Hormone therapy: An update on risks and benefits

More than 60 years ago, experts found that giving estrogen to women going through menopause could relieve some of the changes associated with this change of life — including hot flashes, night sweats, and vaginal dryness. Later on, replenishing estrogen levels was thought to provide a range of other benefits for women once they no longer produced as much of this hormone naturally. In fact, in the 1980s and ‘90s, doctors often prescribed hormone therapy not only to relieve menopausal symptoms but also to help women prevent chronic conditions such as heart disease and osteoporosis, and improve their quality of life after menopause.

However, that all changed in 2002, when a large clinical trial called Women’s Health Initiative (WHI) reported that older women given a popular therapy combining estrogen and a synthetic form of progesterone (Progestin) had an increased risk of developing heart disease, breast cancer, stroke, and blood clots. As concerns about the health hazards associated with all types of hormone therapy grew, doctors became hesitant in prescribing these medications and many women discontinued taking them.

Today, the news about hormone therapy isn’t quite as alarming. Although it’s no longer recommended that women use it long term to prevent serious conditions such as heart disease, there’s evidence that the hormone estrogen may offer some health benefits for women who take it early in menopause. Estrogen remains the most effective treatment for menopausal hot flashes, night sweats, and vaginal dryness. In short, hormone therapy isn’t all good or all bad. Yet, this fact has left many women more confused than ever. To learn the latest on the risks and benefits of hormone therapy and how this information might apply to you, read on.

Hormones And Menopause

Your ovaries, the two small oval-shaped organs found on each side of your uterus, produce eggs as well as the two female hormones, estrogen and progesterone. During the months or years before menopause — a time known as perimenopause — your body begins to make less of these hormones.

When you reach menopause, your periods stop altogether and your ovaries no longer produce eggs. (Menopause is defined as having no periods for 12 months.) Your ovaries also make much less estrogen and no longer provide your body with any progesterone — the hormone that prepares your body for pregnancy.

Natural menopause happens on average around the age of 51, but can occur anytime between the ages of 40 and 60. However, certain medical or surgical treatments, as well as some medical conditions, can bring on menopause earlier than expected. For instance, a hysterectomy can bring on immediate menopause — if your ovaries are removed along with your uterus during the surgical procedure. In some cases, chemotherapy and radiation, used for cancer treatments, also can cause menopause by damaging ovaries and shutting down hormone production.

No matter when and how you go through menopause, symptoms can result as your body adjusts to the change in estrogen levels. The most common are hot flashes. Lower levels of estrogen can also contribute to vaginal and urinary changes. But that’s not all. Estrogen, or the lack of it, can affect other parts of your body as well – including your skin, blood vessels, heart, bones, brain, and breasts.

Types Of Hormone

Hormone therapy typically involves the use of estrogen with or without progesterone. Women who’ve had a hysterectomy and no longer have a uterus can use estrogen alone. Women who still have a uterus need to take estrogen along with a progestin. This combination prevents the overgrowth of cells in the lining of the uterus (endometrium), a problem that can lead to the development of endometrial (uterine) cancer.

In the past, hormones were typically taken in pill form (oral therapy). This is still a common form of hormone therapy. However, there are an increasing number of other options available for delivering hormones to other parts of the body (locally), such as to the vagina. These include skin patches, creams, gels, sprays and vaginal rings, tablets or creams.

Risks And Benefits

There’s no question that hormone therapy is one of the most effective treatments for severe menopausal symptoms. However, hormones are no longer routinely recommended for women just because they’re in their menopausal years. This is especially true for women who have a current or past history of breast cancer, heart disease, stroke or blood clots.

The reason has to do with the results of WHI — a set of clinical trials that examined the long-term effects of postmenopausal hormone therapy on heart disease, osteoporosis, colorectal cancer, and breast cancer risk. The thousands of women in the randomized trials, which compared specific hormones against placebos, were between the ages of 50 and 79. However, the average age of the women entering the trials was 64.

One part of the trial was halted in 2002. The reason: After about five years, the women who were taking a prescription drug combining estrogen plus progestin had a small but significantly increased risk of heart disease, breast cancer, stroke, and blood clots in the leg (deep vein thrombosis) or lung (pulmonary embolism). Another part of the trial was dropped in 2004. That’s because after almost seven years, the women who were taking only a prescription estrogen had an increased risk of stroke and blood clots.

Nevertheless, hormone therapy did offer some benefits. The risk of bone fractures was reduced in the women taking the combination hormone therapy and in those taking estrogen alone. The risk of colorectal cancer also was reduced in women taking estrogen and progestin. Another major finding was that most of the women who had menopausal hot flashes and night sweats at the start of the study got relief from these signs and symptoms when they started hormone treatment. Today, most experts consider hormone therapy to be a safe and reasonable option for healthy women who are bothered with menopausal symptoms such as hot flashes. In addition, newer research is finding again that hormone therapy may offer women some long-term health benefits when started in the early years of menopause.

Reducing Risks

If you chose however to take hormone therapy, how can you protect yourself from potential health risks? According to data from WHI, it’s important to pay attention to the following:

• Timing. The closer you are to menopause when you take hormone therapy, the less likely you may be to facing serious health risks. For instance, recent research has indicated that women in their 50s who take hormones to relieve menopausal symptoms may not have increased risk of heart disease. In fact, some evidence suggests that estrogen may actually protect the heart when taken within the first 10 years of menopause.

• Dosage. Some menopause symptoms, such as hot flashes, can last for years. But it’s best to use the lowest effective dose for the shortest amount of time.

• Delivery method. Today, with more options to deliver hormone therapy, it may be more effective and possibly safer to apply it directly than orally. For example, estrogen vaginal cream or a vaginal ring is often recommended for menopausal symptoms limited to the urinary tract and genital area, such as vaginal dryness. Direct application of a very low dose of estrogen to the affected tissue can provide relief from symptoms while minimizing side effects.

Tailoring Treatment

When it comes to hormone therapy, one thing is clear: There’s no one treatment that’s right for all women. The only way to determine if hormone therapy is right for you is to talk with your gynecologist about your own menopausal symptoms and your personal risk of such conditions as osteoporosis, heart disease, stroke, blood clots, and breast cancer.

Questions you may want to ask include when to begin, what type and dose are most appropriate for you, the possible health risks and side effects, additional tests or procedures you might need, and the length of time you need to be on hormone therapy. You may also need to review your treatments with your doctor on a periodic basis to make sure they’re still your best option. As researchers learn more and more about hormone therapy and other menopausal treatments, recommendations may change. The types of hormone therapies available and your risk of certain conditions also may change over time. –Tyrone M. Reyes, M.D. (The Philippine Star)