Hormone replacement therapy
Findings on HRT since the Women’s Health Initiative — an individual
approach is best
by Marcelle Pick, OB/GYN NP
If you’ve been keeping up with the news, you’re probably aware of the recent questions
about risks and benefits of hormone replacement therapy (HRT). These reports, along
with new scientific evidence, are leading some women and their healthcare practitioners
to reconsider the 2002 mandate to stay off of HRT. Both at the clinic and in our
Personal Program, I hear this question again and again: “What’s changed since the
negative results of the Women’s Health Initiative?”
I’m happy to say that researchers have been busy over the past few years, and their
findings give the medical world new perspective on the use of HRT for menopause
symptoms. The answers we now have are similar to what Women to Women has been telling
women all along — the decision to go on hormone replacement therapy is individual,
and the risks, benefits, and side effects differ depending on the individual.
I have seen some menopausal women do well on conventional HRT (though we don’t keep
them on it if we can get them off), and others who soar following a gentler approach,
like bioidentical HRT or
phytotherapy. In the end, you can take comfort in the fact that there are
several options for menopause symptoms — and we’re here to help you understand them.
Want to get off HRT safely?
Consider our Personal Program for getting off HRT. It’s uniquely tailored for women
to minimize side effects and symptoms during their transition off of hormone replacement
The Women’s Health Initiative results — then and now
Time has given researchers more perspective on the results that came out in 2002,
when women were warned that hormone replacement therapy leads to higher risks for
breast cancer, cardiovascular events, blood clots, cognitive decline, and more.
An extensive collection of data has been scrutinized and published. Though we still
don’t know everything there is to know about the risks and benefits of HRT, the
research is bearing out what I’ve seen in practice for years — timing and individual
circumstance are key.
New studies suggest that women under 60 years old and within ten years of menopause
can benefit from HRT with much less risk (even with potential benefit) than older
women who are more than ten years away from menopause. The majority of the women
enrolled in the WHI study were older and much past menopause.
The most recent evidence on the use of hormones for menopause
Here’s an overview of how HRT may affect certain health issues:
Coronary heart disease. If HRT is initiated within ten
years of menopause or in women under 60, it may help reduce the incidence of coronary
heart disease. It appears that estrogen therapy alone delivers better results than
combined estrogen and progestin (any hormone that causes progesterone-like
effects.) But women with a uterus need a form of progesterone to “oppose” potential
risks of estrogen alone.
Cognitive health. The 2004 Women’s Health Initiative Memory
Study showed that initiating estrogen therapy or estrogen/synthetic progesterone
therapy in women over 65 had a negative effect on cognition — particularly if they
had already experienced some cognitive decline. But another study looking women
between the ages of 50 and 63, showed that those on hormone therapy had a lower
risk of Alzheimer’s disease than those that weren’t.
Cholesterol and triglycerides. In 1997, the Postmenopausal
Estrogen Progestin Intervention trial showed that women aged 45–60 on Premarin alone
or Premarin and natural progesterone had significant increases in “good”
cholesterol, compared to those receiving Premarin with a synthetic progestogen
(Prempro). Now, we also have evidence that bioidentical estradiol delivered across
the skin reduces triglycerides, rather than increasing triglycerides as pill forms
(synthetic and bioidentical) do.
Blood clots. Estrogen has long been known to increase
blood clotting. A recent study showed that the lowest risk comes with using natural
progesterone and the highest comes with synthetic progestogens. Estrogen, on the
other hand, if given transdermally (across the skin), comes with no increased risk
of blood clots.
Breast health. The relationship between HRT and breast
cancer risk continues to be the subject of intense debate. Close scrutiny of data
on women in the WHI who were ages 50–59 who had undergone hysterectomy reveals that
estrogen therapy alone did not increase their risk of breast cancer. However, women
of that same age group who had not undergone hysterectomy and who took estrogen
with a synthetic progesterone did.
A recent large study in France following over 80,000 women observed a much lower
risk of breast cancer when they used estrogen combined with bioidentical (natural)
progesterone than nonbioidentical progesterones — as long as they used
it for less than about six years. But for users of estrogen alone, compared to “never-users”
of HRT, the researchers noted a significantly increased risk of breast cancer.
In the end, making generalizations about HRT and breast cancer risk is not a
good idea; the number of variables keeps increasing and the field is changing daily!
Although the new research is promising, one limitation is that much of it still
looks only at synthetic progesterones and equine estrogens (estrogens derived from
a pregnant horse). These hormone forms are molecularly different from the hormones
we make in our bodies, so drug companies can patent them.
Bioidentical hormones, on the other hand — those that
have the same molecular structure as those made in our bodies — are becoming more
popular. We’ve always used bioidentical hormones at the Women to Women Clinic because
we feel they are gentler on the system than synthetics, and a significant and growing
body of research is now bearing this out.
Above all, hormone therapy, synthetic or bioidentical, is not the right
choice for every woman — because we all have our own unique set of circumstances.
In my practice, I evaluate each HRT case individually at each appointment so women
can make informed decisions about starting or continuing bio-HRT on her own terms.
And I generally recommend women stay on hormones for fewer than five to seven years.
Risks and benefits of HRT — individuality is central
Do the benefits outweigh the risks for you?
Consider these questions while making your decision about HRT:
- Are you less than 60 years old?
- Are you close to menopause and still having symptoms?
- Does your personal or family medical history include breast cancer, endometrial
cancer, ovarian cancer, or liver disease?
