🎧 Friday Q&A: vitamins K + D; when to stop HRT; & optimal blood pressure readings

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Today’s subscriber questions:

• Do I need to take vitamin K in order for vitamin D to work?

• How and when should I stop taking HRT (hormone replacement therapy)?

• What is the optimal blood pressure for diabetics?

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Prefer to read the Q&As? Transcripts are below.

Q: I have a question concerning vitamin D. I've also heard that in order for vitamin D to be effective, you have to take it with vitamin K. Do you have any thoughts on that? I asked my physician and she told me she really didn't know much about vitamins. Makes me wonder about her. Anyway, thank you very much. -Barbara

A: Barbara, thanks so much for this question. It's a great one and I get it all the time. So vitamin K and vitamin D are both important for bone health, but they do different things. So vitamin D, as you probably know, helps your body absorb calcium. Calcium is essential for your bones, while vitamin K helps the calcium go to the right places. It helps the calcium get directed to your bones and your teeth, for example, and it helps keep it from accumulating in the arteries and other places where you don't want calcium.

But it's not strictly necessary for vitamin D to be taken with vitamin K. In other words, a lot of these vitamin companies throw in extra ingredients to make them sound extra special, but it's not essential to take vitamin K in order for your vitamin D to work. Especially if you are someone who gets vitamin K naturally through food. So for my patients who get green leafy vegetables like kale and spinach and some broccoli and Brussels sprouts, all of which have vitamin K in it. And for people who eat eggs and dairy and basically have an unrestricted diet that's full of lots of colors, I don't recommend vitamin K when I'm telling them to get vitamin D if they need vitamin D.

You might ask, is vitamin K deficiency common? It’s really just not. I mean, certainly, there are patients who can have malabsorption problems, conditions that impair fat absorption, like celiac disease or cystic fibrosis, people cannot absorb vitamin K. And so vitamin K supplementation might be necessary. People who take antibiotics long-term that disrupt gut bacteria might need vitamin K. But in general, vitamin K supplementation isn't necessary. On the other hand, vitamin K toxicity is also very rare. So I actually appreciate your doctor telling you she doesn't know much about vitamins. I think that is, while I am sure you wish she knew more about vitamins, I actually appreciate the humility and people being honest about what they don't know.

And the short story to your question, Barbara is that I don't think you need vitamin K with your vitamin D if you eat a varied colorful diet and you don't have any particular medical problem that prevents you from absorbing vitamin K in a regular diet. I hope that is helpful. I wish you all the best.

Q: Hey Lucy, it's Ashley. I would love for you just to discuss the off-ramp for HRT. Obviously you put me on it years ago. I think it's been nothing short of life-changing. It's made me feel so much better in every possible regard. But Mayo is talking about the off-ramp and I will turn 60 this year. But now that I know more about all the cardiovascular benefits and other benefits to your overall health, I'm not dying to go off. So I need information about that risk-reward ratio and sort of what your thoughts are on it for a person who really doesn't have any other issues. It's been fantastic. So I would love your thoughts on that. Hope you're well, bye.

A: Hi, Ashley, great question. When and if should a woman stop HRT and how do you take it down? How do you taper it? So the decision to start HRT, to remain on HRT, or to stop HRT is entirely dependent on the risk-benefit ratio for that unique person at that time. In other words, when I'm talking to a patient about whether she should start HRT around perimenopause or menopause when it starts, or if she should continue it in her 60s or she should stop it, we have to look at what the HRT is doing for that woman in the present time and what it is potentially preventing in the future, and what are the current downsides and what are the potential downsides for continued use in that moment.

So what I'm saying is there's no rule that you have to get it off of HRT. We do know that based on accumulated data, that the benefits of HRT tend to outweigh the downsides in large populations of women when HRT is started, that is, it is initiated within the first 10 years of the woman's last menstrual period. Let me say that again. If started within that 10-year window after a woman stops menstruating, the benefits outweigh the risks for all comers. That is not to say that every woman should be on HRT if she starts it in her 50s, or that a woman can't start HRT at 11 years from her last menstrual period. It's just saying that in general, all comers, the benefits outweigh the risks. In other words, I have to find a good reason not to start a woman on hormone replacement therapy if she's in that 10-year window and has just sort of an average risk for breast cancer, cardiovascular disease, osteoporosis, et cetera.

