Doctors often refrain from prescribing Hormone Replacement Therapy (HRT) to women over the age of 60 or advise stopping HRT after five years due to concerns about blood clots and breast cancer. This caution is based on findings from the Women’s Health Initiative (WHI) study, which observed a slight increase in breast cancer risk at the five-year mark among women who began HRT at an older age, specifically those who used synthetic progesterone and oral estrogen. The synthetic progesterone was identified as the main contributor to the increased breast cancer risk, and oral estrogen, metabolized in the liver, was linked to a higher risk of blood clots.

In the 20+ yrs since the Women’s Health Study, HRT practices have evolved which mitigates these risks. First, modern HRT avoids synthetic progesterone associated with increased risks. We use bio-identical micronized progesterone.  Second, modern HRT does not prescribe oral estrogen to women over 55 or those at risk. Instead, we use transdermal estrogen (the patch), which bypasses liver metabolism and does not carry the same risk of blood clots as pills.

Recent studies, such as the E3N French Study, indicate that using transdermal estrogen and micronized (bio-identical) progesterone does not increase the risk of blood clots and is associated with a lower incidence of breast cancer.

Additional workup for women who want to start HRT after age 60 (or more than 10 years after last period):

It is important to assess your risk for blood clots and plaque rupture which can lead to stroke and heart attack.  Estrogen can soften plaque lining your vessels causing it to rupture- this is where the risk is in HRT for older women.  This risk reduces after 6 months to a year on estrogen.  It’s highest risk when first starting so we start at low doses to acclimate the body to having estrogen once again. Because we start low during the first 6 months not all symptoms will show improvement so expect this transition period. 

Unfortunately, the necessary imaging test listed below (CT scan) is not covered by insurance. It generally costs around $60-$150. We can provide the prescriptions for these tests for a small fee, or you can request them from your primary care doctor before joining Bloom. Some states do not require a prescription to get the test or include the prescription in the cost of the test. Check with the testing facility first.  

If you have Medicare I recommend the Cleerly Scan. Medicare just started covering the test ($1500) for those with chest pain symptoms. This test uses ai and 3D imaging to look at the coronary arteries. Superior to the ct scan alone because it can also assess soft plaque in addition to hard plaque. The soft plaque is the type that is more dangerous because it is easier to break off. Unfortunately this is a newer test not available nationally.

The lab work may or may not be covered by your insurance. First submit any labs you had done in the last 60 days so we don’t repeat them.  We look at labs to assess your risk of plaque build up and instability (breaking off and causing stroke or heart attack).  We also look at labs to assess your risk of a blood clot. Now here’s the catch. We look at much more specific labs that regular doctors do not typically order. Health insurance may deem our labs as unnecessary if your other basic labs are “normal” and you don’t have a history of heart attack, stroke or clots. Then you will get stuck with a bill if insurance denies the claim.  The alternative is to cash pay for these labs which can be about $200.  We can also tell you which labs to get and you can take them to your primary care doctor and see if they will order them.  Most cash pay lab centers you don’t need a prescription you can simply order them yourself- you can shop them around. We don’t mark up or make any money off of labs. We make the money off of the interpretation and care provided. Once your labs and scans come back there is a $99 telemed visit to go over everything which takes about an hour. 

• Coronary Calcium CT Scan  ($60-$120)
• Lab work to assess blood clot risk and heart disease. ($200)
• Telemed visit to interpret results $99

Factors that increase the risk for starting HRT. 

• Known heart disease
• Smoking
• Obesity
• Inactivity
• Diabetes
• Uncontrolled high blood pressure
• High triglycerides
• High cholesterol
• Known clotting disorder
• History of stroke
• History of blood clots
• History of heart attack

Starting HRT after age 60 requires careful consideration and thorough medical evaluation. While modern HRT practices have mitigated some of the risks associated with synthetic hormones, potential hazards like blood clots and breast cancer still necessitate caution. The above tests will give us real data to assess your actual risk.  We’ll take that along with your history, lifestyle and other risk factors to evaluate your candidacy for HRT.

Cancer Risks

If your concerned about the use of HRT and your risk of cancer there are a few things we can do.  First, if you’ve ever had DNA done by services like Ancestry.com or 23andme.com take a look at your genes and evaluate certain SNP’s linked to breast cancer, ovarian cancer and how your liver and body detoxifies (get’s rid) hormones. If you have the MTHFR genetic defect this is a huge implication in poor detoxification that must be addressed. Next, after being on HRT for a few months we can do a DUTCH test to evaluate how your body is metabolizing your hormones. Some people metabolize them down pathways which increase cancer risk.  Again can be due to your genes so it’s helpful to know what your DNA says.  This can also be due to lifestyle, obesity, metabolic syndrome, and nutritional deficiencies to name a few.  Lots of things impact your pathway. If you are metabolizing hormones down the bad pathway we can use supplements and lifestyle changes to alter the pathway and encourage it to take the safer pathway.  The DUTCH test is not covered by insurance and runs $399.  It’s a simple test done at home using dried urine samples taken thorough out the day.  I even recommend young menstruating women obtain this test to look at how their own natural hormones are being metabolized so they can take steps to prevent cancer as they age.  If you have a daughter or granddaughter and want assistance obtaining and interpreting this test reach out to hello@bloomhrt.com and we can help. Why insurance does not cover it and why it’s not routine for all women is really disheartening as it can be so very helpful and a huge step towards prevention. I guess our health system is not set up for this kind of medicine–but I digress…