Ep. 52: The Hormone Whiplash — with Dr. Regina Druz, MD, MBA, FACC, FMCP-M

More than two decades ago, women were warned that hormone replacement therapy was dangerous for the heart. Today many of them hear the opposite. In this remix episode, Dr. Regina Druz traces the whiplash from the inside — the Prempro era, the 2002 Women’s Health Initiative, the day she was told to call every patient and stop their prescriptions, and the senior colleague who told her that merely thinking about hormones was malpractice. She brings back conversations with Dr. Lorraine Maita, Dr. Amy Killen, Dr. Polly Watson and Dr. Arash Bereliani, covers what the menopause transition does to blood pressure and the arteries, and then agrees with most of the case for hormone therapy before naming the one gap that stops her going further: where are the outcome trials?

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Episode Chapters

[00:00] Same Medicine, Opposite Directions on Hormone Therapy
[01:50] The Prempro Era When Hormones Were Standard Care
[04:30] What the Women’s Health Initiative Really Found
[10:50] A Cardiologist’s Warning That Hormones Were Malpractice
[13:05] FDA Removes Certain Hormone Therapy Boxed Warnings
[14:55] Why Menopause Changes Blood Pressure and Heart Risk
[17:12] Perimenopause Blood Pressure and Stiffening Arteries
[21:50] The Critical Window for Starting Hormone Therapy
[24:30] Should Women Take Hormones to Protect the Heart
[27:50] Outcome Trials and Where Dr. Regina Lands

Transcript

[00:00] Same Medicine, Opposite Directions on Hormone Therapy

Dr. Regina Druz: One of my guests trained at a time when it was considered almost malpractice not to put a menopausal woman on hormones. Years later, as a junior cardiologist, I was told by a senior colleague that just thinking about hormones was malpractice. Same medicine, same word, opposite directions.

Welcome to Own Your Heart Health. I’m Dr. Regina Druz, your holistic cardiologist. This week we will dive into common heart health concerns, uncovering root causes and unpacking scientific discoveries and controversies. The information provided does not constitute medical advice. Please contact your healthcare practitioner before making any changes that may impact your health.

I’m Dr. Regina Druz, and this is an Own Your Heart Health remix on hormones and the heart, the whiplash, the data, and where it leaves you and me today. You’ll hear Dr. Lorraine Maita on the era before the Women’s Health Initiative and what came after. Dr. Amy Killen on timing, route, and the black box warning. Dr. Polly Watson and me on menopause as a whole body event, a stress test for blood pressure, heart rhythm, and your arteries. My own story of the critical window. And then preventive cardiology colleague Dr. Arash Bereliani and I push on the hardest question of all. Hormones may protect the heart, but where are the outcome trials? Hold on to that thought. It is the honest version of what is shaping the hormone and heart conversation today.

Let’s go back to where it got started.

[01:50] The Prempro Era When Hormones Were Standard Care

Dr. Lorraine Maita: At that time Prempro was big and they were doing a study. Then it was okay to give hormones, but nobody knew about the bioidentical hormones. And what happened in this company, the people on Prempro would come down and they didn’t feel as good. You know, they had depression, they had a lot of breakthrough bleeding, and you know, the women…

Dr. Regina Druz: So the Prempro, let’s just reframe it, right? If I recall correctly, there was something called Wyeth Pharmaceuticals, right?

Dr. Lorraine Maita: Wyeth Pharmaceuticals.

Dr. Regina Druz: And there was this notion, and this was honestly before I even, I was just beginning in medicine, perhaps in medical school. That sort of happened, you know, even before that. There was a sort of a mechanistic concept, right? The idea was here are women, they go into menopause. The estrogen and progesterone wind down, and we start seeing issues like weight gain, hypertension, coronary disease. The prevailing wisdom at the time was that they’re catching up to guys, right? They’re almost like turning into guys, right?

And so Wyeth Pharmaceuticals came out with a synthetic medication, Prempro. So you’ll have to explain what Prempro is. And I remember, I think I was an intern or resident.

