MAKING SENSE OF HRT
Hormone Replacement Therapy (HRT) has been much in the news because of the findings of the WHI (Women’s Health Initiative) study which found some increased risks in one of the groups in the study. This result received enormous play in the media which carried headlines like, “The End of the Era of Estrogen” or “HRT Does More Harm than Good.” Journalists know that scaring people sells. Hardly a woman of menopausal age has not been confused or distressed by these stories. My goal in this newsletter is to present the issues as objectively as possible as an aid in decision-making. There are both good and bad things about estrogen and I will cover both.
One of the problems is that the issues regarding HRT have been cast in a misleading way. There are two kinds of possible benefit to HRT: better long term health and improved quality of life. The medical profession is often uncomfortable dealing with quality of life issues and so has emphasized the supposed long term health benefits, particularly protection from heart disease and osteoporosis. I’ll return to these shortly.
What has left out of most articles about menopause is how women feel at this phase of their lives. Sad to say, the health care establishment has not always considered women’s feeling well to be an issue worthy of its attention. In my view, medicine is more than just keeping people alive; it is also helping them to feel well and enjoy their lives. In my view, both long term health and immediate quality of life are important.
Here is the real issue involved in the HRT decision: Do you need HRT to feel well and function at the level you want? If the answer is no, then there is no reason to take it. On the other hand, if you feel miserable off HRT, then taking it may at least be considered.
What are some of the effects of menopause? The first thing to keep in mind is that there is no single experience of menopause; it is different for every woman who goes through it. Some breeze through and hardly notice that anything is happening. For some others it is a different story: Night sweats interfere with sleep so that one awakens unrefreshed in the morning. Daytime hot flashes are extremely uncomfortable and may be embarrassing at work if noticed by others. Mood swings can be very disruptive in these years.
One of the menopause problems which most distresses women is hardly ever written about: loss of scalp hair (alopecia). The skin changes too, looking thinner and frailer and becoming more sensitive. Some women report that combing their hair is painful or that the sensation of clothes brushing against their skin is acutely uncomfortable. It may even hurt to be hugged.
Here is what estrogen can do: It can stop hot
flashes and night sweats, restore sleep, smooth mood swings, slow or stop hair
loss, make the skin stronger and less sensitive. Some women who decide to take
HRT put it this way: “I feel like myself again.”
Some women lose interest in sex around the time of menopause. While lack of estrogen does not cause a change in sex drive, it does result in the tissues of the vagina becoming not only dryer but also thinner and less elastic. The vagina can actually shrink after menopause. If intercourse becomes uncomfortable, estrogen can often help by making the vagina moister and more resilient. It can also be used in cream form. For others, simply using a lubricant is enough.
Estrogen is involved in brain function and recent studies suggest that when estrogen levels drop, thinking and memory get a little slower. The risk of Alzheimer’s seems to be reduced by taking estrogen. Needless to say keeping one’s mind intact in old age is an important goal. On the other hand, we all know women who have been mentally sharp into their nineties and beyond, despite never taking HRT.
We do! But by one of the ironies of nature, while women’s ovaries stop making estrogen, men’s testicles do not. So men usually have higher estrogen levels than postmenopausal women.
First, there is some bad news. The group discontinued from the Women’s Health Initiative (WHI) study did have increases in certain health risks. They also had decreases in some other risks. All of these results were suspected from earlier studies.
Let’s look at the risks in more detail. The study found slight increases in the risk of invasive breast cancer, heart attacks, stroke and blood clots in the lungs. The risk of each is less than one in a thousand per year. There was a decreased risk of colon cancer and hip fractures. The risk of breast cancer did not start to rise until after the fourth year which is consistent with other studies. This is very important because it means that women can try HRT for a while to see how much it helps without affecting their breast cancer risk. Earlier studies have found that breast cancer in women on estrogen is usually more favorable in prognosis so the death rate is probably not higher. Still, no one wants to have a breast removed. Most women do not know however that drinking an average of two glasses of wine a night increases breast cancer risk as much as does taking estrogen. Yet we do not see magazines announcing the end of the era of wine.
