Talking to your doctor about hormone therapy
Plus, new information on how women can protect their brains.
Hello everyone. I write to you from Los Angeles, CA where my book tour continues with cooking classes, brain health talks, and lots of book signing. I am really enjoying meeting BHK readers out in the world! Whenever I get a break, I have been riding a beach cruiser along the beach to enjoy the sunshine. Today, I’m excited to delve into a hot topic in the Alzheimer’s world.
I get A LOT of questions about menopausal hormone replacement therapy (HRT). These come from friends, colleagues, BHK readers, and people I meet when speaking about brain health. And I have a personal interest, too, because before I started Brain Health Kitchen, I was an OB/GYN physician specialized in menopausal medicine. During the 8 years this was my focus, I took care of thousands of perimenopausal women (defined as the transitional years before and after the last menstrual period). In fact, helping women navigate the cognitive symptoms of menopause—like memory loss and brain fog—is what sparked my interest in brain health years ago.
So today I’d like to share an important study that came out last month about how taking hormones may reduce Alzheimer’s in high-risk women. We’ll also take a look at the Estrogen Hypothesis and the current thinking about how hormones protect the female brain. And, if you are considering taking HRT, I’ll give you the same “back of the napkin” advice I give my girlfriends—the practical tips you need to know to find the best care during menopause and beyond.
The Estrogen Hypothesis
Estrogen is a key player in the brain, impacting cognitive function, behavior, and the risk of getting Alzheimer’s. The Estrogen Hypothesis is a concept arising from several recent papers that show this hormone has a central role in healthy brain aging in women. And when I say “estrogen” I mean both the natural kind your body makes and other forms that can be supplemented through a pill, patch, or cream.
Simply put: estrogen is neuroprotective. The more years of life a woman has estrogen reaching her brain, the lower her likelihood of developing Alzheimer’s. I write in more detail about the Estrogen Hypothesis here.
Does this mean that taking HRT will surely prevent Alzheimer’s? Definitely not. This has been difficult to prove with large studies, as women need to be followed for a long time to see a positive result. There are currently 4 observational studies that show taking HRT for more than 10 years can reduce the risk of dementia by about half. While many physicians in the field believe this to be true, the data isn’t strong enough to recommend taking HRT to prevent Alzheimer’s or dementia for all women. Which is why the following study is so important.
Hormone Therapy May Prevent Alzheimer’s in Female ApoE4 Carriers
In this study of 1,178 women, researchers looked at the brain health benefits of taking HRT in two groups of women: those who carry one or two copies of the ApoE4 risk gene for Alzheimer’s, and those who do not. They compared HRT users with non-users, and noted whether HRT was started early or late in the perimenopausal transition. Participants were followed with cognitive testing and brain imaging over time.
ApoE4 is a gene variant that increases the risk of late-onset Alzheimer’s disease (the type of Alzheimer’s that can be prevented through food and lifestyle). Carrying one copy of this gene increases risk 3- to 5-fold; carrying two copies increases risk 15-fold. Women who carry one or two copies of ApoE4 seem to have an accelerated path to Alzheimer's compared to male carriers. In other words, this risk gene is more dangerous for women. For more details, check out this article I wrote for Neuroreserve.)
In the study, the ApoE4 carriers who took HRT starting early in the perimenopause had the best results. They performed better on cognitive tests, especially word retrieval and delayed memory tasks. They also had larger brain volume in key areas like the hippocampus (important for short term memory) and the amygdala (which has a central role in anxiety and stress response).
The Critical Window Hypothesis
The idea that HRT is most beneficial when started early in menopause is a recurring theme in studies, dubbed the Critical Window Hypothesis. Hormonal fluctuations during menopause can trigger Alzheimer’s pathology in the brain, especially in those at high risk such as ApoE4 carriers. Starting HRT early is key; late starters may not get the same benefits and are more likely to have adverse effects.
