Menopause vs Stroke

Continuing this series of posts on strokes, I want to direct your attention to a nice review article published in this month's Lancet Neurology.  Points to ponder include an increase risk of stroke in the decade immediately after menopause, theorized to be due to androgen excess (although early menopause might add a wrinkle).  It's also been noted that route of administration has the potential to affect stroke risk.  For instance, some observational studies have demonstrated that transdermal estrogen is associated with lower stroke risk than oral estrogens because the latter must undergo first-pass metabolism in the liver, thus increasing thrombophilic factors.

Furthermore, estrogen dose appears to make an impact on stroke risk, too, such that low dose estrogen is associated with lower stroke risk than high dose estrogen.  Of course, low dose estrogen is useless if it doesn't ameliorate vasomotor instability.  Thus, the currently accepted recommendation is to offer the lowest dose (for the shortest period of time) necessary to achieve relief.  With that said, the American Heart Association doesn't recommend hormone therapy (estrogen +/- progestin) to prevent heart disease and/or stroke.  Instead, we need to focus on the traditional stroke risk factors, eg blood pressure, cholesterol, smoking, nutrition, exercise & atrial fibrillation.  

Up until a decade ago, life used to be easy for physicians counseling & treating women going through menopause: take estrogen +/- progestin as the benefits are innumerable and the risks minimal if existent.  Then came the first in a series of analyses of the Women's Health Initiative.  Immediately, we threw the baby out with the bath water as a large percentage of women gave up their hormone therapy or refused to start.  From one end of the pendulum to the other.  The good news is that in the past few years, we've discovered that nuances exist as to hormone therapy, eg route, dose, timing, etc, possibly type, eg bio-identical vs non-bio-identical.  These are exciting times as we learn more & more about hormones.  Stay tuned!

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