Women: Take a New Look at Hormone Therapy

Let’s talk about hormone therapy for menopause.

It’s not always easy to do that. Consider, for instance, my cardiologist’s reaction when I asked if my heart would benefit from the estrogen therapy I had begun a year earlier.

He couldn’t say. Despite years of studies that explore the link between cardiovascular health and menopausal hormone therapy, he said he had stopped trying to discuss the subject with patients. The issue had grown too polarized in the medical community.

“It’s like Republicans and Democrats,” he said. “The two sides won’t even talk to each other.”

As unhelpful as that sounded, I left his office somewhat relieved. It explained why I and many other women for the past decade have been so confused as we tried to get clear-headed, down-the-middle talk from our doctors about using estrogen to manage the bothersome symptoms of menopause.

If we aren’t skulking to practitioners who enthusiastically tout the benefits of compounded “bioidentical” hormones (ones that have a chemical structure similar to human estrogen or progesterone) then we might be enduring well-intentioned but insensitive comments from doctors urging us to wait out the uncomfortable symptoms — for years, if we can.

When I first complained to my family doctor, he told me proudly that his post-menopausal wife had never taken hormones despite eight years of hot flashes. “She just has her fan,” he said.

That, frankly, was not helpful.

No one is to blame, really. Doctors have simply been erring on the side of caution since 2002. That’s when the emergency brake was pulled on menopausal hormone therapy after a large, decade-long study of 161,808 women as part of the Women’s Health Initiative (WHI) reported that estrogen plus progesterone significantly increased the risk of heart attack, stroke, blood clots and breast cancer.

Prior to that, estrogen therapy was more widely recommended as a way to improve the bothersome symptoms of menopause — particularly hot flashes — as well as a hedge against osteoporosis and even cardiovascular disease or other age-related health issues, as some studies had suggested.

But after the initial WHI results, patients and doctors did a U-turn. In 1999, an estimated 20 percent of menopausal women were taking some kind of hormone therapy; today, that has dropped to less than 5 percent.

“Most patients and doctors swung in the other direction,” said Dr. Margery Gass, a practicing gynecologist and executive director of the North American Menopause Society, also known as NAMS.

“If you’re taking something you had no symptoms for, and it was supposed to keep you healthy, and all of a sudden you say, ‘Oh there’s some breast cancer, there are some strokes, blood clots in your legs and lungs.’ You think, ‘Why should I take this?’”

More than a decade later, however, most researchers agree the WHI study’s initial results were incompletely reported.

Importantly, the study did not break down the results by age group within the span of ages 50 through 79. It turned out those increased health risks applied only to women in the older age group, particularly for those who began taking hormones over age 60 and had more than 10 years since their last period.

“In retrospect, and everyone admits, there was a lot of misinformation, unnecessary extrapolations, fearmongering and so forth,” said Dr. Roger Lobo, a practicing reproductive endocrinologist and professor at Columbia University. The backlash, he said, suddenly stranded women suffering from difficult menopause symptoms.

“A whole group of women over the span of maybe 10 or 15 years were just afraid. They couldn’t find providers who were comfortable doing it [hormone therapy],” Lobo said. “But in fact, there was no evidence any harm was rendered by doing it, and they have a lot of gain in terms of benefit of relief."

What’s worse, Lobo argues, is that doctors educated since 2002 aren’t knowledgeable about hormone therapy, making it even harder for ailing women to get help.

NAMS’ Gass agrees that doctors sometimes avoid discussing hormone therapy because of time constraints or lack of expertise. Even so, she encourages women with questions to seek professional help, preferably from a gynecologist or, even better, one who has been certified by her organization in menopause care.

While getting an appointment may be easy, it's trickier to figure out if you should even consider hormone therapy as an option.

Here are five questions to ponder:

No one disputes hormone therapy can offer healthy, relatively younger women relief from the worst of menopause’s symptoms. Chief among those are hot flashes, which affect about 75 percent of women, and “genitourinary syndrome,” vaginal and urinary discomfort affecting 45 percent of women.

