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Confused? That’s understandable – many people believe that HRT is no longer an option for women in menopause due to early findings from that very same study. In a nutshell, here’s what we know.
In 2002, federal health officials took the unusual step of stopping one part of a multi-year major national study of hormone replacement therapy early because a review of preliminary data found increased health risks for women using the hormone combination of estrogen and progestin, compared with women receiving a placebo. Specifically, the women using the combination hormone had a 26 percent increase in breast cancer, a 29 percent increase in heart attacks and a 22 percent increase in total cardiovascular disease.
Although this was only one branch of the research– and despite the fact that there was no evidence that estrogen alone increased these risks (and in fact that branch of the study continued) – the public reaction was swift.
Nationwide, many doctors and their patients discontinued the use of hormones for menopause symptoms. For hundreds of thousands of women, this was no mere inconvenience or irritation. Menopause symptoms can be quite profound and disruptive: from hot flashes, weight gain and bone loss, to memory loss and depression, each woman’s experience is individual and for some, quite severe – years ago, some women were institutionalized due to behavior that developed in menopause.
While there are other ways of managing menopausal symptoms, HRT has over the past few decades provided a seemingly simple and cost-effective way of addressing many of them.
Taking a Second Look at the Study
As in all studies, however, there were many unanswered questions, because researchers deliberately study only very small, specific pieces of data in order to control the variables involved. In this branch of the overall study, they studied only the estrogen-progestrin (Prempro) combination. What about other hormone combinations? What about women who had hysterectomies or those who were pre-menopause, or those who used a single hormone, who used a patch, topically applied hormone, or bio-identical hormones?
These specific circumstances weren’t part of this study, yet when the announcement was made regarding the results of the Prempro combination, it was widely perceived to apply to all women and all hormone applications.
Now, in an interesting twist on the original announcement, we have learned something else. In the five years since this study on Prempro was discontinued, researchers have not stopped analyzing the data it gathered. In particular, they have followed up on several age groups of participants and found interesting and potentially important differences between them.
Published in April, 2007, in the Journal of the American Medical Association, the analysis showed that women who were in their early 50s when the study was initiated, and who took a combination of estrogen and progestin, or estrogen alone, had a 34% lower risk of cardiac disease than women in the same age group who didn’t take hormones.
However, women who were ten to 15 years older at the outset of the study had much different results. They were far more likely than non-hormone users in their age range to have a heart attack. This seems to imply that women in their 50s can benefit from hormone replacement therapy, including having fewer heart attacks and strokes. By age 60 or 65, however, the benefits of HRT are far less obvious, and, may not be a good choice.
To Take Hormones or Not: Now That’s the Question
The Hormone Replacement Therapy debate and the release of seemingly conflicting conclusions from the same study five years apart is confusing, not only for patients, but for their doctors, as well.
At Sound Family Medicine, we think it helps make one thing perfectly clear, however: it’s essential that you talk with your health care provider about your specific health care needs and background. General recommendations are only that. Different women have different health histories and the severity of their menopausal symptoms may vary also.
Although the recent announcement focused on the age of the patient, it’s certainly not the only way to gauge whether to use HRT. Any family history of cardiovascular disease should be discussed with your doctor. And because all hormones can slightly increase a risk of breast cancer, hormones may not be a good option if there is history of cancer in the patient’s family. If a woman has had a hysterectomy, the extent of her surgery will help determine which type of hormones she should use.
A benefit of the HRT debate is that it has encouraged doctors and women to consider other alternatives. Although the latest information indicates it’s helpful for some women to use HRT, it’s also very clear that not every woman should do so. Hot flashes can be treated with anti-depressants. Self-care, including exercising regularly and eating a healthy diet, is also very important. Nutritional supplements, such as certain oils and fats may be helpful, and women have reported relief from some alternative treatments, including acupuncture.
Some women have used bio-identical hormones, a series of different self-administered creams and drops that relieve menopausal symptoms, very successfully. If you are considering their use, be aware that they are not yet FDA approved. They are also expensive compared to the FDA approved hormones, because they are personalized for each person and are compounded by a pharmacist. This option should be discussed thoroughly with you doctor.
What about Younger Women Who Have a Hysterectomy?
Women who have had hysterectomies generally take estrogen without progestin, although the type of hormone prescribed for a woman in this situation depends in part on the type of hysterectomy required. (The surgery may involve the removal of the uterus only or may also include the removal of the ovaries.)
Because the ovaries produce the body’s natural hormones, their removal causes the body to go into instant menopause. Doctors will generally provide a HRT patch to the patient before the hysterectomy is done to reduce the shock to the patient’s body.
In another branch of the same major national study, researchers are still studying estrogen-alone drugs used by women who have had a hysterectomy. The Women’s Health Initiative (WHI), which is conducting the study, has not stopped that portion of it, because the evidence has so far shown neither an overwhelming risk nor an overwhelming benefit.
Whether you are moving forward into your menopausal years, or expect to have a hysterectomy, this can be a confusing and frustrating time. Your health care provider can share the latest information about menopause and hysterectomies, and ways to reduce or eliminate your symptoms.
Especially given the latest research, you may want to consider hormone replacement therapy. If hormones are prescribed for you, remember to take them on a regular schedule, at the same time every day. Ideally, hormone replacement therapy should be used only for a limited time, up to 5 years, for control of hormone deficiency symptoms. If a woman is able to tolerate stopping the hormone replacement therapy by age 60, she will avoid the increased risk of heart disease, stroke, and breast cancer that continued use may cause.
If you have questions, feel free to see Cyd Marckmann, SFM’s residential menopause expert, or your SFM family physician.
Here are some web links that may give you additional information:
http://www.nhlbi.nih.gov/whi/
http://health.webmd.com/cgi-bin21/DM/y/euoP0Hefau0GI08AK0ES
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If
you’re a woman in or beginning menopause, there’s good reason to
talk with your health care provider about options for
alleviating your symptoms – and the most recent news coming out
of a major national study on hormone replacement therapy (HRT)
indicates that hormone use can and should be part of your
discussion.
Mark
your calendar for 