Ever since the Covid-19 pandemic began, health authorities worldwide have been extremely concerned about the extent of serious complications and high rate of death caused by this infectious disease.

Covid-19 deaths are mainly due to acute respiratory distress syndrome (ARDS), and in some cases, heart and multiple organ failure. Although vaccines are now becoming available to us in the fight against this disease, we are still vulnerable to getting infected while we wait our turn to get vaccinated.

Even after we are fully vaccinated, there is still a risk of infection, even if it is significantly reduced by the vaccine. Meanwhile, many are left wondering about the side effects of continuing to take medication or treatments for existing conditions like asthma, allergies, and even hormonal imbalances, if they should get Covid-19.

When it comes to treating hormonal imbalances, the concern that some have expressed about continuing hormone replacement therapy (HRT) while having Covid-19, is the worry that it will speed up the progression of the disease by encouraging the occurrence of blood clots.

Blood clots form in a blood vessel, and if they break loose, end up plugging up another vessel in a vital organ such as the lungs, gastrointestinal tract, brain or kidneys. However, this concern isn’t founded on any solid proof.

Thrombophilic states – an abnormal condition of blood coagulation that increases the risk of thrombosis or blood clots – is not one of the conditions that accelerates the progression of Covid-19. Rather, we are now seeing a number of older studies that confirm what we already know about HRT resurface.

Meanwhile, newer findings conclude that even women in the most thrombophilic states (i.e. pregnant women or those on contraceptive pills) have not had a worst prognosis of Covid-19. Hence, it is fine to continue with your HRT even if you have Covid-19.

In fact, Covid-19 and HRT might be more closely linked than we thought, with the latter possibly being a contributing factor in strengthening your immune system to fight against the disease.

Effects of oestrogen

Let’s examine more closely why this might be so. In a retrospective study, researchers did an analysis of health records from nearly 70,000 people and found that women taking HRT were 50% less likely to die of Covid-19, compared to counterparts who were not on HRT.

These findings shine a crucial light on the importance of hormones on women’s health, especially in older age groups. The study also found that women were less likely to die from severe complications compared to men.

Meanwhile, an earlier study from Wuhan, China, had found that women with lower oestrogen levels experienced more severe symptoms. The researchers who conducted the retrospective study speculated that balanced levels of oestrogen are helping to fight off serious Covid-19.

We know that oestrogen supports and improves our immune system in a few ways. There are oestrogen receptors on all of our infection-fighting cells, including the different types of white blood cells. Healthy amounts of oestrogen increases the number of immune cells including neutrophils, macrophages, dendritic cells and natural killer cells. Oestrogen stimulates cells to be more efficient and less prone to becoming inflamed.

Cells that are inflamed increase the risk of conditions such as heart disease, obesity and diabetes. Hence, oestrogen is essential to regulating immune responses to ensure that they are effective and balanced.

The well-known protective effect that oestrogen has on our cardiovascular health is also thought to play a role in the response to the SARS-CoV-2 virus. There has also been a lot of discussion about cytokine storms in relation to the immune response to Covid-19, and oestrogen plays a role in fighting those too.

Cytokines are immune system proteins that surge when the body needs an extra boost to fight infection. However, too strong a response leads to a cytokine storm, where large quantities of cytokines are produced in the body, which results in cell and organ damage.

It’s not easy to switch off cytokine production once it goes into overdrive, and the detrimental effect causes problems, particularly in the lungs. A healthy presence of oestrogen regulates cytokines and can even block the production of some chemicals found in severe Covid-19.

This means that these proteins are prevented from damaging healthy cells. It may also explain why fewer women are likely to die from Covid-19 than men.

Continue HRT

If low levels of oestrogen affect the strength of our immune system in combating Covid-19, then HRT is an effective way to ensure our bodies have enough of this very helpful hormone.

Replacing oestrogen safely through HRT can help make sure we keep all of our immune cells in the right balance. Achieving that balance means they can effectively fight infection and keep healthy tissues safe. In the event that you are infected, here’s some advice from the board of doctors at the Italian Menopause Society:

• Hormone therapy or hormonal contraceptives should be continued, unless the woman is severely ill – a condition in which hormonal balance is probably not so crucial.
  
  In other conditions, the possibility that hormone withdrawal may accelerate Covid-19 progression cannot be excluded, and withdrawal should be avoided.
• In the case of disease progression from a simple flu to more severe symptoms, it seems wise to rely on the expertise of specialists who will consider the need of adding heparin, useful as anti-coagulant, anti-inflammatory and immune-modulator.
• Shifting from oral to transdermal oestrogens (patch, gel, spray) may be considered, but is not mandatory.
• In order to start or restart therapy, it is probably useful to use transdermal instead of oral oestrogens.
• In the case that HRT is discontinued, it should be remembered that withdrawal bleedings may occur.

By Datuk Dr Nor Ashikin Mokhtar
Published in Star Newspaper, 31 May 2021