Sep 24th, 2020

Greg Wolf, one of our esteemed Clinical Advisory Board members, shares his clinical experience about Heart Health and Physiologic Restoration in Menopause via his 3-part series.

Every woman I treat for the hormone deficiency syndrome of menopause is most concerned about her cholesterol. Perhaps surprisingly, it turns out that it has never been conclusively demonstrated that lowering a woman’s cholesterol with a statin will protect her against aging blood vessels or lower her risk of developing coronary artery disease, dying of a heart attack or getting a stroke.(1)

What does prevent all degenerative vascular diseases which occur in menopause is topically applied 17-beta-estradiol as part of a regimen of bio-identical hormone replacement therapy

A truly remarkable example of this truth was observed in my practice a decade ago. Two women, unknown to each other, came to my office at the same time around 2009, with a nearly identical and somewhat unusual medical history.

Around the age of the 30 they both underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy, meaning they each had their uterus and both ovaries removed. Thus, at the age of 30 both were thrust into a harsh surgical menopause. Neither was offered bio-identical hormone replacement therapy. Rather, they were given oral conjugated equine estrogens, aka Premarin, which they used over the next 20 years.

At the age of 50 they both suffered a heart attack. They both had stents placed in their coronary arteries to restore blood flow to the heart. They were both taken off Premarin and told that estrogen was harmful to the heart. They were both placed on aggressive statin therapy and told to take a baby aspirin every day. Despite statin therapy they both struggled with progressive coronary artery disease requiring a new stent every two years over the next eight years.

When I meet these two women at the age of 58 they each have 5 stents in their coronary arteries. Prior to arriving in my office, they were admonished by their cardiologist not to see me because of what their doctors perceived to be the risk of menopausal HRT, especially after the onset of heart disease. One of the cardiologists even went so far as to say that the patient would only see me over his dead body! (Apparently, she stepped right over his carcass). Despite these warnings they told their cardiologist that they were feeling so poorly they were willing to take the “risk.”

I placed them both on the same rhythmic dosing treatment protocol, a protocol now called Physiological Restoration or PR. PR is a high dose, topically applied, bio-identical estradiol and progesterone replacement therapy, which recreates a woman’s youthful hormonal rhythms and levels with a cyclic pattern of hormone dosing that also produces a monthly menstrual cycle.

After being placed on PR they felt fantastic and were able to reclaim the vitality of their youth. However, that is not what is so truly memorable about what unfolded. The remarkable part of their stories is what happened after two years of PR.

When I started these women on PR they were dealing with the anxiety provoked by their cardiologist’s warning about the dangers of HRT. I reassured them that not only was PR not going to hurt their heart, it was, in fact, good for their hearts. Reassured they both decided to start HRT.

Unbeknownst to me, it happened that after two years of PR they had their biennial reassessment of their coronary arteries. It is now that the story gets remarkably interesting and rather amazing. Shortly after their cardiac evaluations and within a month of each other they return to my office with the same story. It is only then that for the first time I appreciate that I simultaneously have two women on PR with the same unusual medical history.

Not only do they share a particular history they now also share a particular outcome. They both report to me that for the first time in 10 years their coronary artery disease has stopped progressing and they will not need another stent.

One of the patients was informed of this based on a nuclear heart scan. A nuclear scan is a noninvasive medical procedure, which allows a doctor to assess cardiac blood flow. A questionable or worrisome outcome from this test will lead to a coronary angiogram, which is an invasive procedure and the gold standard for assessing the status of coronary artery disease...

The second patient skipped the nuclear scan and just had the coronary angiogram. The cardiologist was amazed at the results. Not only had the angiogram showed no progression of the patient’s coronary artery disease, it actually suggested improvement. This was the cardiologist, by the way, whose dead body my patient had to step over to get to see me. This patient informed me that her heart doctor did an 180º shift regarding the value of estradiol in the treatment of menopausal women. I was impressed!

The question naturally arises. Why all this resistance by conventional medicine to the use of bio-identical HRT in menopause? Why all the misguided fear?

Stay tuned for Part 2 in how this started


  1. Hodis HN and Mack WJ. The Timing Hypothesis: A Paradigm Shift in the Primary Prevention of Coronary Heart Disease in Women: Part 1, Comparison of Therapeutic Efficacy. J Am Geriatr Soc. 2013 Jun;61(6): 1005-1010
  2. Hodis HN and Mack WJ. The Timing Hypothesis: A Paradigm Shift in the Primary Prevention of Coronary Heart Disease in Women: Part 1, Comparison of Therapeutic Efficacy. J Am Geriatr Soc. 2013 Jun;61(6): 1005-1010
  3. Fonseca MIH, et al. Impact of Menopause and Diabetes on Atherogenic Lipid Profile: is it worth to analyze lipoprotein subfractions to assess cardiovascular risk in women. Diabetol Metab Syndr. 2017 Apr 7;9:22
  4. Schierbeck LL et al. Effect of Hormone Replacement Treatment on Cardiovascular Events in Recently Postmenopausal Women: Randomized Trial. BMJ. 2012;345:e6409
  5. Hodis HN, et al. Vascular Effects of Early versus Late Post Menopause Treatment with Estradiol. N Engl J Med. 2016 Mar 31;374(130:1221-1231
  6. Hodis HN and Mack WJ. The Timing Hypothesis: A Paradigm Shift in the Primary Prevention of Coronary Heart Disease in Women: Part 1, Comparison of Therapeutic Efficacy. J Am Geriatr Soc. 2013 Jun;61(6): 1005-1010
  7. Rossouw JE, et al. Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by Age and Years Since Menopause. JAMA. 2007;297(13):1465-1477
  8. Canonico M, et al. Postmenopausal Hormone Therapy and Risk of Stroke: Impact of the Route of Estrogen Administration and Type of Progestogen. Stroke. 2016 Jul;47(7):1734-1741
  9. Vongpatanasin W. et al. Differential Effects of Oral versus Transdermal Estrogen Replacement Therapy on C-Reactive Protein in Postmenopausal Women. J Am Coll Cardio. 2003 Apr 16;41(8):1358-63
Previous Blogs

The goal of WHN is to expand the Standard of Care by promoting, advocating, and advancing women's wellbeing and longevity through clinical research and education about the benefits of Physiologic Restoration to reduce the symptoms of hormone imbalance, chronic disease and degenerative decline.
WHN is a registered 501(c)3 not-for-profit corporation