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There are some very hard choices in life for which there are no clear right answers. One of these choices presents itself to many women in their 40s and 50s as the natural estrogen hormone production of the ovaries dwindles down to nearly zero.
This ovarian failure is called menopause or, by many, “the change of life” or even just “the change”. It frequently brings hot flashes and many other characteristics, which may even include personality changes.
The choice that menopause brings is whether or not to take hormone replacement therapy (HT). This might seem like a simple question to answer since few women (or those around them) are happy with the problems menopause brings and that hormones can resolve. However, HT carries some risks that must figure into the decision-making process.
Recently, the North American Menopause Society issued Guidelines on Hormone Therapy, which I will review for you.
They point out that the benefit-risk ratio for HT is good for women who start the hormone treatment early in menopause. However, this ratio is not as good in older women and when there is a long time between the onset of menopause and the start of hormones in previously untreated women.
The Women’s Health Initiative (WHI) trial of estrogen therapy (ET) offered evidence of considerable safety for 0.625 mg/day of estrogen, supporting the position that at least for this form of HT, the potential risks are low. In the WHI trial of combined estrogen-progesterone therapy (EPT), most risks were determined to be rare, except for stroke, which was above the rare category.
Evidence to date is conflicting about the role of HT and risk for ovarian cancer, with no association or a modest increased risk in most studies. The statement suggests that the association between ovarian cancer and HT should be considered as rare or very rare, but that women with a family history or other increased risk for ovarian cancer should be counseled about this rare association.
The data suggest that starting EPT in older women with a history of smoking cigarettes may speed the growth of existing lung cancers. On the other hand, evidence from some studies suggests that use of HT in women younger than 60 years offers some protection against lung cancer.
The safety of EPT in survivors of breast cancer is controversial and needs to be discussed with the treating physician.
For the sole or main indication of preventing age related deterioration of thinking or dementia, the guidelines do not recommend HT at any age. In fact, HT is actually linked to increased incidence of dementia when started in women age 65 years and older. Available information does not adequately address whether HT started soon after menopause has any effect on dementia risk, and limited evidence does not support the use of HT as a treatment of Alzheimer’s disease.
In terms of cardiovascular effects, the guidelines note that HT is currently not recommended as a sole or main indication for protection from heart disease in women of any age. Starting HT by age 50 to 59 years or within 10 years of menopause to treat typical menopausal symptoms does not seem to increase the risk for CHD events. There is even some recent evidence that starting ET in early postmenopause may lower CHD risk.
Study results have been inconsistent regarding stroke risk with HT. Two major studies showed an increased risk for stroke, but other studies showed no effect on stroke risk.
Current data suggest that when HT is either tapered or abruptly discontinued, rates of hot flashes and flushing symptom recurrence are similar. The statement therefore makes no recommendation concerning how or when to discontinue therapy.
A woman’s willingness to accept risks of HT will vary depending on her individual situation, particularly whether HT is being considered to treat existing symptoms or to lower risk for osteoporotic fractures that may or may not occur.
There are times when a woman should not consider HT because of previous history of estrogen-receptor positive breast cancer, hormone-related migraine headaches, or blood clots in the legs or lungs, among others.
However, I have noted that almost every one of the middle-age female patients I see and note that they appear “younger than their stated age” are taking some form of estrogen replacement drug.
I also know that the “secret” ingredient in many cosmetics that have claimed to “make you look younger” has been estrogen or estrogen-like chemicals.
The question for many menopausal women really boils done to “How much risk in your future are you willing to take, in order to look younger and feel better now?”
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