Beyond Hot Flashes: Health First Nurse Practitioner Ann Quesada Says HRT Helps Protect Heart, Bones and Brain

estrogen is key, beneficial hormone in women’s health

FDA yanks ‘black box’ warning. A Health First menopause and bone expert explains why it’s time to rethink outdated fears and embrace prevention early in menopause.

BREVARD COUNTY, FLORIDA — Ann Quesada has seen it for years. Women, smack-dab in the middle of perimenopause, going through the emotional and physical wringer – and not saying a word.

Be it hot flashes, brain fog, joint aches, not sleeping well, or the other symptoms of decreasing hormones, the attitude around menopause has often been considered something like this – it’s just part of the deal when it comes to being a woman.

“It’s amazing what women put up with without complaining about it,” said Quesada, APRN, gynecology, Health First Medical Group. “They just don’t come seek care unless they feel like they’re dying, or it’s so bad that it’s affecting their work or affecting their relationship.”

But the FDA recently removed the “black box” warning from hormone replacement therapy (HRT) following a July FDA panel recommendation, noting the warning was a disservice to women. It reiterates what Quesada has preached for some time – that estrogen is a key, beneficial hormone in women’s health.

“The removal of the black box warning, based on the best science and data, is an incredible step forward to empower millions of women to live longer, healthier lives,” said Alicia Jackson, Director of Advanced Research Projects Agency for Health, in an FDA statement.

To backtrack a bit: In 1993, the Women’s Health Initiative (WHI) hormone therapy trials began – and then were halted early in 2002 and 2004.

Findings had linked combined estrogen–progestin (synthetic compounds designed to mimic the effects of natural progesterone, such as in birth control pills) therapy to increased risks of breast cancer, heart disease and stroke.

It scared providers and patients alike, and HRT use among U.S. women plummeted — from about 17.9 million users in 2001 to 5.8 million by 2008. It continues to influence medical guidelines and public perception today, but this black box reversal may start shifting the narrative.

Currently, only 4.7% of women in the U.S. use HRT, according to the JAMA Health Forum. 

Quesada, a specialist in menopause and bone health, reiterated the benefits of HRT. But timing is critical – and so is having a provider who is well-schooled in menopause.

Before, women in various stages of menopause were tapping into HRT. Now, the timeframe when HRT is begun is narrower. Research shows HRT started within 10 years of menopause can reduce fracture risk by up to 50%.

“The reduced risk of bone fractures is huge,” Quesada said. “A lot of people don’t want to take actual osteoporosis medication…But trying to prevent that first fracture and trying to prevent the bone loss from happening to begin with is huge. And yes, estrogen can really greatly do that.”

Quesada is an advocate for DEXA scans, a diagnostic tool for determining bone mass. Bone scan recommendations suggest starting them around age 65, unless there’s an extenuating circumstance.

Menopause counts as one. 

“We know you can get into a rapid bone loss state for up to five years once menopause hits,” Quesada said.

Younger women typically don’t have DEXA scans, and 30 is believed to be the peak bone mass time, Quesada said. However, bone density isn’t just tied to age – it can drop due to malnourishment, lack of vitamin D, or if you’re taking medications that impact bone mass.

Quesada said DEXA scans are typically low-cost and are radiation-free, making them a vital tool.

“If you’re 45 years old and you go through menopause, that’s when I start DEXA scans,” Quesada said of varying ages to begin testing. “If you’re 50, that’s when I start DEXA scans. A lot of this is easier to prevent than it is to try to cure.”

Research has also shown that cognitive health gets a boost from HRT, too. There is a 35% lower risk of Alzheimer’s in those who start HRT at the appropriate time.

“Again, that’s not somebody starting it at 70,” Quesada noted. “That’s somebody that was on it beforehand.”

However, HRT isn’t for everyone, including:

■ Women with irregular mammograms. Estrogen can affect how mammograms look.

■ Those with high blood pressure (okay if stable with medications)

■ Clotting disorders or a family history of them

The key to getting the best benefits from HRT? Being proactive.

With the FDA’s new stance, Quesada said hormones provide a more cost-effective alternative to newer medications aimed at menopausal relief. However, those newer prescriptions, such as Veozah (fezolinetant) and Lynkuet (elinzanetant), may be able to help women who are not candidates for HRT or women who prefer non-hormonal treatment. Those can help with hot flashes and other vasomotor symptoms.

As research and policy evolve, Quesada’s advice is clear and simple: Be your own health care advocate.

“If you don’t complain about it or investigate it early enough, you’ve kind of out-aged your ability to go on estrogen and get the fullest benefit out of it,” Quesada explained. “Don’t be quiet about it.”

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