Hormone Replacement Therapy… is it the right choice for you?
As you grow older, you expect to grow older better than did your mothers and grandmothers, and you want good information to know how to do just that, including the straight story about Hormone Replacement Therapy.
If you live without major illness to your 50’s, the odds in our times are that you will live into your 80’s. Because the average age of menopause in America is about 52, you can expect to live about 1/3 of your life in the menopause. And, it’s a gilt-edged certainty that you do not plan to spend the time rocking on the front porch in a shawl and headscarf! No, modern women expect to be active in all aspects of their lives: professional, civic, and social activity, sports, travel, and sex. Modern women want to look as good as possible, for as long as possible, preferably without the expense and risk of cosmetic surgery. And last, modern women do not expect to encounter major illness because of the effects of medications – they expect them to prolong their lives and increase the quality with minimal, and therefore acceptable, risk. The trick is to pick things where the proven benefits outweigh the known risks. Modern women ask tough questions, and they expect good, non-patronizing answers that can be backed-up with proof.
Modern women are an especially hard audience when it comes to the confusing and frustrating recent news of the risks of estrogen therapy for menopause, as if the benefits you heard your mothers and grandmothers extol were untruths. So, as you grow older, you expect to grow older better than did your mothers and grandmothers, and you want good information to know how to do just that, including the straight story about Hormone Replacement Therapy.
Until a few years ago, all women were given estrogen when they started to enter into menopause – the “change” - or even after they were menopausal. They were told they should and could take this “hormone replacement therapy” (“HRT”) for the rest of their lives.” After all, it made their skin softer, their hair shinier, their bones stronger, and their backs straighter. In addition it made their hot flashes minimal or gone, their attitude positive, their libido strong, and their bodies able to respond to their maintained libido. And, it was safe, because the major risk of the main ingredient of HRT, estrogen, was that it could induce the lining of the uterus into endometrial cancer or pre-cancer, and that this was easily prevented by adding a little of the other “HRT hormone,” progesterone (a progestogen).
Then, came the dire warnings of scientist-physicians who stopped “one arm, or part” of a major scientific study (with several arms, taking estrogen only, estrogen and a progestogen, or neither) of the relation of postmenopausal estrogen and estrogen/progesterone therapy to cardiovascular disease in women. They reported that information collected partway through the scheduled duration of the study showed that women in one arm were at higher risk to develop cancer of the breast. Rapidly, regulatory action ensued, requiring that women be told that they should only use HRT for a year or two, in the smallest possible dosages, and primarily for the limited treatment of vasomotor symptoms, “hot flashes.” Other data from the study were interpreted such that women were also told that HRT was of little or no value for prevention of bone weakness, heart disease, and other problems which had previously been touted as benefits of HRT and that HRT use for longer than recommend placed them at higher risk for other problems as well. The “short of it,” the HRT, which made their mothers and grandmothers, feel so much better seemed to have become effectively “off limits.”
Confusion, consternation, and not a little anger ensued for many women, especially if their already-prescribed HRT was taken away causing the return of disabling hot flashes, sleeplessness, and all the mental difficulties associated with lack of sleep, not to mention a dry, uncomfortable vagina and lowered libido. Modern women began to ask probing questions about this abrupt change in their care. In summary, I heard two questions:
The symptoms and effects of menopause and pros and cons of HRT:
- What is the interpretation of the study information?
- What does the present information tell about whether or not I should use HRT as I approach and or am in menopause? What can I…
- do safely that is effective?
- not do safely, effective or not?
- probably avoid pending more and/or better information.
Two important notes:
1. Before you start HRT or any other medication or health regimens for symptoms you think are related to menopause, see your physician or nurse practitioner first. He or she should complete a comprehensive history and physical examination, including a pelvic examination, and order or review your Pap smear, mammogram, Thyroid Stimulating Hormone test, and lower GI / colonoscopy study according to nationally accepted guidelines as modified by your individual characteristics. Various nostrums and treatments are sold over the counter and on-line, often by people without medical training. Some are dangerous, some are without any value except profit for the maker; and in all cases, you may ignore a symptom of another problem you have at the same time, delaying diagnosis, perhaps to a disastrous outcome, which could have been avoided by timely diagnosis and treatment.
And, as we noted above, this is the process of making your individual risk/benefit ratio so that you can make the best decisions, for yourself!
2. If you do not have a uterus, you do not have a uterine lining (an endometrium) which may be stimulated by estrogen toward an endometrial cancer. Thus, you also do not need a progestogen in addition to the estrogen.
The study that, rightly, changed our thinking about HRT and menopause:
The relatively older women in the study are more likely to have the adverse outcomes which are worrisome - breast cancer, heart disease, stroke, and so forth - simply because of their age.
