To To HRT or not to HRT? The debate over hormone replacement therapy is one that has confounded doctors, confused the menopausal, and, ultimately, jeopardized the health of millions of women. Not on my watch! So buckle up and get ready for a crash-course in all things hormone replacement therapy!
First, let's get something straight: Most of the confusion out there isn't the spawn of some evil plot. It's simply about the misinterpreted findings of one landmark, long-term study called the Women's Health Initiative (WHI). The study examined estrogen and combination hormone therapy use among menopausal women to establish their effects on women's most common causes of death, disability, and poor quality of life--cardiovascular disease, cancer, and osteoporosis. However, the study ended prematurely after an interim review found an increased risk of adverse health events associated with combined hormonal therapy of conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA).
Published in July 2002, results from the study led to a rapid drop-off in the use of estrogen by menopausal women, even though the findings included women who were taking estrogen and progestin together, not estrogen alone. Within 18 months of publication, half of the women who had been using menopausal hormone therapy stopped, according to Dr. David L. Katz, Founding Director of the Yale University Prevention Research Center and author of Disease Proof. Currently, less than one-third of hysterectomized women are using estrogen to manage their symptoms.
While the study wrapped up more than a decade ago, continuing research shows that there were holes in its findings--potentially life-threatening holes. A follow-up analysis in 2004 showed a reduction in mortality risk among WHI participants who had undergone hysterectomy and were treated with estrogen alone. What's more, another follow-up review of the WHI in 2011 confirmed a decreased mortality risk of 13 per 10,000 per year among women 50 to 59 with hysterectomies who took estrogen. It also found that estrogen decreased rates of breast cancer and heart attacks by 23 percent and 50 percent, respectively.
Meanwhile, results from the Kronos Early Estrogen Prevention Study (KEEPS)--a four-year clinical trial examining how low-dose oral and transdermal hormone therapy affects the risk of heart disease in healthy, newly menopausal women--were published in 2012 and found that estrogen/progesterone treatment started soon after the onset of menopause relieves many of the symptoms of menopause while improving mood, bone density, and several markers of cardiovascular risk. According to KEEPS, heart disease is to blame for 45 percent of all deaths among women. Still, prescriptions for all types of hormonal therapy have continued to decline, according to Dr. Katz.
Most recently, research conducted by Dr. Katz and colleagues, which was published in the American Journal of Public Health showed that tens of thousands of relatively young women who have undergone hysterectomies are dying because of an overgeneralized fear of hormone therapy stemming from the WHI. "Published data from the WHI showed a decisive survival and health benefit for women who had undergone hysterectomy and took estrogen replacement in their 50s," says Dr. Katz, who notes that roughly eight million women age 50 to 59 in the United States today have undergone a hysterectomy.
Still, the WHI data also showed that the effects of hormone therapy vary considerably with the age of the women taking it, along with the inclusion or exclusion of MPA. However, that variation was not expressed in the original results and the publicity that followed. In fact, while the average woman who participated in the WHI was far past menopause and 63 years old--and 70 percent of the women in the study were over 60--the harmful effects the researchers found was expressed as being representative of all menopausal women. When the data was later divided by the age of the participants, the results were much more positive for younger women who were newly menopausal. Luckily, we now understand that if hormone therapy is started at the onset of menopause, the risks involved are much lower. The results of hormone replacement therapy vary widely between newly menopausal women and those who start treatment a decade or more after the onset on menopause, says Dr. Katz.
Also, the WHI only studied one kind of hormone therapy, and one that is not widely used anymore. The trial only studied HT that contained conjugated equine estrogens (yes, hormones from horses!) and medroxyprogesterone acetate (MPA). When the study started back in 1991, this was the most common form of therapy. It seems that equine estrogen may differ enough from the human variety to have different effects on the body, while as a fairly high-potency synthetic progesterone, MPA, is apt to induce side effects that aren't seen in women taking the bioidentical equivalent. Conjugated equine estrogens also carry a higher risk of heart attack, venous thromboembolism, and blood clots than do oral estradiol, according to a new study from the University of Florida College of Medicine-Jacksonville.
I recently attended the North American Menopause Society 2013 Convention in Dallas. Here is their latest, "Global Consensus Statement on Menopausal Hormone Therapy."
The delivery system is also important to consider. All of the women in the WHI received oral conjugated equine estrogens. In contrast, transdermal bioidentical HT (It's identical to what your body--not a horse--makes! I, for one, hate eating hay!) is delivered through systems such as patches, sprays, and gels and absorbed directly through the skin into the bloodstream and is not metabolized by the liver. Transdermal estrogens do not appear to increase the risk of blood clots that can lead to strokes and heart attacks
Other studies to consider:
Estrogen and Thromboembolism Risk Study (ESTHER): A French study of postmenopausal women evaluated the risk of venous thromboembolism (VTE) in those taking oral estrogen therapy versus transdermal estrogen. Researchers concluded that oral, but not transdermal, estrogen is associated with an increased VTE risk. The women who took hormones in pill-form were four times more likely to suffer a serious blood clot than those who used transdermal delivery systems.
The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial: PEPI was a three-year, multicenter, randomized, double-blind, placebo-controlled trial performed with 875 healthy postmenopausal women between the ages of 45 and 64. Researchers concluded that estrogen alone or in combination with a progestin improves lipoproteins and lowers fibrinogen levels. Estrogen with natural bioidentical progesterone has the most favorable effect on HDL-C and comes with no excess risk of endometrial hyperplasia.
Unfortunately, there is no one size fits all answer to the question, "To HT or not to HT?" "Hormone therapy is not right--or safe--for everyone, but neither is forgoing hormone therapy," says Dr. Katz. The effects of treatment vary with each individual, and it's important for women and their perimenopause and menopause specialists to discuss those individual factors.
No matter whether you prefer calling it HRT, HT, or MHT--it's best to base your healthcare decisions on facts instead of fear! Together with your healthcare professional, have an open conversation about your health history, quality of life, and your individual set of pros and cons. Then you can be sure your answer is the right one for the health, happiness, and life you deserve!
Suffering in silence is OUT! Reaching out is IN!
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