And I remember our attending telling us that, you know, when a woman comes in, if she is in her fifties, menopausal, you need to start her on Prempro. And that was the wisdom of the day, right? So what was Prempro, what was in it? And what have you seen with it?

Dr. Lorraine Maita: We also gave Premarin, which was…

Dr. Regina Druz: Premarin, yeah.

Dr. Lorraine Maita: Estrogen given orally, made from horse urine, and Provera, which is a synthetic progestin. So what Prempro did is they combined the two.

Dr. Regina Druz: Right.

Dr. Lorraine Maita: And that became the big deal. But during that time, it was almost malpractice not to give women hormones.

Dr. Regina Druz: Correct.

Dr. Lorraine Maita: I worked in a big company and that was the highest prescribed drug, Premarin and Provera and Prempro. But during that time, they didn’t have oral micronized progesterone.

Dr. Regina Druz: Keep that phrase in your head. Almost malpractice not to.

Then came 2002. I was a junior attending and I still remember what happened next.

[04:30] What the Women’s Health Initiative Really Found

Dr. Lorraine Maita: What we learned after that is then the Women’s Health Initiative came out.

Dr. Regina Druz: Right. So that watershed moment, right? So I want our listeners to understand, right, that the hormonal therapies specifically for women, because men really didn’t have these types of studies. They had some studies, and I think our idea on testosterone is also changing right now. But for women, we sort of went from here to a hundred and eighty degrees.

And I literally remember being in my clinic as a resident. And if you recall, as a resident, right, you have an attending who supervises you, and being called to this attending’s office. And I’m thinking to myself, I must have done something really bad, but all the patients are happy. So I don’t know what I’ve done bad. And he was very serious. And he was like, I want you to call all of your patients and stop all of your hormonal prescriptions. And you know, like right now. And so that was the Women’s Health Initiative. So tell us about what happened.

Dr. Lorraine Maita: So what happened with the Women’s Health Initiative is the study was hijacked, right? So the press got a hold of it and publicized that it increased the risk of heart attack and stroke, and it increased the risk of breast cancer. So they stopped the study.

And then all women…

Dr. Regina Druz: Well, so first of all, what was the study? If you could just tell us briefly, what was the study? Who were those women, what they were given, and you know…

Dr. Lorraine Maita: So this study was really designed to see how long after menopause can you give hormones, right? It wasn’t designed for seeing how safe hormones were or when was the best time to give it. So it was given high dose synthetic hormones to women whose average age was 63. Ten years past menopause. And what I say to people, by that time the ship has sailed. A lot of damage has been done. And not to say you can’t reverse some of this damage, but a lot of damage has been done. They didn’t look at lifestyle. They didn’t talk about lifestyle.

They just studied it. It was a very, very big study. That’s why they continue to study this study.

Dr. Regina Druz: Right.

Dr. Lorraine Maita: Quote this study, because it’s so hard to get people to be in studies and it’s so expensive to do a study. They’re taking that study and over the years have dissected it. And they started looking at… so the press got a hold of it and it was like, my God…

Dr. Regina Druz: Well, the premise also, let’s just remember that the premise in that study, right, was also to see whether hormones, because that was one of the situations, was to ascertain if the hormones were actually protective for the cardiovascular system, right? So some of the endpoints that were studied were blood clots, heart attacks, strokes, and of course breast cancer, right? So it was meant to be a study that would, for lack of maybe a better word, put a definitive proof that what we thought was supposed to happen, which is when a woman goes into menopause and you replace her hormones, that it’s actually good for you.

So we wanted, you know, the scientists, and I think one shouldn’t probably minimize the fact that that was a fairly good question to ask. You know, what are the outcome studies? And that was actually in the age where outcome studies were not the norm.

In many ways, the Women’s Health Initiative was a study that really put out outcome measures as relevant measures for scientific research. So what did they find in this study that was concerning and, as you said, heavily promulgated in the press?

Dr. Lorraine Maita: Well, they found eight more cases of breast cancer and an increased risk of heart attack and stroke, which is why they stopped the study.

Dr. Regina Druz: Okay.

