Scott Webb (Host): I'm joined again today on the podcast by Nurse Practitioner Caitlin Luebcke. She has a special interest in women's cardiology care, and today we're discussing the truth about hormone replacement therapy, birth control, cardiovascular risk, and so much more. This is the Franciscan Health Doc Pod. I'm Scott Webb.

Caitlin, it's great to have you back on the podcast.

 We're talking today about hormone therapy and the heart, right. And the truth about hormone replacement therapy, birth control, cardiovascular risk, all that important information we want to share with listeners. So what is the current evidence on oral contraceptive use and hormone replacement therapy in supporting or harming a woman's cardiovascular system?

Caitlin Luebcke, DNP: First off, I think people are always really surprised when they hear about contraceptive use in Franciscan. You know, we're a Catholic organization and oral contraceptives are used to treat many other conditions aside from just preventing pregnancy.

So, we do give this to our patients and we see it. So contraception, we've known for years, and this came out when the first birth control pill came out, contraception that includes estrogen, which are combination pills. They are associated with an increased risk for hypertension or high blood pressure, stroke, heart attack, and then even blood clots.

There's a lot of data that goes back and forth with all of it. You know, some studies show, eh, the risk isn't that bad, but overarchingly, it all kind of points to these do raise your risk and the risk is higher for some people than it is for other's. We'll talk about what we should do about that, depending on your risk.

Hormone replacement therapy for menopausal symptoms similarly, has mixed data. Although the effect is a little clearer here, it appears to at least be partially dependent on, the timing of the initiation of the therapy. So, you know, if you start hormone replacement therapy for menopausal symptoms, and we're talking about oral hormone replacement therapy, prior to the age of 60; it's not associated with any increase in cardiovascular disease risk, and it may even provide some protection against cardiovascular disease. But even as I say that, understand that we're still getting those studies. I mean, we, we haven't been great about studying menopause for years.

And so some of the data is still even mixed on that, but that's, that is where it's sort of pointing right now. Unfortunately, if we miss treating you in earlier years of your life and we're wanting to start estrogen therapy after the age of 60, it tends to be associated with an increased risk for stroke, heart attack and blood clots.

Similarly to, if not even more so than like oral contraception pills are earlier in your life.

Host: Yeah. Yes. I wanted to ask you like, does the mode of delivery of hormone therapy matter, let's say oral versus topical? Does that change the effect on the heart? Sounds like maybe.

Caitlin Luebcke, DNP: It does. Yeah. So again, I'm kind of splitting these things up. So when we talk about contraceptives, transdermal patches and vaginal rings, which to me I think about that's pretty far away from the heart. And it's not, it's not going into, it's not a pill you swallow. We always think of pills being very systemic.

So I would think that the, the pill would be more problematic, but that's not actually what we found. The patch, the ring, those actually are associated with a higher risk for adverse cardiovascular outcomes. Oral combo pills that contain estrogen seem to be safer. In contrast, when we look at our older patients that are menopausal, transdermal patches and creams. So the same sort of things that are dangerous when we're younger actually seem to have less risk when we are older.

Host: That's just confusing.

Caitlin Luebcke, DNP: Uh, it, it sure is. It sure is. But again, I think that's where you get more of that thought of, oh, if you take an oral estrogen, it is more systemic. And if you're just using creams for local menopausal symptoms in like vaginal creams and things like that, it, you have, I believe it's less than 5% of like systemic absorption. So, that's probably why it's a little different.

Host: So then, Doctor, what are some of the things that patients and providers should keep in mind? They're trying to balance the risks and benefits of symptom relief with patient's cardiovascular risk. Like what do they need to be mindful of?

Caitlin Luebcke, DNP: Sure. So generally, both combined, oral contraceptive pills and hormone replacement therapy are for the most part considered very, very safe. The FDA has taken away the black box warnings off of hormone replacement therapy. You don't ever really see much in the way of black box warnings for oral contraceptive pills.

There were some that have since been taken off the market. So by and large, these are really safe medications. However, if you have a known history of cardiovascular disease or a history of blood clots; these probably aren't good therapies for you. probably shouldn't be surprised if your healthcare provider says, we need to look for an alternative.

You're not a good candidate. In patients that are being treated with PCOS or endometriosis, which both carry slightly higher risk for cardiovascular disease in the general female population; oral formulations are known to be safer. So, if you're taking one of these contraceptive pills for one of these other conditions, it's probably safer for you to take the combo pill rather than having a transdermal patch or the vaginal ring.

And in all patients, regardless of how old you are, what phase of life you're in, if you have a history of stroke, heart attack, or blood clots, I would not personally pursue these for myself, if I were in that category. But ultimately any decision you make should be made through shared decision-making after a very thorough history, a very thorough physical, and then a really comprehensive discussion with your healthcare provider about the symptoms that you're dealing with, and how it affects your quality of life, and kind of balancing that with your individualized risk.

 Because you know what's right for me may not feel right for my patient, may not feel right, for my friend, may not even feel right for like a sister or, or some other family member. So, healthcare should be individualized and you need to find a provider that's going to explain things to you and balance things out for you.

Host: Yeah, well, as we established last time we spoke Doctor, you know, women are not just smaller men. They are majestic, they are unique. And so it's, it's, not a one-size-fits-all approach with you and at Franciscan Health. And there may be some trial and error, so to speak, in getting it just right and finding that balance.

But it's important. So, speak up, advocate for yourself, shared decision-making. All good stuff. Thank you again.

Caitlin Luebcke, DNP: Yeah, absolutely.

Host: And to learn more, visit franciscanhealth.org/ herheart.

And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.