Hormone replacement therapy
New 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 about hormone replacement therapy
(HRT), you may have heard Oprah recently discussing the benefits of bioidentical
HRT. This positive press, along with new scientific evidence, is 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 each
women’s unique health picture.
I have seen some menopausal women do well on conventional HRT (though we never keep
them on it if we can get them off), and others who soar on 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. Let’s take a closer look at the new HRT findings and explore
some of your options for menopause symptom relief.
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, and we still
don’t know everything there is to know about the
risks and benefits of HRT. But thankfully, the research is now bearing out
what I’ve seen in practice for years — timing and individual circumstance
are key.
Of note, 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.
New evidence on the use of hormones for menopause
Here’s a quick overview of what’s new in HRT:
- 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.) The caveat for women with a uterus, however, is that they do need a form
of progesterone to “oppose” potential risks of estrogen alone.
- Cognitive health. The 2004 WHIMS (Women’s Health
Initiative Memory Study) study showed that initiating estrogen therapy or estrogen/progestogen
(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 at younger 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. Back in 1997, the PEPI
(Postmenopausal Estrogen Progestin Intervention) trial showed that women aged 45–60
on conjugated equine estrogens alone (Premarin) or conjugated equine estrogens and
natural progesterone had significant increases in “good” cholesterol,
compared to those receiving conjugated equine estrogens with a synthetic progestogen
(Prempro). Now, we also also have evidence that bioidentical estradiol delivered
across the skin reduces triglycerides, rather than increasing triglycerides as do
estrogens that are swallowed in pill form — both synthetic and bioidentical.
- Blood clots. Estrogen has long been known to increase
blot clotting, and this is why certain women couldn’t use birth control pills.
In HRT pill forms that are swallowed, the risk for a blood clot (also known as venous
thromboembolism) seems to vary by the type of progesterone or progestogen
used. A recent study showed that the lowest risk comes with using natural progesterone
and the highest comes with norpregnane derivatives (synthetic progestogens).
Estrogen, on the other hand, if given transdermally (across the skin), comes with
no increased risk of blood clot. Why this is true is not really understood.
- Breast health.We want women to know that the relationship
between HRT and breast cancer risk continues to be the subject of intense debate.
Close repeat 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 progestogen (synthetic progesterone) did.
Some might say that this means women aged 50–59 can “safely” take estrogen
alone without worrying too much about breast cancer. We wish it were that simple,
but several other studies over the years have shown differing results, and the final
word is probably not yet in.
In a recent large study in France, researchers following over 80,000 women observed
a much lower risk of breast cancer when they used estrogen combined with bioidentical
progesterone than when the women used estrogen combined with most 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.
Laying the findings of the WHI reanalysis alongside those of this French study,
we realize why making generalizations about HRT and breast cancer risk is not a
good idea; the number of variables keeps increasing — apples to oranges, Macs
or Delicious to lemons or grapefruit — the field is changing daily! The French
study was large; the women were, on average, only 52.4 years old at the start of
the study; and they were followed for an average of eight years postmenopausally.
The majority of the women also used a topical (skin) estrogen, and not Premarin
like in the WHI. So in the former respects, at least, they looked a lot like the
smaller group of younger American women that researchers broke out when reanalyzing
the WHI data. Yet the results, as noted above, were rather different.
What should a woman make of all these findings? First off, it’s important
to keep the issues of timing in mind: While new analysis suggests a postmenopausal
woman’s increased risk of heart attacks, blood clots and strokes appears to
fade as soon as she stops taking hormones, other new data suggest her risk of breast
and several other cancers may not.
It’s also important to note that 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,
especially with Oprah’s recent discussions. We’ve always used bioidentical
hormones at Women to Women because we feel they are gentler on the system than synthetics,
and a significant and growing body of research is now bearing this out. For more
about the differences between synthetic and bioidentical hormones, see our
bioidentical hormones article.
But above all, we have to remember that 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. Every time I see a woman on or considering HRT, we discuss individual
risks, look at the recent research, and discuss her quality of life, so each woman
can make an informed decision 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.
Take a look at the questions in the box to the right. 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.
If you think about it logically, reintroducing hormones when the system has adjusted
to life without them — like the majority of women enrolled in the WHI study
(average age 63) — doesn’t make much sense. Their estrogen and progesterone
receptors have most likely diminished in activity, and adding hormones when the
body isn’t expecting them or in need of them sends mixed messages. I’ve
heard some patients describe menopause and perimenopause like a plane crash —
you can feel it coming and then suddenly you hit the ground. I know that your perspective
on life can change with the fluctuation of your hormones — after all, the
body and mind are intimately connected. But supplementing those hormones as close
to menopause as possible can “soften the landing,” so there is less
shock to the system.
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
disease.
- 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
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 with
out 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, either in whole food form or in the
form of standardized extracts and supplements, for healing purposes. We have been
drawing on the effective healing power of plants for centuries — and in fact,
many of the pharmaceutical drugs you hear about today are derived from plants. Phytotherapy
is a wonderful alternative for menopause treatment because it works with
your body to give you what you need.
We evolved alongside the plant world, so many plants are at home in our endocrine
systems, and they have the unique power to communicate and adapt to their environment.
In other words, by communicating with plant molecules in herbal therapies, your
body can often get what it needs and only what it needs. So it’s more of a
give-and-take relationship, rather than the “sledgehammer effect” pharmaceutical
drugs often provide.
Some herbs encourage your body to make more of a hormone you’re lacking, and
others can minimize symptoms by quieting hormone receptors or creating the same
physiologic response a hormone would have in your body. The bottom line is that
herbs offer a gentler approach to menopause symptoms. This means there’s less
risk to you than taking a hormone. Though using herbs for menopause may not be enough
for some, we’ve found in our clinic that 85% of women can find relief from
a plant-based product like our Herbal Equilibrium. For more information, read my
article on phytotherapy for hormonal balance.
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. In certain cultures, women
do not experience uncomfortable menopause symptoms at all. This suggests that diet
and lifestyle play a large role in exacerbating menopause symptoms. After all, the
foods and nutrients we eat make up the building blocks for our hormones. 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. For more on eating and lifestyle choices that support
hormonal balance, see our
Nutritional and Lifestyle Guidelines. 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 — the list of plants Nature provides for healing menopausal symptoms
is lengthy and time-honored. You can choose to work with a practitioner to find
the right plant-based combination for you, or explore our Personal Program’s
Herbal Equilibrium, which provides a safe and effective combination of herbs for
gentle endocrine support and menopause symptom relief.
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. At one time bioidentical hormones were only available
through compounding pharmacies. But now there are several brand-name bioidentical
HRT products to choose from that can be prescribed by conventional practitioners.
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 may sound familiar to you. These 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. Each woman has the right to know her options, and to decide
what’s best for her health.
Your body, your choice
Your body is your temple, and only you can decide what is best for it. 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!
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.
Related to this article:
References & further
reading on new findings on the WHI
Original Publication Date: 03/02/2009
Last Modified:
09/01/2009
Principal Author: Marcelle Pick, OB/GYN NP