Dr. Lorraine Maita: And you know, we learned a lot since that study, but that is fixed in people’s minds, even to this day. That study was done in 2002. Now, one of the things that we learned, because at the time all they had was oral estrogen. And they had oral synthetic progestins. But we know if you take it by mouth, oral estrogen, it goes through the liver, and the liver makes clotting factors, so you have increased risk of clots. And clots can break off, and if they break off and go to your brain, you get a stroke. If they break off and go into your heart, you get a heart attack. But they can break off and go anywhere. So you can get deep vein thrombosis, but you know, you get the same thing from the birth control pill. So let’s… people do not even bat an eyelash when it comes to being on birth control.

Dr. Regina Druz: But these are also synthetics, right?

Dr. Lorraine Maita: They’re synthetic.

Dr. Regina Druz: Yeah. The world has changed, drug delivery has changed. The way the timing, the dose, and the form seems to make a difference.

Dr. Lorraine Maita: So what they found is that now they started making patches that go on the skin, right? So estrogen could be given through the skin. Like, alternative medicine used creams. They had compounding pharmacies making creams. And we know that drug delivery through the skin does not cause clots. The risk of clots is negligible. So that risk of heart attack and stroke went way down.

Dr. Regina Druz: I want to add precision here, because this study still gets misquoted in both directions.

The Women’s Health Initiative’s main question was whether hormones prevent heart disease. The dose was the standard dose of that era, not an unusually high one. And eight more breast cancers means about eight more per 10,000 women per year. The lower clot risk with patches and gels is consistent across observational studies. The heart attack and stroke advantage is less certain.

[10:50] A Cardiologist’s Warning That Hormones Were Malpractice

Dr. Regina Druz: Now, here’s what that fear looked like inside cardiology years later.

Years ago, I was very much inspired by some of the senior cardiologists. A lot of them were women, and they were pioneers because they launched the concept of women’s cardiovascular health. A sort of a separate focus for cardiology. And it’s not really a specialty or subspecialty, but it’s a recognized facet where a lot of cardiovascular effort in prevention, diagnosis, and treatment is taking place.

And what was interesting, I was a faculty member at the American College of Cardiology, and I was in a faculty lounge. The American College of Cardiology is a massive organization that essentially defines what cardiology is in the United States and even globally, and I’m thrilled to be its member and volunteer in various positions. But at that time, I was fairly junior. I was in that faculty lounge, speaking with an extraordinary cardiologist, the one who truly, as a female, put women’s health in cardiology on the map, made it a term, made it something that people know.

And I casually mentioned in conversation that I’m interested in learning how hormones or hormone replacement therapies may be affecting some of these things that we are seeing in our female patients. And this cardiologist said, basically, “Regina, just talking about hormones and cardiology is malpractice.”

Wow. And so obviously it’s been many years, and many things have come and gone. And there’s a lot of new findings and new thinking. So, you know, A, we don’t talk like this anymore, and B, we don’t think like this anymore. Hopefully, hopefully my fellow cardiologists, if you’re listening to this, you don’t think like this anymore.

That was a senior colleague, and she wasn’t unusual.

[13:05] FDA Removes Certain Hormone Therapy Boxed Warnings

Dr. Regina Druz: Then last November, the FDA announced it would remove the boxed warning about heart disease, breast cancer, and dementia from menopausal hormone therapy, while keeping the warning about uterine cancer when estrogen is used alone, or unopposed, in a woman who still has her uterus. Around that time, I asked Dr. Amy Killen, a longevity physician and hormone guru, whether that warning was ever justified.

Dr. Amy Killen: The route of delivery matters, right? And the level of risk matters.

Dr. Regina Druz: And I think, you know, cardiac risk, one of the things that I learned with my experiences with hundreds of patients is that as much as we make cardiac risk a priority in cardiology, because we always do, we have those population-based calculators and guidelines, and it all evolves every single time, we are still not able to truly personalize risk, because these are population-based level metrics. And the moment you use them, they are sort of the floor. The problem with traditional cardiology is that a lot of cardiologists think that they are a ceiling, and they’re not. They’re the floor.

