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Welcome to “Should I Call a Doctor?” The podcast where we dive into trending health topics to separate fact from fiction. We bring in experts to talk about all things health, to empower you with knowledge and answer your questions hosted by Inova Health.
4: Welcome to, should I call a doctor,
the podcast where we dive into the questions you have about your health and
today's trending health topics to separate fact from fiction.
I'm one of your hosts, Dr. Sam Elgawly, an internal medicine physician at Inova.
5: I'm Tracy Schroeder. I lead communications for Inova.
Dr. Sam will give you the clinical perspective while I ask the questions that
keep patients up at night.
Joining us today is Dr. Paula Pinnell-Salles,
who is a co-founder of Innova's Women's Cardiovascular Program.
She's board certified in cardiovascular disease and specializes in general
cardiology and vascular medicine. Welcome. Thank you for being with us.
6: Oh, thank you. Nice to be here. Yes.
I wanna go back to how it is that we came to where we are in terms of our
management of hormone replacement. So globally, we had of course,
always noted that heart disease risk elevated in women in their sixties,
and so it seemed that there may have been some, uh, premenopausal,
uh, benefit. Right. Um, and then in the seventies, eighties,
I believe there was the Nurses' health initiative where, um,
nurses reported their hormone replacement and heart risk,
and it seemed to correlate that women with hormone
replacement were having less heart disease. And then came a, you know,
the largest study of hormone replacement,
aiming to show a benefit in reducing heart risk using hormone replacement,
which is called the Women's Health Initiative. And this was conducted in the,
um, nineties, I believe. And it was, um,
stopped early because there was actually an increased risk of cardiovascular
events, um, in just the first two years, I think. Um,
and what we have since kind of teased out
was first of all,
that whole patient population where the average age was 63,
so they were 10 on average, about 10 years into menopause. Um,
and there was a high clustering of heart risk factors
more than like, I think 50% had some smoking history.
About 10% were active smokers. Um,
and so in patients who have heart disease,
who have significant risk factors,
then the use of hormone replacement would actually be
detrimental because we know it causes,
it has prothrombotic meaning clotting risk, and it has pro-inflammatory risk.
It increases inflammation. And in those women,
it seems to accelerate that cardiovascular risk. Um,
and so definitely anybody who's got significant vascular risk or established
plaque buildup, you would not consider the option of hormone replacement.
Um, and, um,
whereas on the flip side,
if you take a woman who has no significant vascular risk factors
and doesn't have those markers of risk, um,
then there have been, uh,
studies since showing that perhaps there's actually a benefit,
um, in terms of heart,
a hormone replacement where there may be less progression in
early plaque buildup. Um,
the data is so muddy that really there is no role to
treat heart risk with hormone replacement.
That is not the take home that I would be giving. Um,
we have other means by which to address your cardiovascular risk.
So no one should go on hormone replacement thinking.
5: That's.
6: The solution . Yeah. That,
that's gonna lower their cholesterol and improve their risk. But, um,
hormone replacement we know is really good for bone health and we know it's good
for maintaining muscle mass and, um,
for sleep and mood and a lot of things that, you know,
our quality of life.
5: Make it really attractive.
6: Make are very powerful. Right. And, and unfortunately a lot of, um, women,
um, you know, little old ladies and falls and hip fractures,
those are life-changing events. Right.
And so hormone replacement has huge potential benefits outside of any
cardiovascular.
And one reason to be really proactive about your heart health from age 20
until, you know,
starting at age 20 is so that when you hit menopause,
you've got a full menu of options to potentially choose
to go on hormone replacement for these other benefits.
Whereas if you have these unaddressed risk factors and have early plaque
buildup.
4: It's such a great takeaway. It honestly, it's a great way of thinking about it.
The way we've always thought about things is, listen, just live,
enjoy your youth , don worry about this stuff later. Right. We'll.
6: Treat you when you're sick, right?
4: Yeah. Right.
When really it's like you need to start investing in that health from day one
because it's all additive or contributory as you said,
but then this sort of additional way of you putting it I really like,
which is you set yourself up for success later on, right.
Because of the decisions you made earlier on and you actually expand the options
that you have. Right. But to me,
that's very helpful to understand and hopefully to listeners that distinction is
very important because it's not a one size fits all.
5: There was a recent research study that was covered in a number of places that
now says the risk of women having one alcoholic drink per day
raises their risk for heart disease considerably.
Have you seen this study and what's your take on that?
6: So yes, uh, it, I did look into it. It is a Kaiser study.
Um, so I think it's important for us to sort of understand how it was done,
even though we have very limited, it hasn't been published,
so I don't have the details of it,
but it was done in more than 4,000, um,
uh, men and women to look at heart related risk. Um,
was initially a, um,
questionnaire provided by the primary care with self-reported alcohol use and
separated them into four categories according to how much alcohol they took.
Low was one to two drinks a week.
Moderate in women was three to seven drinks a week.
Men was three to 14 high in men was more than 15 in women,
more than eight drinks a week. And then they also tracked binge drinking,
which was reporting any episodes of having had more than four
drinks in one sitting for men and three drinks for women in one
sitting one day, anytime in the preceding three months.
And what they found was that binge drinking in particular carried the highest
risk,
and that risk was greater in women than it was in men.
So binge drinking in women increased the rate of heart events in
just a four year follow up period by 68%.
5: Wow.
6: Versus 33% in men. So less of an effect.
Clearly in in men, we know that women metabolize.
5: Alcohol differently. I was just gonna say watch. Yes.
6: Were smaller. Right. There's, there are differences, biological differences,
why that would be. Um,
and so even though they had the definitions of what was moderate and high and
binge, all those were modified by gender,
it still signaled a much higher risk for women.
And that's super important because actually drinking, especially among women,
is on the rise. Men plateaued. But women self-reported drinking,
binge drinking by a recent CDC. Um,
13% of women reported some binge drinking in the past
week. Huh. And we're talking about binge drinking episodes, months. Is there a,
this here defined as three explanation?
4: Why do we know? I mean, is it just a guesswork or do we I think.
6: It's A little, it's a very interesting,
I I think it's a little bit this notion of oh, it's, it might be healthy.
And then also, um, this culture of.
5: Social.
6: Yeah. This,
that it's okay that I come home and unwind with my two or three drinks of Got
it.
4: Whereas before maybe it was more taboo.
So it's just sort of an unmasking of that, or undoing of that limitation. Yeah.
5: I also always wonder if people are reporting accurately
that this was self reported, how much they drinking. It's a flawed study,
but like, if anything, you know, it could be more dramatic. 'cause I,
people reported people, I think people underreport because they're,
they're concerned about the judgment.
6: Right, right.
4: Right. Well, that's a well known thing for sure.
I don't know in this study if they designed it in a way that reduced
underreporting. But what you're saying is like.
5: Masking individual.
6: Absolutely.
4: True. And the average interviewing of a patient, um,
with this particular question or,
or questions that are similar in nature where there could be a fear of judgment
that there is, I'm not gonna say like unanimous,
but very high level of underreporting. Yeah. Yeah. That's interesting. Well,
we'll look forward to the actual publication of the study.
5: Thank you so much. Thank you, Paula. This was so informative.
Really enjoyed the conversation. Thank you so much. I did too.
Thank you so much. Yeah. Thanks for tuning in. We hope you enjoyed this episode.
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