Until 2002, hormone therapy was routinely used to treat menopausal symptoms and protect long-term health. Then a large clinical trial unearthed its health risks.
1. What does this mean to women who are entering menopause?
During menopause, the ovaries decrease production of the female hormones estrogen and progesterone, which puts a permanent end to menstruation and fertility. However, it can also cause hot flashes, mood swings, vaginal dryness and urinary problems. For decades, doctors routinely eased these symptoms with hormone replacement therapy - medications containing female hormones to replace the ones the body is no longer making. It was widely believed that boosting estrogen levels after menopause could also ward off heart disease and osteoporosis, while improving quality of life and keeping women young.
2. What happened to change doctors' minds about prescribing hormone replacement therapy?
In 2002, a large clinical trial called the Women's Health Initiative (WHI) reported that hormone therapy actually posed more health risks than benefits for the women in the clinical trial. As the number of health hazards attributed to hormone therapy grew, doctors became less likely to prescribe it. At the time, approximately two-thirds of women on the therapy discontinued its use, often without talking to their doctors.
Today, there's plenty of confusion about hormone replacement therapy. The truth is that hormone therapy is not the magical cure for aging that it was once believed to be, but it's still the most effective treatment for unpleasant menopausal symptoms for most women.
3. What are the benefits of hormone therapy?
Estrogen remains the most effective treatment for relief of troublesome menopausal hot flashes and night sweats. It can also ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort during intercourse.
Long-term hormone therapy for the prevention of postmenopausal conditions is no longer routinely recommended. But women who take estrogen for short-term relief of menopausal symptoms may gain some protection against:
- Osteoporosis. Studies show that hormone therapy can prevent the bone loss that occurs after menopause, which decreases the risk of osteoporosis-related hip fractures.
- Colorectal cancer. Studies show that hormone therapy can decrease the risk of colorectal cancer.
- Heart disease. Some data suggests that estrogen can decrease risk of heart disease when taken early in your postmenopausal years. A clinical trial is under way, but won't be completed for several years.
For women who undergo menopause naturally, estrogen is typically prescribed as part of a combination therapy of estrogen and progestin. This is because estrogen without progestin can increase the risk of uterine cancer. Women who undergo menopause as the result of a hysterectomy can take estrogen alone.
4. What are the risks of hormone therapy?
The Women's Health Initiative found that women taking the combination estrogen-progestin used in the study had an increased risk of developing certain serious conditions. According to the study, 10,000 women taking estrogen plus progestin compared with a placebo might experience:
- Seven more cases of heart disease
- Eight more cases of breast cancer
- Eight more cases of stroke
- 18 more cases of blood clots
Based on these numbers, the increased risk of disease to an individual woman is small. However, the overall risk to menopausal women as a group became a substantial public health concern. In addition, researchers found that women taking combination estrogen-progestin had an increase in abnormal mammograms. The higher number of false-positives - signs of possible breast cancer that ultimately prove inaccurate - was probably due to estrogen, which increases breast tissue density.
For women taking estrogen alone, the WHI found no increased risk of breast cancer or heart disease. But researchers did find that over one year, 10,000 women taking estrogen compared with a placebo might experience 12 more cases of stroke and six more cases of blood clots in the legs, plus an increase in mammography abnormalities. This last point is important, because women who take estrogen or combination estrogen-progestin therapy may need more frequent mammograms and additional testing.
5. Who should consider hormone therapy?
Despite the inherent health risks, estrogen is still the gold standard for treating menopausal symptoms. For women who experience moderate to severe hot flashes or other menopausal symptoms, the benefits of short-term therapy outweigh the potential risks. A woman should talk with her doctor about her personal risks.
6. Who should avoid hormone therapy?
Women with breast cancer, heart disease or a history of blood clots should not take hormone therapy for relief of menopause symptoms. Women who don't suffer from menopause symptoms should not take hormone therapy for preventing memory loss or strokes. Instead, talk to your doctor about other medications you can take or lifestyle changes you can make for long-term protection from these conditions.
7. If you take hormone replacement therapy, how can you protect yourself from the added risks?
Recent analysis of the WHI data and other trials suggests that there are several ways to reduce the inherent risks of hormone therapy.
- Timing. The risk of hormone therapy causing heart disease is not significantly raised in women under age 60. In fact, some studies suggest that estrogen may protect the heart when taken early in your menopausal years.
- Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed to treat symptoms. On the other hand, don't be scared to continue treatment as long as you have debilitating menopausal symptoms.
- Find the best delivery method for you. You can take estrogen in the form of a pill, patch, gel, vaginal cream, slow-releasing suppository or vagina ring. If you experience only isolated vaginal symptoms, estrogen in a vaginal cream, tablet or ring is usually a better choice than a pill or a skin patch since estrogen applied directly to the vagina is more effective at a lower dose than is estrogen given in pill or skin patch form.
Women who haven't had a hysterectomy and are using oral or skin patch hormone therapy, will also need progestin, which is available in a pill, combination pill, vaginal gel, intrauterine device or combination skin patch. Your doctor can help you find the delivery method that offers the most benefits and convenience with the least risks and cost.
8. What can you do if you can't take hormone therapy?
Women shouldn't have to suffer through menopause. You may be able to manage your menopausal symptoms by making healthy lifestyle choices. In fact, your doctor may recommend that you change your exercise or eating habits before you try medication. If lifestyle changes aren't providing enough relief from bothersome symptoms, there are many medications besides hormone therapy to relieve discomfort.
The bottom line: Hormone therapy isn't all good or all bad
Clearly, hormone replacement therapy hasn't lived up to its billing as a panacea for age-related disease. But the news isn't all doom and gloom either.