Because these other factors, especially for women, maybe a little bit less for men, because men don’t really go through menopause, but especially for women, these other factors play an enormous role. Genetics, level of inflammation, level of oxidative stress, how detoxification happens. And now we have these cardiac imaging techniques that can literally show us the composition of the plaque in the coronary artery wall. We can certainly see the carotid, but coronary arteries, we can actually measure plaques, measure their composition, measure flow. So I think we’ve come a really long way.

Route and timing are the whole ballgame for safety.

[14:55] Why Menopause Changes Blood Pressure and Heart Risk

Dr. Regina Druz: But why does a cardiologist like me care about menopause in the first place? Because the transition itself changes the heart, blood pressure, heart rhythm, and a couple of conditions that strike women far more frequently than men. Here’s how I put it on Dr. Polly Watson’s episode.

The definitions in my mind, having seen women and the emergence of these cardiovascular risk factors, right? You mentioned this one study, and this one study did recognize that there are fairly distinct blood pressure trajectories, right? Some women continue to stay normotensive. They’ve been normotensive before. Some become hypertensive early, some become hypertensive late. But we know that these hormonal fluctuations increase arterial stiffness. And of course you already mentioned vasomotor symptoms, hot flushes. They are linked to almost a 40% bump in the risk of hypertension. So this is very profound.

You know, women continue to die from heart disease as the leading cause of death. One in three women. We temporarily had an improvement after many years of dedicated advocacy and focus on women’s cardiovascular health. At one point it dropped to one in four women, but technically right now it’s one in three women that actually die of cardiovascular disease. And the majority of women, over 60-some percent, have no symptoms prior to their first heart attack. They basically may have some atypical symptoms and then boom, they have a heart attack. And this is again very different from their male counterparts, and women continue to have higher mortality after their first MI.

Women also continue to have this cluster of syndromes that is sort of unique to perimenopause and menopause, things like spontaneous coronary artery dissection or takotsubo cardiomyopathy. They’re fairly rare, but we recognize them as having some hormonal connection.

And here’s something I appreciate about Dr. Killen. When I pushed her on blood pressure, she didn’t oversell.

[17:12] Perimenopause Blood Pressure and Stiffening Arteries

Dr. Regina Druz: The cardiometabolic angle is much more difficult with hormonal replacement therapy, probably because of the difference in forms, right? Oral versus transdermal, especially when it comes to estradiol. So we’re not necessarily seeing a great impact on lipids. It’s highly variable. And women who are starting it because they’ve been found to have dyslipidemia are probably going to be disappointed, because the major driver behind that dyslipidemia is insulin resistance. It’s cardiometabolic. And so this is where we need to figure out our insulin sensitivity, change our diet, achieve better body composition, and so on and so forth. But with regard to other things, I think that’s where the story is more nuanced and a little bit more interesting.

And I’m curious as to your opinion. How do you define perimenopause? Because I have a cardiovascular definition of perimenopause, since it’s sort of vague, right? Women come in with a multitude of symptoms, but very often I start thinking of hormonal replacement therapy for women when they are 40 or older. They are not technically menopausal. Most of them aren’t. But they are having issues with blood pressure fluctuations. So they don’t necessarily have hot flushes, right? But they do have labile blood pressure, or blood pressure that is just starting to go up from normal. And we know about 25% of women in menopause actually have early hypertension.

So I’m wondering, are you seeing this? Is it your clue to really give them an opportunity at hormonal replacement therapy, especially transdermal estradiol? And do we have any evidence to show that it has an impact on blood pressure or anything blood pressure related?

Dr. Amy Killen: Yeah, great questions. I think that last time I looked at blood pressure, the data wasn’t as strong for estrogen as it is for, like, blood sugar or lipids. Even though lipids isn’t perfect, we do know we can have some effect.

Last I looked, and you would know more than me probably, but I don’t remember seeing that estrogen was as helpful, or as reliably helpful maybe, for blood pressure. But it makes sense that it would be, because we know that estradiol works via nitric oxide. It works to help vasodilate the various blood vessels in the system. So it makes sense to me that it would be. I don’t know why I have in my mind that it’s not as helpful, but maybe you can shed some light on that.

