Hormone replacement therapy
Our perspective on the risks of HRT
by Marcelle Pick, OB/GYN NP
Several years have passed since the publication of the first of the Women’s Health Initiative studies on the risks of HRT. And newer studies regularly appear, mostly adding to the impression that synthetic HRT is dangerous to your health. But confusion concerning the safety of HRT continues to abound. This seems a good time to put some perspective on the findings that caused such concern and confusion — among women as well as among their healthcare providers.
There is no loss of urgency on the issue. Over 13 million women were on some form of HRT before the initial studies were published. Millions quit “cold turkey” and saw their symptoms rebound. Millions stayed on HRT but live in fear of the consequences and hormone replacement therapy side effects. And millions of women have been moved onto antidepressants as pharmaceutical companies have campaigned to position those drugs as substitute products — even though most of these women are not depressed and are thereby exposed to a new set of potential side effects.
While we agree that women should consider alternatives to synthetic HRT, most of the fear and confusion is unnecessary. Let’s talk about both sides of the debate, starting with the point of view that in light of the studies, all HRT is bad and no one should use it.
Before the WHI study, about eight million women who had undergone hysterectomies were on synthetic estrogen replacement therapy, and another six million were on a combination of synthetic estrogen plus synthetic progesterone, as recommended by their practitioners. The great majority of these women were either on Prempro or some other combination of Premarin, and because these were the drug used in the WHI study, it’s understandable that so many felt some combination of fear and panic.
First, note that the majority of studies published to date have concerned synthetic HRT, specifically Premarin and Prempro. Very few have involved or say anything about bio-identical hormone replacement therapy.
Second, the women in the WHI studies were on HRT after menopause, which is most often unnecessary therapeutically and obviously unnatural. The most common therapeutic use of HRT is for perimenopausal symptoms. So we can’t say the WHI studies really predict the health risks for women in their 50’s who are the typical users of synthetic HRT.
Third, there clearly are women who want HRT — even synthetic HRT. We believe they are entitled to make that choice for themselves.
Now let’s turn to the other point of view — those that say HRT should still be considered safe because the absolute risks are small, and, as they claim, there’s no good alternative.
Tips for Personal Program Success
Permission to nurture yourself: Granted. Stress can help create hormonal imbalance. Nurturing self-care can help restore that balance. If, like many women, you spend a lot of your time taking care of everyone else, it’s more important than ever to make time for yourself. Do something to care for your body, your mind and your soul — like getting a massage, a reiki treatment, even taking a nap or hot bath.
First, consider that there is a mountain of evidence indicting synthetic HRT. Alternative practitioners have recognized the problems with synthetic HRT for many years. There are dozens of studies documenting its adverse health risks. In fact, it’s disappointing that it has taken a massive government program like the Women’s Health Initiative to change the standard of care.
Second, while the higher risks are small in absolute terms, the increases in relative risk are significant. To take heart attack as one example, the WHI data taken as a whole indicated that out of 10,000 women on Prempro, an extra six would have a heart attack each year compared to women not on Prempro. That may not seem like a substantial risk. But it is a much greater relative risk.
A newer study at Penn State (June 2005) found that levels of CRP are increased with intake of HRT and oral estrogen. CRP is a pro-inflammatory blood protein associated with increased risk of heart attack and stroke.
The WHI study indicated that the overall increase for women on Prempro for breast cancer was 26%, for heart attack 29%, for stroke 41%, for blood clots 100%, and for Alzheimer’s or dementia, over 100%. Many of the top problems in women’s health are on that list. And even if there is not as great a risk of heart attack as originally supposed for women closer to menopause, the overall risk-benefit ratio speaks volumes (see our press release on the 2007 reanalysis of the WHI data).
Third, there are good alternatives to synthetic HRT. Most women don’t even require hormone therapy. (As one writer put it, saying hot flashes are the result of an estrogen deficiency is like saying a headache is the result of an aspirin deficiency.) But for those who do, we find they generally get better results from bio-identical hormones, for which the safety data — though limited — are far more promising.
I generally recommend that women on Prempro or Premarin consider other options. The foundation should be a program of core nutritional and endocrine support such as Women to Women’s Personal Program. If that is not sufficient to bring relief of your symptoms, or if you are a woman under 40 who has had her uterus or ovaries removed, the option is to overlay a compounded form of estrogen and progesterone that is bio-identical to the formulation found naturally in the human female body. (Note that the nutritional underpinnings remain vital!)
When switching over from Premarin or Prempro to natural forms of estrogen and progesterone, there is a transition period. It is as if the body’s hormone receptors have been primed by the synthetic molecules and have trouble recognizing other forms, even a woman’s own. When a woman chooses to go off Premarin, I generally recommend that she take two to four months to make the transition and not stop “cold turkey.” If she does stop abruptly, she may experience extreme hot flashes and vaginal dryness, or any of the other symptoms that caused her to turn to HRT in the first place. (There is a special version of the Personal Program for women transitioning off HRT. Click here for more information.)
There are a number of nutritional supplements available that can be extremely helpful in this process. A medical-grade multivitamin combined with calcium, magnesium and essential fatty acids (such as Women to Women’s Essential Nutrients) is critical in diminishing the number and severity of symptoms that occur while one is stopping HRT and afterward.
Besides the nutritional and endocrine support provided in the Personal Program, I would like to emphasize the importance of regular exercise, and perhaps even weight training. Although this may seem like a lot of things to do for oneself, it will make a huge difference in terms of the number and intensity of symptoms one experiences after stopping Premarin or Provera.
The use of black cohosh as well as soy (80–100 mg of isoflavones a day) may also help abate the symptoms of hot flashes. (Be sure to avoid genetically modified soy; choose products labeled “Non-GMO.”) The lovely thing about soy is that it has also been noted to be helpful in reducing the risk of heart disease; some studies have demonstrated improved bone density; and most recently, studies have shown its ability to decrease the response of insulin in the body, which is particularly important for those who are insulin resistant or diabetic.
Women take control of their health in stages. You begin by reading and increasing your awareness. Next comes working with your practitioner, or perhaps finding a more appropriate practitioner. You also begin to help yourself, taking action across your whole life to improve your nutrition and metabolism, reduce stress and make time for yourself. These steps unlock your body’s ability to heal itself. And it’s never too late to begin to heal.
Our Personal Program is a great place to start
The Personal Program promotes natural hormonal balance with nutritional supplements, our exclusive endocrine support formula, dietary and lifestyle guidance, and optional phone consultations with our Nurse–Educators. It is a convenient, at-home version of what we recommend to all our patients at the clinic.
We’re always happy to welcome new patients to our medical clinic in Yarmouth, Maine, for those who can make the trip. Click here for information about making an appointment.
Original Publication Date: 12/08/2003
Last Modified: 05/08/2008
Principal Author: Marcelle Pick, OB/GYN NP