- Is your quality of life being seriously compromised by your symptoms?
When I sit down with a woman considering hormone replacement therapy, I always look
at her age, proximity to menopause, medical history, and her quality of life. Quality
of life is so important, and it’s something conventional practitioners often dismiss
if the research shows any kind of risk associated with a given treatment. I have
one patient who was diagnosed with breast cancer years ago, and even after the 2002
WHI results came out, she decided she’d never go back to life without bio-HRT. I’ve
always respected her position. (Keep in mind, we’re checking her hormone levels
yearly — sometimes twice a year — and she’s taking bioidentical HRT.) Each woman,
especially when given the information to make an educated decision, has the right
to decide what is best for her body.
Researchers tell us that the risk profile for hormone replacement therapy goes down
in women under 60, women less than ten years from menopause, and women who don’t
have a history of breast cancer, endometrial cancer, or liver disease.
In my opinion, whether or not your hormones are still fluctuating is a more important
consideration than whether it’s been less than ten years since you entered menopause.
It is safer to introduce HRT when hormones haven’t tapered off yet. This way, your
estrogen and progesterone receptors are still active.
Each woman has a different set of circumstances that determine her personal
risk, but based on the new evidence and what I’ve experienced in practice, the safety
of HRT is enhanced if the following guidelines are met:
- It is given to younger women (under 60), who are close to menopause and whose hormones
are still fluctuating.
- The woman does not have a history of breast, ovarian or endometrial cancer, or liver
- The woman uses bioidentical hormones as opposed to synthetic HRT.
- The woman uses transdermal, transvaginal, sublingual, or “melt” forms of HRT instead
of pills that need to be swallowed.
- Hormone replacement therapy doesn’t go on for more than five to seven years.
For a broader discussion of risks, read our perspective on the risks of HRT.
Phytotherapy: a safe and effective alternative
For a natural approach
Try Herbal Equilibrium
We formulated Herbal Equilibrium with herbs like Black Cohosh, Red Clover, Passionflower,
and more to help with the most common menopausal symptoms. We’ve found in our clinic
that 85% of women can find relief from a plant-based product like Herbal Equilibrium.
Learn more about Herbal Equilibrium and our
Personal Program for Hormonal Imbalance.
Many of the women who were on hormone therapy in the past were instructed by their
practitioners to get off of it. Now, as their bodies have gone for some time without
replacement hormones, it’s not a great time for these women to start up again —
even though their symptoms are still bothering them. A safe and effective option
for these women, and for those who just don’t feel comfortable with HRT, is phytotherapy.
Phytotherapy is the use of plants for healing purposes. Herbs like Black
Cohosh, Red Clover, Passionflower, and many others are wonderful alternatives for
menopause treatment because they work with your endocrine system to ease symptoms
instead of the “sledgehammer effect” pharmaceutical drugs often provide.
Herbs offer a gentler approach to menopause symptoms, which means there’s less risk
to you than taking a hormone. Though using herbs for menopause may not provide enough
relief for some, we’ve found in our clinic that 85% of women can find relief from
a plant-based product like our Herbal Equilibrium.
Your options for menopause symptom relief
The media can often make it seem like we have limited options when it comes to our
health, but if we’re willing to adopt a more holistic approach, the options are
endless. Here are just some of the treatment options we’ve had success with at the
clinic and in our Personal Program.
Diet and lifestyle changes. Diet and lifestyle play a
large role in exacerbating menopause symptoms. For some women, adding more protein,
high-quality fats, and fresh fruits and vegetables, while limiting refined carbohydrates,
sugar, gluten, and highly processed foods can make a world of difference. You may
also want to consider supplementing with a quality multivitamin like the one we
offer in our Personal Program.
Phytotherapy. Soy, Black Cohosh, Red Clover, Ashwagandha,
Wild Yam, and other botanicals can offer satisfying relief from menopause symptoms.
You can explore our Personal Program’s Herbal Equilibrium, which provides a safe
and effective combination of herbs for gentle endocrine support and menopause symptom
Bioidentical HRT (bHRT). Bioidentical HRT consists of
hormones made in a lab, primarily from Wild Yam and soy, that are identical to the
hormones your own body produces. Bioidentical hormones are available through compounding
pharmacies by prescription. For more on how to choose the right bioidentical hormones
for you, see our guide to bioHRT options.
Synthetic HRT. Hormone replacement therapy drugs like
Premarin and Prempro are the drugs studied in the original Women’s
Health Initiative. Premarin is made from the urine of a pregnant horse, while Prempro
combines Premarin and a synthetic progestogen. There are also synthetic forms of
testosterone. We feel most comfortable with bioidentical HRT, but understand that
there are cases where synthetic hormones are a viable choice.
Your body, your choice
Only you can decide what is best for your body. I know from my own personal experience
and that of my patients, that menopause can be a confusing time, a time when it’s
difficult to make decisions (especially if you haven’t slept well in weeks!). But
know that there is an option out there for you — and it’s okay to take your time
in deciding. I have some patients who don’t mind enduring the symptoms as long as
they know there will be an end to them in good time. Others simply can’t perform
their day-to-day activities without some relief from their symptoms. Look inside
to make your decision, and don’t ever be afraid to ask questions!
Related to this article:
References & further
reading on new findings on the WHI
Last Modified Date: 07/23/2012
Principal Author: Marcelle Pick, OB/GYN NP