Dr. Regina Druz: You know, it depends, because what I’m finding looking at the literature is that the degree of vasomotor symptoms matters, right? So women that have intense hot flashes, very frequent hot flushes, this sign of autonomic instability is related to a remarkable uptick in hypertension, right? Some 32 up to 60 percent will actually develop hypertension. So I think removing the driver of hot flashes by stabilizing hormonal fluctuations should, at least down the line, we hope, impact their cardiovascular risk.

Another thing that always comes to my mind is, are we measuring the right things? Because some of the earlier changes with age, and it’s true for both men and women, women are not unique in that, is that we have early changes in the heart itself. They’re conformational changes. And we have changes in the stiffness of the arteries, right? Our arteries get stiffer. So I think that sweet spot that you mentioned, ten years after menopause, the stiffness may not have fully set in yet. And so when you go to older women, you probably have missed that window of opportunity. And the stiffness is very difficult to reverse.

So there is something called… when we do vascular age staging, we measure pulse wave velocity as one of the indicators. Are your arteries stiff or not? It’s basically like a fancy blood pressure measurement that calculates a number for us. So I’m wondering whether that’s what we should be measuring, and whether that should be a surrogate measure.

Do the hormones really work? Because if you’re just measuring blood pressure numbers, there are so many things that are influencing blood pressure that I don’t really think we’ll be able to have a consistent answer. But we’ll have some answer.

[21:50] The Critical Window for Starting Hormone Therapy

Dr. Regina Druz: Which brings me to the window itself. In January, I told you my own story, a breast cancer diagnosis that started with a mammogram at a moment. Part of what it taught me is that the same years that shape a woman’s heart risk also shape her cancer risk.

Heart disease and breast cancer are two diseases. And one could say, well, what is the connection? The connection comes from the critical window of perimenopause plus menopause. And it really tells us that there is so little that we know about this stage of life in all women. All women, if they make it to their 40s, 50s, and 60s, will actually go through the menopausal transition.

In the current medical literature, perimenopause, which is about a 10-year or so period before menopause, is not actually even recognized as a stage, although we recognize it clinically. The challenge of perimenopause is that the definition isn’t really there. There could be many different symptoms and many different signs, but we don’t have very strong objective markers. Menopause is still being defined in a very simplistic way. It’s defined as a period of life where a woman doesn’t have her menstrual period for about a year, right? So it’s a very mechanistic way, but it’s also very rudimentary.

And so we know that there is this overlap in terms of risk that starts in perimenopause, and sometimes even earlier, escalates into menopause, and manifests itself postmenopause. The overlap between heart disease and breast cancer. And so this window, approximately 10 years or so before menopause, and of course menopause and postmenopause, this is the critical period.

And perimenopause is actually a critical window of opportunity, both for heart disease and breast cancer prevention. So why is that true? You can see here on the slide that cardiovascular risk becomes particularly evident approximately seven years after a breast cancer diagnosis, right? So this window isn’t short. But if you’re a woman in your late 30s or even early 40s, it isn’t too early to start thinking, what is my breast cancer risk and what is my heart disease risk? And while you may be going for regular mammograms, and I absolutely endorse that, having gone through my own experience, you should also be going for regular cardiovascular disease screening.

[24:30] Should Women Take Hormones to Protect the Heart

Dr. Regina Druz: So should women take hormones to protect their hearts? I put that question to a preventive cardiology colleague, Dr. Arash Bereliani, and I want you to hear both his answer and my discomfort with it. This is the honest center of this entire conversation.

Dr. Arash Bereliani: Exactly, the time window. And if it’s given the right way, the right form, you know, the right form, estradiol, estriol, biest, even given on a patch or gel or cream as opposed to oral, if it’s done the right way with the right woman, not only is it not dangerous, I believe that it could be protective, beneficial.

However, however, I want to be very clear. I don’t think we’re at that stage yet where we should give hormones purely for cardiovascular protection. But if a patient needs it, if somebody needs it for, let’s say, symptom control during menopause, if a patient needs it for, let’s say, osteoporosis, if a patient needs it for other reasons, I’m a big advocate of hormonal replacement therapy, as long as it’s given at the right time to the right patient.

