Life Update + Is HRT Right for You?
Is HRT Right for You?
Hormone therapy for menopausal symptoms can be a good medical option — it's just not for every woman. Here's what you need to know before you decide what's best for you.
By Katherine Lee
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For decades, starting in the Fifties, doctors routinely prescribed hormone replacement therapy (HRT), also referred to as menopausal hormone therapy (MHT), in the form of oral or topical medications containing the female hormones estrogen and progesterone, and sometimes estrogen alone. This was done primarily to alleviate symptoms of menopause, such as hot flashes and vaginal dryness, as well as to ease problems of concentration and mood swings. It was believed that replacing estrogen and progesterone also helped protect menopausal women against heart disease and osteoporosis, and that it could help women feel and look more youthful.
HRT: A Question of Risk
In 2002 a large-scale study called the Women's Health Initiative (WHI) suggested a possible link between hormone replacement and an increased risk for breast cancer and heart disease. This wasn't completely a surprise: Previous observational studies had suggested an increase of breast cancer with hormone therapy use and a study conducted in 1998 exclusively involving women with a history of heart disease had led researchers to conclude that within this group, hormone therapy given in the early phase of treatment could pose an increased risk of heart-related problems. The WHI study, however, was the first to link possible adverse health effects to the use of HRT among generally healthy women.
According to the WHI study, women taking estrogen and progestin (a synthetic progesterone) were 26 percent more likely to get breast cancer than women not taking hormones, and 29 percent more likely to suffer a heart attack. HRT was also found to increase stroke risk by 40 percent, and to double the risk of blood clots. As a result, the trial was stopped immediately amid front-page headlines. In the ensuing confusion about HRT, many women and even some doctors opted against hormone therapy entirely.
Six years later, attitudes about HRT seem to be readjusting, a trend that concerns some experts even as others applaud it. Mounting evidence now suggests that HRT may indeed be safe and beneficial for healthy women who are in the early stages of menopause, and HRT is therefore being considered a sound treatment option again by many doctors.
"As researchers examined data from numerous studies on HRT — including the WHI — it became clear that the risks were overstated and misunderstood," says Rogerio Lobo, M.D., a professor of obstetrics and gynecology at Columbia University and a leading expert on menopause who has helped author guidelines on hormone therapy for various organizations, including the North American Menopause Society. He points out that the women in the WHI study were older — in some cases as much as ten years past menopause — when they first started taking hormones, and that many already had risk factors for heart disease, such as obesity and high blood pressure. As for HRT affecting breast cancer risk, new research suggests that limited-term use of hormone therapy (five years or less) at recommended dosages, which are one-half to one-third those given ten years ago, may not increase the risk for breast cancer, especially when compared with other breast cancer risk factors, like obesity. And while some research has suggested that a decrease in breast cancer rates in recent years may be linked to decreased use of HRT, Dr. Lobo says there may be other explanations, such as a reduced rate of mammography among women living in the United States.
The key lesson learned from these revised analyses, say experts, is the importance of individualization. "Not everyone should have one therapy," says Dr. Lobo. In other words, while certain segments of the population may benefit from hormone therapy, HRT isn't for every woman.
On the other hand, some experts argue that HRT still poses enough risks that it should be a last-recourse treatment, if used at all. "While it's true that the absolute risks for heart disease and stroke are low among younger women, there's still the question of whether or not one should choose any drug that may pose any additional risk for serious illnesses, such as heart disease and breast cancer, as well as side effects ranging from incontinence to breast tenderness," notes Marcia Stefanick, Ph.D., chair of the WHI steering committee and a professor at the Stanford University School of Medicine. Moreover, says Dr. Stefanick, some evidence indicates that HRT may in fact prolong symptoms of menopause. "Research shows that between 25 and 40 percent of women go back on HRT after the currently recommended period of three to five years because their symptoms are so bothersome," she says. "Most women get past menopause within two years, so the drugs may in effect be prolonging symptoms after initially providing relief."