The study (The Women’s Health Initiative) is excellent science from which we have learned and continue to learn. It is clear that one aspect of the study’s design has substantial implications regarding how we view the information and recommendations that were released from the WHI preliminary information. Women in the WHI study (and in the other major study, the HERS or Heart and Estrogen/progestin Replacement Study) were enrolled and either started therapy with estrogen or estrogen and a progestogen, or did not have therapy (i.e., the “control” patients) a decade after menopause on average. As you will see, most of the indications for HRT are in women starting to be symptomatic before menopause (the “perimenopause”) or in the first years of menopause. In addition, the relatively older women in the study are more likely to have the adverse outcomes which are worrisome - breast cancer, heart disease, stroke, and so forth - simply because of their age. As a general case, it is difficult to ascribe the same concerns for all women from information about women given HRT ten or more years into menopause as compared to women given HRT in the years before menopause or during the early years of menopause (a group not studied in the WHI study).
What can you take from this data to help in your decision-making? The present cautions may not fully apply, in general, but most especially for you as an individual. This underscores the tremendous importance of a complete evaluation of your individual health so that you can weigh the benefits for you against the risk for you – this is called a “risk-benefit ratio” and it is the task you and your physician or nurse practitioner will complete before you decide about HRT.
Sleep and mood:
- Hot flashes and “night sweats”
- May be mild, or may be extremely severe and actually disabling.
- Hot flashes (vasomotor symptoms) are the primary indication for HRT
- HRT is very effective, even in small doses, and the present recommendation is the smallest possible dose giving good results for a few years - one to perhaps two or three years.
- Hot flashes “go away” in many women in a few years, but persist in some for many years.
Vaginal health, libido, and sexuality:
- The quality of sleep is disturbed by hot flashes, and improved as they are lessened or eliminated with HRT.
- Sleep and mood may be directly influenced by estrogen and/or progesterone, but the relationship is not sufficiently understood to consider direct therapy.
Mental function (“cognition” & depression) and Dementia:
- Vaginal (and vulvar) symptoms of estrogen deficiency (vaginal dryness, painful intercourse, and an associated vaginitis (atrophic vaginitis) may be mild to severe, and all respond to HRT. Note: if vaginal dryness is your only symptom, a local estrogen product may be a better choice than a pill - this is called “systemic therapy.” The exception is if you have a uterus, you may not need a progestogen if you only use a topical vaginal preparation – discuss this in detail with your physician or nurse practitioner.
- Pain during intercourse and vaginitis may have other causes and are another example of the need for a general evaluation before starting therapy.
Osteoporosis: Bone strength and the risk of fracture:
- The evidence about HRT protecting or decreasing “cognitive dysfunction” is not sufficient to recommend HRT although it is also not sufficient to suggest the converse - it is just an area that needs more research.
- HRT has been suggested as a direct, or supplemental therapy for depression, but there is no evidence to support its value at this time.
- A note specifically about the tragedy of Alzheimer’s disease. It is so human to “try some estrogen” when faced with this horrible disease, but right now there is just no evidence to suggest it can help.
Coronary Heart Disease:
- There is excellent evidence that HRT reduces the risk of bone fracture associated with the weakening of bones (osteoporosis), hence, it is indicated. However, there are other medications that act by other mechanisms, which should be considered on an individual basis - either in the place of HRT or in addition to it.
- And, remember the “THREE LEGGED STOOL” of good bone health: calcium, weight control, and exercise. For all women in all situations this “stool” is helpful.
There are no high level scientific studies that show a clear benefit of HRT in the prevention or reduction in risk for heart attack (coronary artery disease); although research is being conducted because some preliminary studies suggest that there may be a benefit for women who start HRT in the perimenopause. However, at this time there is no indication for HRT for this purpose.
We know now that there is an increase in the absolute risk of breast cancer for all women using HRT for more than five years. However, this information must be qualified by knowing that there are yet no good studies comparing HRT in perimenopausal women, early menopausal women, late menopause women, or in estrogen alone or estrogen and progestogen. So, the decision about HRT when considering the issues of breast cancer must be individualized, including family history (greater family history suggest higher risk), physical examination, and mammography.
There are some excellent websites that provide additional information: www.acog.org (website of the American College of Obstetricians and Gynecologists, Women’s Health Specialists) and www.menopause.org (North American Menopause Society, clinicians and scientists of all kinds dedicated to research and the comprehensive care of women entering and in their menopausal years). Remember, whomever helps with your healthcare - OBGYN, Family, or Internal Medicine Physician or Advanced Practice Nurse - should never object to your questions or try to avoid or answer your questions incompletely; if one does, I suggest you find someone else to help with your care.
Like everyone else, you modern women are unique; and your answers about the use of HRT are as unique as are you are.
Have a long and good life, ask good questions, and require good answers!
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"Hormone Replacement Therapy… is it the right choice for you?"
Dr. Beckmann is a professor of obstetrics and gynecology in Philadelphia specializing in ambulatory womens health care and medical and health professions education, and is the author of many articles and abstracts and half-a-dozen books, including Ob...