Why Women Aren’t Getting Help With Menopause
An article published this week in the New York Times does a good job explaining why menopause often goes untreated and why doctors have largely given up offering and prescribing hormones to women. It all goes back to one study that looked at the safety of taking HRT—the Women’s Health Initiative (WHI)—that was halted in 2002. Widespread misinterpretation of data and bungled communication scared an entire generation of women (and their physicians) away from taking HRT. Sadly, because we now know that HRT is very safe for most women and the only truly effective treatment we have for menopausal symptoms like hot flashes, brain fog, and vaginal discomfort.
How to Talk to Your Physician About HRT
It can be difficult in this post-WHI-study era to find a physician who’s comfortable prescribing hormones for menopause. Here are a few tips:
Find the right health care provider. Ideally this is a board-certified OB/GYN physician or specialist in Reproductive Endocrinology.
Find the right age practitioner. This is a time to choose a more mature doctor, one who was practicing pre-WHI. The truth is: most physicians under age 50 have very little or no experience prescribing hormones.
Have a compelling list of reasons to start HRT. Most physicians won’t recommend taking HRT unless you have significant symptoms, such as bothersome hot flashes, sleep disruption, vaginal dryness, and memory loss. It’s also helpful to be clear about your long-term health goals. Communicate that you want to do everything possible to maintain bone, heart, and brain health in the next decades. You could also add that HRT reduces the risk of colon cancer, diabetes, and osteoarthritis.
Know your personal and family history. Not everyone is a candidate for HRT because there are certain health risks, such as a family history of breast cancer, a personal history of blood clots, or existing heart disease. Be clear about your history so your physician can prescribe more safely.
Print off a copy of the North American Menopause Society’s 2022 HRT position statement. If you’ve found a physician well-versed in this topic, they will have read and referred back to it often. If not, it may help educate your health care practitioner.
Even though I practiced as an OB/GYN for 20 years, this doesn't count as medical advice. I have been fully immersed in food and Alzheimer’s prevention for the last 13 years. If you are a perimenopausal woman, however, I hope this is helpful and that you find a physician with experience taking care of menopausal women.
Book Tour News
I thoroughly enjoyed my time in the San Francisco Bay area. First, before our conversation at Copperfield’s Books in Santa Rosa, my friend Katie Morford greeted me with my own bundle of Chocolate Hemp Amaze Bars, an original recipe she shares HERE. Snacking on these tasty, nutty bars sustained me for days during hectic book tour events. While in Santa Rosa, I was on the radio with the iconic and delightful Chef John Ash and Steve Garner who have been at the helm of the Good Food Hour for decades. (Listen to the episode here.)
Book Passage in Corte Madera hosted me in conversation with my friend Dr. Jeanne Rosner of SOUL Food Salon, with a lovely group of curious people. Jeanne and I hadn’t seen each other since before the pandemic. There was a lot of hugging! Next it was an epic day of cooking at the Civic Kitchen in the Mission district of San Francisco. I fell in love with this cooking school. So much so that I jumped at the chance to return. Stay tuned for announcement of my next class there in May.
After my events in Los Angeles wrap up, I’ll be headed home for a short break. March finds me traveling to Dallas, Texas then on to Panama for the next Brain Health Retreat. (We still have a beachside cabaña available. Maybe it’s calling your name!) Book tour updates are coming soon.
Finally, just for fun, I’ll leave you with this little cooking video I made with my son Nick and my friends at HFC. Have you tried the Coffee Berry Smoothie yet? I’ll be back on Friday with some brain-healthier inspiration for Super Bowl Sunday.
Love,
Annie
This topic is so important and I find it can be very confusing. For so long I was scared of HRT due to the increased risk of breast cancer, which seemed to make headline news stories. However, after finding out I am an APOE4 carrier, I have been doing more research on this topic and I need to address this situation as soon as possible. We need to share this information with as many women as possible so they can make the best informed decision for their individual health situation. Thank you for sharing this valuable information.
Thank you for shining a light on this topic and sharing important research and information (HRT). Most OB/GYN practices and the specialties of the MDs are focused on women's reproductive years that when those years are behind you, finding an GYN whose specialty is Menopause (and perimenopause) is an incredible challenge. I hope your article starts to change this!