et al., 2024).1 The study assessed the risks of myocardial infarction (MI), ischemic heart disease, stroke, composite cardiovascular disease (CVD), and venous thromboembolism (VTE).​

The study showed that:

1. Tibolone (not available in the U.S.) was not associated with increased risks for ischemic heart disease, stroke, and composite CVD, nor was there an increase in VTE risk due to its unique pharmacologic profile.
2. Oral Estrogen was associated with a small (20%) increase in ischemic heart disease risk with estrogen plus progestin therapy and a doubling of VTE risk with both estrogen alone and estrogen-progestin combinations.
3. Transdermal Estrogen was associated with no increased risk of ischemic heart disease, stroke, or composite CVD, and it showed a reduction in MI and composite CVD risks, likely due to avoidance of first-pass metabolism, which can increase clotting factors

The clinical indications of the study suggested that:

Transdermal estrogen has a better cardiovascular safety profile compared to oral estrogen, particularly for women with cardiovascular risk factors. Hormone therapy (oral or transdermal) remains a reasonable option for healthy women in early menopause with bothersome symptoms, but clinicians should prefer transdermal forms for those with increased CVD risk.

Hormone replacement therapy and IBD.

Research data show that hormone replacement therapy (HRT) may improve inflammatory bowel disease (IBD) symptoms, and reduce the risk of moderate to severe disease in post-menopausal women (Freeman, et al., 2023).2 Of course there are no official research data available regarding HRT and microscopic colitis (MC), but we can probably safely assume that the effects of HRT will be relatively similar for all forms of IBD (until proven otherwise).​

The research (published by Freeman, et al.) shows that postmenopausal women who took HRT were 82% less likely to have active IBD in the postmenopausal period, and the risk of surgery was reduced. Obviously, an 82% improvement with the use of HRT, is a huge advantage.

There's no research comparing oral with transdermal HRT for IBD patients.

Therefore, we can only speculate that in view of existing research showing the significant advantages of transdermal over oral HRT treatments, those advantages will almost surely carryover to IBD patients. It appears that the primary advantage of transdermal HRT is associated with its reduced impact on the liver, which likely lowers the risk of exacerbating IBD symptoms. Oral HRT can affect the liver during its first-pass metabolism, and potentially influence inflammatory processes in the gut. ​

Our own experiences show that transdermal HRT is safer than oral HRT.

And although the study cited above didn't consider any effects that hormone replacement theory (HRT) might have on IBD symptoms, our own experiences (as evidenced by the epidemiological data shown by the posts in the archives of the discussion and support forum associated with our website) show that transdermal patches are far less likely to trigger a microscopic colitis (MC) reaction, than oral HRT treatments.

What about the sexual side effects?

A Study of 670 healthy women aged 42 to 58 Years, within three years of their last menstrual period showed that transdermal estradiol significantly improved sexual satisfaction and the physical aspects of sexual function, compared with placebo (Taylor, et al., 2017).3 By comparison, oral estrogens modestly improved overall satisfaction, with the primary benefits seen in the physical aspects. All in all, transdermal delivery showed better results than oral treatments in the study.

According to Dr Sharyl Magnuson (on our Board of Directors) the topical form of estrogen that's normally the most helpful for sexual functioning is the vaginal cream preparation (Premarin or Estrace creams). These help maintain a healthy vaginal mucosa, prevent vaginal atrophy and sexual discomfort.​

In conclusion:

Research data show that transdermal HRT treatments typically provide more benefits and are less likely to create problems when compared with oral HRT treatments, especially for IBD patients. And the epidemiological evidence based on our shared experiences, recorded in the archives of the discussion and support forum associated with our website, agrees with those findings for MC patients.

References

1. Johansson, T., Karlsson, T., Bliuc, D., Schmitz, D., Ek, W. E., Skalkidou, A., . . . Johansson, Å. (2024). Contemporary menopausal hormone therapy and risk of cardiovascular disease: Swedish nationwide register based emulated target trial. BMJ, 387, e078784. Retrieved from https://www.bmj.com/content/387/bmj-2023-078784

2. Freeman, M., Lally, L., Teigen, L., Graziano, E., Shivashankar, R., and Shmidt, E. (2023). Hormone Replacement Therapy Is Associated with Disease Activity Improvement among Post-Menopausal Women with Inflammatory Bowel Disease. Journal of Clinical Medicine, 13(1), p 88. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC10779540/

3. Taylor, H. S.,Tal, A., Pal, L., Li, F., Black, D. M., Brinton, E., A., . . . Harman, S. M. (2017). Effects of Oral vs Transdermal Estrogen Therapy on Sexual Function in Early Postmenopause. JAMA Internal Medicine, 177(10), pp 471–1479. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC5710212/