So what does this mean for women considering HRT? Here's what's known today:
Timing: Important for Heart Disease
Hormone therapy may reduce the risk of heart disease if it is initiated early in menopause, when the heart is more likely to be healthy. But it may increase the risk of heart disease if started late in menopause, when atherosclerosis, a disease that causes blockage of the arteries, may be present. Nevertheless, JoAnn Manson, M.D., a professor of medicine at Harvard Medical School and an Everyday Health menopause specialist, believes that HRT should be primarily regarded as an option for treating significant symptoms of menopause and not as a method of heart disease prevention.
Dosage: Less Is Better
For most women, doses that are fully one-third to one-half the amount deemed necessary a decade ago are just as effective in relieving menopausal symptoms. This is significant because new analysis reveals that breast cancer risk was more of a concern when the traditional higher doses of estrogen and progesterone were taken for more than five years. Today's reduced doses of estrogen-only hormone therapy appear to only slightly increase risk, according to Dr. Lobo.
Effectiveness: Targeted for Menopausal Symptoms
Studies have shown that hormone therapy relieves hot flashes and vaginal dryness. "HRT is still an appropriate option for healthy, younger women with moderate to severe symptoms that are serious enough to interfere with sleep and quality of life," says Dr. Manson.
Eligibility: Who Should Consider HRT?
- Women whose symptoms are serious enough to interfere with daily routines.
- Women younger than age 60 or within ten years of onset of menopause.
- Women who are healthy, with no history of heart disease, breast cancer, or diabetes.
Ineligibility: Who Shouldn't Use HRT?
- Women with
- Heart disease
- History of blood clots
- History of breast cancer
- Only mild menopausal symptoms
Progestin or estrogen can be delivered in a number of ways:
Pill:Preferred by most women in the United States because of its convenience and ease of use.
Transdermal patch:Associated with lower risk of blood clots than oral hormones, which go through the liver, affecting the liver's production of clotting factors. Downside: Some women experience skin irritation.
Vaginal ring:Similar to a diaphragm, the ring is inserted into the vagina for extended periods of time.
Vaginal cream, gel, or suppository:Effective for vaginal dryness but only a local remedy; doesn't treat hot flashes.
Alternatives: Options Other Than HRT
Discuss your particular situation with your health care provider. If hormone therapy is not the best choice for you, any of the following may be suggested:
- SSRIs (selective serotonin reuptake inhibitors).Traditionally prescribed as antidepressants, SSRIs can be used before or after menopause to treat hot flashes. They may also relieve irritability and boost mood.
- Antihypertensives.Prescribed to treat high blood pressure, this class of drugs can help protect against heart disease.
- Statins.Prescribed to help keep cholesterol low, these drugs thus protect against heart disease and possibly stroke.
- Gabapentin.This antiseizure medication has been shown by some studies to reduce hot flashes by 30 to 40 percent.
- Osteoporosis drugs.These medications can help improve bone health; they include bisphosphonates, such as Fosamax (alendronate) and Actonel (risedronate), and selective estrogen receptor modulators, such as Evista (raloxifene),
- Alternative medicine.Some pilot studies have shown that acupuncture, meditation, restorative yoga, and trigger-avoidance may help alleviate menopausal symptoms for some women. A few small studies have shown herbal remedies and soy products containing isoflavonoids — plant-based compounds that contain weak, estrogenlike substances — to have a limited degree of benefits, while other studies have found them to be no more effective than placebos, says Dr. Lobo. "There can be a powerful reduction of symptoms with placebos, but this effect is not sustained with time," he notes. Before you try any alternative therapies, be sure to discuss them with your doctor.
- Lifestyle changes.You can also help alleviate and prevent hot flashes by dressing in light, removable layers, opening windows or using air conditioning to keep the temperature comfortable, and avoiding spicy foods. Regular exercise has also been shown to reduce hot flashes (and prevent weight gain and depression).
Video: How hormones (HRT) change a trans woman’s body | Riley J. Dennis
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