More details on the study statistics are available on line. The Association of Reproductive Health Professionals website has excellent links to these. URL is www.arhp.org/hrtresources.
The study group which was discontinued was not on estrogen alone but on Prempro® which is a combination of conjugated equine (horse) estrogens (Premarin®) and a synthetic form of progesterone called medroxyprogesterone acetate (Provera®) ,abbreviated MPA. Another group is getting equine estrogens alone but, so far as we have been told, is not at increased risk. This raises the possibility that the real culprit is not estrogen but MPA. In fact, its been known for some time that MPA causes a host of other problems such as mood swings. For this reason, about ten years ago I switched to recommending natural progesterone (Prometrium®) in most situations.
Why are women still being prescribed horse estrogens? So far as I can tell, it is only force of habit. The natural version of estrogen, estradiol, has been available for more than a decade and seems a more sensible choice to me. I do have to admit there is another reason I rarely recommend Premarin: as a vegetarian I believe that we should not use medications made from animals unless there is no good alternative.
My own view is that for women who have decided that they do want estrogen, estradiol in patch form and natural progesterone come closest to supplying the hormones in the way the ovary does. Does this mean that there is less risk with this regimen? We don’t know yet; but until more studies have been done, this approach seems to make the most sense.
Be careful about products promoted as natural or bioidentical hormones. Some of these are neither natural nor bioidentical to estradiol. The last thing you want to do is take something when you don’t know what is in it.
First, you need to discuss your HRT decision with a knowledgeable and interested physician. The purpose of this newsletter is to give an overview; I can’t cover everything which might bear on a particular individual’s decision.
Here are some of the major factors to consider in deciding about HRT:
1) If you feel great, sex is comfortable, and your skin and hair are normal, there is no reason to take estrogen unless circumstances change.
2) If you have osteopenia (low bone calcium) or risk factors for osteoporosis, bisphosphonates such as (alendronate) Fosamax® or (risedronate) Actonel® are more effective than estrogen. Another option is Evista® (raloxifene).
Even if your bones are in good shape, taking calcium 1,000 to 1,000 mg per day together with vitamin D 600 to 800 units daily is important for prevention. (These vitamin D doses are safe but megadoses are not. If any doubt, discuss with your physician.) Exercise helps too but exercise and calcium by themselves will not completely prevent loss of bone.
3) For heart disease risk factors, standard measures such as lowering high blood pressure and high cholesterol are appropriate. Estrogen is no longer considered a way to prevent heart disease.
4) If you have the symptoms I discussed above such as:
Night sweats or insomnia,
Frail and/or uncomfortable skin,
Discomfort with intercourse not resolved with lubricants,
then estrogen will probably help you feel better. Whether to take it or not depends on how much your symptoms disrupt your life. Sometimes, but not always, there are other treatments which will work as well as estrogen.
5) Herbs such as black cohosh or soy (tofu or fresh soymilk, not powders or capsules) can be considered for symptom relief. Studies are limited and it is my general impression is that these help mainly those who symptoms are mild.
Here is a vital point to remember: Starting estrogen is not a life-long commitment. Risks rise slowly so you can try it for a few months to see if it really makes a difference for you. You can change your mind at any time. A good way to do this is to reassess at six month intervals.
Despite all the negativity circulating now, many women feel well on estrogen and make the decision to continue to take it. Others decide not to start or to stop. The study told us something that many of us thought anyway: HRT is for some women, not all.
No one should have to decide between feeling better and taking a health risk, however small. Unfortunately, that is where HRT is at the moment. Remember though that the risks, though real, are low – less than one in a thousand. Though I’d like to be able to write something that makes the decision seem easy, I can’t because it is not easy. I’ve done my best here to clarify the medical issues to at least help in the process.
Here are some links to articles on The Hormone Center Website which discuss related subjects:
Help for Hormone Problems
Question of the Month
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