Hormone Relpacement Therapy

WHAT ABOUT HORMONE REPLACEMENT THERAPY?

For years, prescribing estrogen replacement therapy was standard of care for women who no longer produced this hormone naturally, due to surgery or menopause. It was given to treat the symptoms of menopause such as hot flashes, night sweats and disturbed sleep. Some women believed it slowed the normal aging process. Health care providers believed that hormone replacement therapy (HRT) lowered a woman’s risk for certain cancers, heart disease, and osteoporosis because the incidence of these diseases increased after a woman went through menopause. Local estrogen placed in the vagina (cream, tablets or ring) improves the blood supply, decreases atrophy and helps relieve vaginal dryness and painful intercourse. Although not clearly understood, local estrogen may help slow the process of pelvic organ prolapse, and treat stress urinary incontinence.

The Women’s Health Initiative (WHI) study looked at the effects of HRT on diseases such as breast cancer, cardiovascular disease, osteoporosis, and colorectal cancer. The Women’s Health Initiative was a large, multi-center clinical trial that involved more than 161,000 postmenopausal women in their fifties, sixties, and seventies. Women in the study who still had their uterus were prescribed a combination of estrogen/progestin. Women without their uterus were prescribed estrogen alone. In July 2002, NIH stopped a major part of this study early because they found an increased risk of breast cancer, stroke, heart attacks, and blood clots (in the lungs) in the group of women taking combined estrogen/progestin. In May 2003, the WHI found estrogen alone increased a woman’s risk for dementia (severe confusion and decline in memory), including Alzheimer’s disease. More recently, the study also found an increased risk for stroke in the estrogen alone group, similar to what they found in the estrogen/progestin group. Therefore, women in the study who were taking estrogen alone were instructed to stop taking their study pills as of March 2004.

All of a sudden, women who have been advised to take hormones to treat the symptoms of menopause and to protect their heart and bones are faced with a confusing dilemma. Is it safe to continue HRT?

The FDA suggests that hormone therapy should not be taken to prevent heart disease. Short courses (less than five years) of oral HRT are an approved therapy for relief of moderate to severe hot flashes and symptoms of vaginal atrophy such as dryness and painful intercourse. Although hormone therapy is effective for the prevention of postmenopausal osteoporosis, it should only be considered for women at significant risk of osteoporosis who cannot take non-estrogen medications. Women who have taken HRT for more than 5 years are at increased risk for breast cancer, but this risk returns to normal after being off HRT for 6 months. The FDA recommends that hormone therapy be used at the lowest dose for the shortest duration needed to achieve treatment goals. It is not known if estrogen in the form of transdermal patches, estrogen gels, and vaginal creams and rings are any safer than oral tablets. The amount of estrogen that enters the blood stream from estrogen-containing vaginal creams and rings can vary depending on the specific product; how it is used, and on factors that vary from woman to woman. Postmenopausal women who use or are considering using hormone therapy should discuss the possible benefits and risks with their physicians.

Important points to remember:

· Hormone replacement therapy does not prevent heart disease or osteoporosis. There are more effective treatments available for these conditions.

· Hormones are effective in treating the symptoms of menopause such as vaginal dryness, painful intercourse, hot flashes, night sweats, or disturbed sleep.

· There is risk involved in taking oral hormone replacement therapy.

· Hormones should be taken at the lowest dose, for the shortest period of time (less than five years).

· You should discuss your particular situation with your health care provider before deciding to take, not take, or stop HRT.

· There are alternates to HRT Click on the following link to view information on alternatives to hormone replacement therapy.

Websites that offer in depth information about this issue include:

Women’s Health Initiative (www.nhlbi.nih.gov/whi/whi_faq.htm)
FDA (www.fda.gov/cder/drug/infopage/estrogens_progestins/Q&A.htm)
FDA fact sheet (www.fda.gov/oc/factsheets/WHI.htm

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