In other words, the choice of hormonal replacement therapy should be individualized for every individual, every patient.

It’s not something that you can give to everybody. So you have to look at the whole history and then decide what’s the best one. And if you decide to give them HRT, it has to be, again, the right form, the right amount, and it has to be carefully monitored. But I think that patients will definitely benefit from it from a cardiovascular standpoint.

Dr. Regina Druz: I agree with you, and I think what bothers me with regard to hormonal replacement therapy is that, just as you pointed out, we don’t really have strong outcome studies. We have some of the older studies that showed us, for example, that at that time it was oral estradiol supplementation, and women that didn’t have a uterus to protect, so they didn’t receive synthetic progestins, which is what the Women’s Health Initiative used, actually had a reduction in cardiovascular event risk. But again, this was a subpopulation of a much larger study where a lot of women were older. These happened to be a little bit younger. So I don’t think we necessarily have a strong outcome base.

And in cardiovascular medicine, this is all about outcomes, right? Outcomes. Non-fatal MI, fatal MI, or total mortality. So if we cannot stop a heart attack, whether fatal or non-fatal, or improve people’s total mortality, which is predominantly cardiovascular, then we don’t really think that we’ve done it.

[27:50] Outcome Trials and Where Dr. Regina Lands

Dr. Regina Druz: One correction to my own words in the last clip. The estrogen-alone arm of the Women’s Health Initiative used conjugated estrogen, not estradiol.

Here’s where I land. Hormones are not the villain the 2002 headlines made them out to be. And they’re not the heart protection magic pill some people now want them to be. A 2025 reanalysis of the original Women’s Health Initiative data found no increased heart risk for women in their 50s and increased risk for women in their 70s. Timing, route, and the woman in front of you decide. What we still don’t have is the solid data and outcomes that cardiologists really care about.

So if you are in your 40s or your 50s, ask two questions. What is my heart risk? And where am I in the hormonal window? Then get your arteries measured, not just your symptoms. The HeartWell Quiz is a good first step. It’s linked below so you can click on it and see what it tells you. And it’s associated with every episode you heard today.

And in December, I’ll sit down with integrative gynecologist Dr. Felice Gersh, one of the strongest advocates for hormonal therapy as heart protection. I’ll put the same question to her. Where are the outcome trials? Subscribe so you don’t miss it.

I’m Dr. Regina Druz. Let’s end heart disease before it ends you.

Thank you for tuning in to Own Your Heart Health with Dr. Regina Druz. This podcast is powered by Holistic Heart Centers. If you enjoy the show, please rate and review us on your favorite podcast platform. To learn more about our services, visit HolisticHeartCenters.com and subscribe to our YouTube channel. The link is in the show notes. See you next week.

If you want to know where your own cardiovascular risk sits before that conversation, the HeartWell Quiz is a starting point.

Frequently Asked Questions

Did the Women’s Health Initiative show that hormone therapy causes heart attacks?

Not in the way the 2002 headlines suggested, and both Dr. Druz and Dr. Lorraine Maita spend time on why. As Dr. Maita describes it in this episode, the trial gave high-dose synthetic hormones to women whose average age was 63, about ten years past menopause, and it was stopped after finding eight more cases of breast cancer along with an increased risk of heart attack and stroke. Dr. Druz adds the precision she says is usually missing: the study’s main question was whether hormones prevent heart disease, the dose was the standard dose of that era rather than an unusually high one, and “eight more breast cancers” means about eight more per 10,000 women per year.

Why are estrogen patches and gels described as lower risk than pills?

Dr. Maita explains the mechanism in the episode: estrogen taken by mouth passes through the liver, the liver makes clotting factors, and that raises the risk of clots, which can travel to the brain or the heart. Estrogen delivered through the skin largely bypasses that first pass. Dr. Druz draws a careful line around how far the evidence goes. The lower clot risk with patches and gels is consistent across observational studies; the heart attack and stroke advantage, in her words, is less certain.

Did the FDA remove the boxed warning on menopausal hormone therapy?