So what I'm saying to you, Ashley, is that if at this moment, at 60, you're enjoying the current benefits of HRT, which can include diminished hot flashes, diminished night sweats, improvement in your cognitive function, sense of sort of energy, mood stability, you don't have vaginal dryness or pelvic discomfort or genitourinary syndrome of menopause symptoms, so if you're enjoying current benefits from hormone replacement therapy, and we think that the HRT is in fact improving your risk down the road for things like osteoporosis, and it may be improving your risk for cardiovascular disease and for cognitive decline prematurely, we don't know that that is going to be true, but we think that that might be true in your case.

And if currently the downsides, are none, like you don't have any downsides like menstrual bleeding, or you don't have active breast cancer, and we don't think that there's any contraindication, like you haven't had a new breast cancer diagnosis, as I said, or some other reason you shouldn't be taking it, if cost isn't prohibitive, if the administration of it isn't difficult… So in other words, if the benefits outweigh the risks, then generally I would tell someone to continue taking it. So we treat the patient, we don't treat the calendar, but again, when we talk about starting HRT, thatstarting date is very important. In other words, the sooner you start HRT, if you are going to start it, the better you do, the more risk reduction it has for long-term health problems. So I hope that's helpful.

I would say this, if you want to stop HRT, if you decide with you and your doctor, you have a shared decision to stop taking HRT, there is a way to stop it, which involves tapering it over time. I wouldn't just yank you, yank it away from you because people can develop rebound symptoms, but I would taper it over time if you decided that was what you wanted to do or if you had to stop taking it. For example, a patient of mine who recently developed breast cancer that on the surface of its cells had receptors for estrogen and progesterone and she was on HRT. She knows, like I do, that the HRT didn't quote, cause the breast cancer, but that it's not appropriate to be on a hormone that is watering, so to speak, that tumor. So she stopped hormone replacement therapy. She stopped it suddenly because she had to. Those symptoms of estrogen and progesterone withdrawal are not pleasant. So if you don't have to stop it for a medical reason and you just want to stop it for either medical reasons or because of just patient preference, I would have you taper it and you would talk with your own doctor about that. Yes, there's a lot of nuance here and I think it's always important to talk to your own doctor about it. And I hope that's helpful. Bye-bye.

Q: Suggestions for 76-year-old slim lady type one diabetic for what my blood pressure should be. -Heather

A: Heather, thanks for your question. So if you have type two or type one diabetes, it depends on who you ask as to what your blood pressure goals should be, which is probably why it's confusing. So the ADA, the American Diabetes Association, recommends a target blood pressure in diabetics of 140 over 90 or below. So less than 140 on top, that's your systolic blood pressure and less than 90 on the bottom, that's your diastolic blood pressure.

Now, many expert cardiology groups, including the American Heart Association, recommend a blood pressure goal that is stricter. So less than 130 on top and less than 80 on the bottom. A study published in the journal called Hypertension in, I think it was 2023, yeah, it was July 2023, they presented the results of a meta-analysis of 30 trials that was conducted over the course of many years and studied almost 60,000 people with diabetes, and they compared blood pressures in diabetic patients at various tiers and then looked at their cardiovascular endpoints. And they came to the conclusion that if you got a blood pressure in the 120s, the systolic 120 to 124 specifically, that was associated with a lower risk of major cardiovascular diseases when compared to higher blood pressure categories. That's not the standard right now, but let's back up for a second and ask the question, why do we care about blood pressure being lower in the first place? Well, because blood pressure, when elevated, can strain the heart, it can strain the blood vessels, it can increase your risk for cardiovascular disease, specifically heart attack and stroke, kidney disease, eye disease.

So, we often think that intuitively lower is better, but actually when it comes to making the decision for you, Heather, as to what your blood pressure should be, it's not just looking at the expert guidelines, it's understanding your particular cardiovascular risks and also understanding how you tolerate and how you experience blood pressure being lower versus higher. In other words, some of my older patients, for example, can't tolerate a blood pressure of 120 over 70. They just feel lightheaded, they feel weak. If they exert themselves, they get fatigued. So lower is not always better. And medicating blood pressure, treating hypertension, in many cases we can go too far, particularly in older patients. So it's an individualized decision as to how aggressive we should be, depends on your risk for falls, your risk for developing low blood pressure, how well you tolerate your blood pressure medications. But in general, yes, the experts say either 140 over 90 or below, 130 over 80 or below, depending on who you ask. And I hope that's helpful.