“The best use of hormones is for treatment of menopausal symptoms that are bothering women,” Gass said, and “bothering” is the key word. Only 20 percent of women who get hot flashes report them as disruptive, she said.

“If they are bothersome to her, then that’s worth treating,” Gass said. “It’s really a personal reaction.”

To treat hot flashes, estrogen needs to get into the bloodstream with oral medication or transdermal patches. Such “systemic” estrogen must be combined with progesterone for women with uteruses to offset the risk of endometrial cancer.

Vaginal or urinary discomfort can often improve with localized estrogen creams, tablets or vaginal rings.

One thing is clear: Don’t wait years to act. The risks of hormone therapy are lower for women in a “window of opportunity,” generally under age 60 and no more than five years since menopause.

It’s also important to know what’s risky for you. Even if you are in the younger group, you still should not take estrogen if you have a history of cancer, blood clots, diabetes or established cardiovascular disease. Side effects are also possible, including breast tenderness, headaches or breakthrough bleeding, which must be monitored closely by your doctor.

For healthy women, most doctors follow the Food and Drug Administration (FDA) recommendation that to eliminate risks, women should only get the lowest dose of estrogen therapy for the shortest period of time to relieve symptoms, said Judy Hannah, a clinical research specialist with the National Institute on Aging who has advised on menopause research.

“No physician wants to put a patient at risk,” Hannah said. “But it’s a different situation if you’re helping a woman who has severe hot flashes get through a year or two with medication, with an estrogen product.”

This is where things get tricky and contentious. As Hannah says, when it comes to other health benefits from estrogen therapy, the medical community is “a very divided camp.”

If you have a family history of weak bone density, or osteoporosis, the evidence is clear: estrogen therapy can prevent that as you age, although other drugs are also effective.

But if you’re crabby or foggy-headed from menopause, the evidence is mixed. One study released in early June showed no impact on mental sharpness, yet a discernible improvement in mood — but only for those who took estrogen pills versus patches.

The strongest debate is whether long-term hormone therapy, begun early in menopause and continued for years, can prevent age-related illnesses, including cardiovascular disease.

An influential 1998 study of women (with an average age of 67) showed no impact of estrogen therapy on heart attacks, despite a notable improvement in related cholesterol levels.

But a 2012 review of more than 40 studies during the past five decades, shows an average 40 percent reduction in coronary artery disease when hormones are started for a healthy woman within 10 years of menopause and continued for at least six years.

For now, however, the FDA does not recommend using estrogen to prevent heart attacks. And many researchers say it’s still debatable whether these results are worth the risks shown in earlier studies, although estrogen therapy can be part of an overall strategy for reducing cardiovascular disease.

Adding to the confusion are doctors who go beyond the bounds of scientific evidence, touting the benefits of so-called bioidentical hormones created in compounding pharmacies, where the products can vary in dosage or purity. (The FDA, incidentally, does not acknowledge the term bioidentical.)

Bioidentical hormones are typically made from plants, such as soy or yams; hormones used in the WHI study, as well as every other peer-reviewed study, were derived from horse urine.

No study has looked at the safety or effectiveness of so-called bioidentical therapies versus other estrogen products, Gass said.

Still, at least one-third — and possibly as many as two-thirds — of women who use hormones during menopause say they use bioidentical hormones from compounding pharmacies, according to two surveys reported earlier this year in the journal Menopause. The surveys also showed that many women don’t understand the risks of compounded products, which are overseen by states and not regulated by the FDA.

For women who do want a chemically identical hormone, the FDA has approved forms for both estrogen and progesterone. So there’s no need for a compounding pharmacy to make them, Gass said.

Not every woman wants to dive into the risk-benefit confusion of estrogen therapy. The good news is that options may exist.

Some antidepressants have been shown to reduce hot flashes. And under the auspices of a National Institutes of Health research effort called MsFLASH, researchers have also found modest benefits from yoga, exercise and sleep.

Gass said general stress reduction can also make a difference. Studies have shown women are more bothered by hot flashes if they also have other stresses in their life, she said.

“And that’s not surprising,” Gass said. “Whenever we have a lot going on, adding one more thing can be the straw that breaks the camel’s back.”