In the episode Dr. Druz says that last November the FDA announced it would remove the boxed warning about heart disease, breast cancer and dementia from menopausal hormone therapy, while keeping the warning about uterine cancer when estrogen is used alone, or unopposed, in a woman who still has her uterus. She then asks Dr. Amy Killen whether that warning was ever justified, and Dr. Killen’s answer is that the route of delivery matters and the level of risk matters.

Can the menopause transition raise blood pressure?

This is the part Dr. Druz says a cardiologist should care about. In the clip from Dr. Polly Watson’s episode she describes distinct blood pressure trajectories through the transition — some women stay normotensive, some become hypertensive early, some late — and notes that hormonal fluctuations increase arterial stiffness. She links vasomotor symptoms, or hot flushes, to almost a 40% bump in the risk of hypertension, and says about 25% of women in menopause have early hypertension. Later in the episode she puts the figure for women with intense, frequent hot flushes higher still: some 32 up to 60 percent will develop hypertension.

What is the “critical window” for hormone therapy?

Dr. Druz uses the phrase for roughly the ten years before menopause, plus menopause and the years after it. Her argument in this episode is that arterial stiffness may not have fully set in during that stretch, and that stiffness is very difficult to reverse once it has — which is why starting a decade or more after menopause, as most women in the Women’s Health Initiative did, is a different proposition from starting within the window. She also notes that perimenopause is not formally recognised as a stage in the medical literature even though clinicians recognise it, and that it has no strong objective markers.

Should women take hormone therapy to protect the heart?

Both cardiologists in this episode say no, for the same reason, and this is the exchange Dr. Druz calls the honest centre of the conversation. Dr. Arash Bereliani says that given the right way, at the right time, to the right woman, hormone therapy is not dangerous and may be beneficial — but he is explicit that we are not at the stage where hormones should be given purely for cardiovascular protection, and that the choice has to be individualised. Dr. Druz agrees and names what still bothers her: there are no strong outcome studies. In cardiovascular medicine, she says, the outcomes that count are non-fatal heart attack, fatal heart attack and total mortality.

What is vascular age, and why does Dr. Druz want it measured?

In the clip with Dr. Killen, Dr. Druz asks whether the profession is measuring the right things at all. Blood pressure is influenced by too many variables to give a consistent answer on whether hormones are working. When her practice does vascular age staging it measures pulse wave velocity — in her description, something like a sophisticated blood pressure measurement that returns a number for how stiff the arteries are. She raises it in the episode as a question, asking whether that is what should be measured and whether it could serve as a surrogate, rather than presenting it as settled.

What should a woman in her 40s or 50s actually ask her doctor?

Dr. Druz closes the episode with two questions: what is my heart risk, and where am I in the hormonal window? Her instruction after that is to get your arteries measured, not just your symptoms. She points to the HeartWell Quiz as a first step, and she is clear throughout that nothing in the episode is a reason to start, stop or change a prescription on your own.

Show Notes & Resources

About This Episode

This is a remix episode hosted by Dr. Regina Druz, MD, MBA, FACC, FMCP-M — a Cornell- and Duke-trained integrative cardiologist and the founder of Holistic Heart Centers in Roslyn, New York. She revisits two decades of reversals on hormones and the heart, with clips from earlier conversations with Dr. Lorraine Maita, a hormone expert; Dr. Amy Killen, a longevity physician; Dr. Polly Watson, a gynecologist and menopause specialist; and Dr. Arash Bereliani, a preventive cardiologist.

Episodes Featured in This Remix

Ep. 15: 3 Myths of Hormone Replacement Therapy: Truth or Dare! with Dr. Lorraine Maita
Ep. 30: The Hormone Whisperer: Unlocking Midlife Wellness for Heart Health, with Dr. Polly Watson
Ep. 36: My Breast Cancer Story: Six Longevity Pillars Connecting Cancer & Heart Disease
Ep. 38: The Critical Window for Hormonal Therapy to Prevent Heart Disease, with Dr. Amy Killen
Ep. 48: "Just a Little Heart Attack": Why and How Heart Disease Affects Women, with Dr. Arash Bereliani

Studies Referenced in This Episode

Women’s Health Initiative, principal results (JAMA, 17 July 2002)

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