Smart Woman Online

Hormone Replacement Therapy: Is it for you?

November 16, 2007
By Dr. Vicki A. Lucas, PhD, RNC
Photography by Fred Sweet

When research connected Hormone Replacement Therapy (HRT) to an increased risk of breast cancer, heart disease, stroke and blood clots several years ago, women across the country threw out their pills. Now, research indicates they might have overreacted. It appears HRT can help and hurt. Let’s try to sort out the issues.

HRT is used to treat menopausal symptoms such as hot flashes, vaginal dryness, sleep disorders, mood swings and bladder symptoms. It is prescribed in two forms: estrogen and progesterone combination therapy for menopausal women who have not had a hysterectomy, and estrogen alone for those without a uterus.

The Women’s Health Initiative is a long-term research project funded by the National Institutes of Health to study the effects of HRT on menopausal women. When the study began in the early 1990s, approximately 40 percent of menopausal women nationwide were taking HRT. The research studied four groups of women: one group took estrogen alone, a second group took the estrogen and progesterone combination, a third took only calcium and vitamin D, and the fourth used exercise and diet to manage menopausal symptoms.

The estrogen-progesterone portion of the

study was abruptly halted in 2002 because researchers found that the combination drug increased the risk of breast cancer, heart disease, stroke and blood clots. The estrogen-only study was stopped in 2004 because of an increased risk of stroke.

That’s not the end of the story, though. The estrogen-progesterone group also saw a decrease in osteoporosis, fractures and colon cancer. In addition, the increased risk of breast cancer was associated with the amount of time spent using estrogen-progesterone; the risk of breast cancer decreased with its discontinuation. Breast cancer rates have declined by 5 percent annually as estrogen-progesterone use has fallen off.

The estrogen-only group demonstrated that estrogen alone may reduce the risk of heart disease, especially in younger women who have had hysterectomies. (Research is now being done, and the results look promising.) The estrogen-only group also saw a neutral effect on colon cancer and demonstrated fewer breast cancer cases and fewer women with fractures. (Refer to Table 1 for a summary of the study findings.)

So what’s a woman to do with all this conflicting and controversial information? The prevailing view of the Food and Drug Administration is that women with troublesome menopausal symptoms should take the smallest dose of HRT for the shortest time possible to gain and maintain relief.

What about alternative therapies: Do they work and are they safe? Because very little research has been done on their efficacy and safety, the conventional wisdom is to not use them or to use them under the guidance of a health care provider.

The alternative therapies fall into three major categories: bioidentical hormones, botanicals and DHEA. (Refer to Table 2 for a list of these treatments.) Bioidentical hormones are custom-mixed formulas containing hormones that are chemically identical to those made by your body. The North American Menopause Society does not recommend these custom-mixed formulas over well-tested, FDA-approved commercial products such as natural estrogen, which is marketed as Estrace, the Climara patch and the Vivelle-Dot patch, and natural progesterone, which is sold as Prometrium.

Botanicals are phytoestrogens, plant products that contain substances that act like estrogen in the body. There is very little scientific evidence to support the safety and efficacy of botanicals in the treatment of menopausal symptoms. If women use these products, they must do so with caution and in collaboration with their health care providers. Botanicals may interact with other medications or place women at risk for diseases or conditions affected by hormones.

DHEA is a naturally occurring substance that is changed in the body to the hormones estrogen and testosterone. It is manufactured as a dietary supplement. There is no scientific evidence to show the safety or efficacy of DHEA in the treatment of menopausal symptoms.

The newest options in HRT are the FDA-approved medications Evista and Tamoxifen, which affect estrogen receptors in the body. Evista reduces the risk of osteoporosis and has been found to reduce the risk of breast cancer in menopausal women by 50 percent to 90 percent. Tamoxifen is currently the only FDA-approved drug for the prevention of breast cancer. Treatment is limited to women with a strong family history of the disease.

The goal of HRT is to alleviate troublesome menopausal symptoms and prevent age-related diseases with as few risks and side effects as possible. Unfortunately, we have not yet found the magic pill. The best we can do is work collaboratively with our health care providers, using the current state of knowledge, to individualize HRT to meet our needs. Last but not least, it is critically important that women maintain healthy lifestyles: exercise, good diet, weight control, no smoking and minimal alcohol intake.

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