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. What does this mean to you?
Hormone replacement therapy — medications containing female hormones to replace the ones the body no longer makes after menopause — used to be a standard treatment for women with hot flashes and other menopause symptoms. Hormone therapy (as it's now called) was also thought to have the long-term benefits of preventing heart disease and osteoporosis.
Attitudes about hormone therapy changed abruptly in 2002, when a large clinical trial found that the treatment actually posed more health risks than benefits for postmenopausal women. As the number of health hazards attributed to hormone therapy grew, doctors became less likely to prescribe it. And most women on hormone therapy discontinued its use, often without talking to their doctors.
What are the benefits of hormone therapy?
Women who choose standard hormone therapy during natural (nonsurgical) menopause typically take estrogen and progestin, a man-made version of progesterone. It can also ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with 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 the following conditions:
· 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 suggest that estrogen can decrease risk of heart disease when taken early in your postmenopausal years. A randomized, controlled clinical trial — the Kronos Early Estrogen Prevention Study (KEEPS) — exploring estrogen use and heart disease in younger postmenopausal women is under way, but it won't be completed for several years.
For women who undergo menopause naturally, estrogen is typically prescribed along with progestin, a man-made version of progesterone. 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.
What are the risks of hormone therapy?
In the largest clinical trial to date, the combination estrogen-progestin (Prempro) increased the risk of certain serious conditions.
According to the study, over one year, 10,000 women taking estrogen plus progestin might experience:
· Seven more cases of heart disease than women taking a placebo
· Eight more cases of breast cancer than women taking a placebo
· Eight more cases of stroke than women taking a placebo
· Eighteen more cases of blood clots than women taking a placebo
· An increase in abnormal mammograms, particularly false positives
The study found no increased risk of breast cancer or heart disease among women taking estrogen without progestin. Over one year, however, 10,000 women taking estrogen alone might experience:
· Twelve more cases of stroke than women taking a placebo
· Six more cases of blood clots in the legs than women taking a placebo
· An increase in mammography abnormalities
The effect of hormone therapy on mammograms is important, because it suggests that women on hormone therapy may need more frequent mammograms and additional testing.
Who should consider hormone therapy?
Despite the health risks, estrogen is still the gold standard for treating menopausal symptoms. The absolute risk to an individual woman taking hormone therapy is quite low — possibly low enough to be acceptable to you, depending on your symptoms.
The benefits of short-term hormone therapy may outweigh the risks if you:
· Experience moderate to severe hot flashes or other menopausal symptoms
· Have lost bone mass and either aren't able to tolerate other treatments or aren't benefitting from other treatments
· Stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian failure)
Women who experience premature menopause or premature ovarian failure have a different set of health risks compared with women who reach menopause near the average age of about 50, including:
· A lower risk of breast cancer
· A higher risk of osteoporosis
· A higher risk of coronary heart disease (CHD)
In addition, hormone therapy appears to reduce the risk of osteoporosis and CHD when started soon after menopause in young women. For women who reach menopause prematurely, the protective benefits of hormone therapy may outweigh the risks.
Talk with your doctor about your personal risks.
Who should avoid hormone therapy?
Women with breast cancer, heart disease or a history of blood clots should probably not take hormone therapy for relief of menopause symptoms. Women who aren’t bothered by menopause symptoms should not take hormone therapy for prevention of 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.
If you take hormone replacement therapy, how can you protect yourself from the added risks?
Talk to your doctor about these strategies:
· Time it right. 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. If you have lasting, debilitating menopausal symptoms, your doctor may recommend longer term treatment, but will follow up regularly to ensure that the benefits of hormone therapy continue to outweigh the risks.
· Find the best delivery method for you. You can take estrogen in the form of a pill, patch, gel, vaginal cream, or slow-releasing suppository or ring that you place in your vagina. 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. That's because estrogen applied directly to your vagina is more effective at a lower dose than is estrogen given in pill or skin patch form.
If you haven't had a hysterectomy and are using oral or skin patch hormone therapy, you 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.
What can you do if you can't take hormone therapy?
Women shouldn't have to struggle 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.
The best way to determine if hormone replacement therapy is a good treatment option for you is to talk to your doctor about your individual symptoms and health risks. Be sure to keep the conversation going throughout your menopausal years. As researchers learn more about hormone therapy and other menopausal treatments, recommendations may change. Review your current treatments with your doctor on a regular basis to make sure they're still your best option.
