Who is immune to the confusion surrounding hormone replacement therapy ion the form of estrogen and progesterone (E+P) — not the millions of women who consider its use, or the health care providers who prescribe it.
For years, hormone replacement therapy was though to be safe in preventing the annoying and sometimes harmful effects of aging after menopause. In recent years however, studies have concluded that some of the risks of hormone replacement therapy outweigh the benefits.
What is menopause?
Menopause is the time in a woman's life when menstruation ends. Gradually over time the ovaries produce less and less of sex hormones — estrogen and progesterone (E+P). Estrogen promotes the development of a woman's breasts and uterus, controls the cycle of ovulation (when an ovary releases an egg into the fallopian tube) and effects many aspects of a woman's physical and emotional health. Progesterone controls menstruation (having a period) and prepares the lining of the uterus to receive the fertilized egg. “Natural menopause” begins when a woman has her last period and is considered complete when menstruation has stopped for one year. this usually occurs between the ages of 45 and 55. Women who undergo surgery to remove both ovaries experience “surgical menopause” — an immediate end to hormone production and menstruation.
What does a woman experience as a result of menopause?
Women experience symptoms such as hot flashes, night sweats, sleeplessness, and vaginal dryness and emotional changes. In addition, some long term conditions, such as osteoporosis, and coronary heart disease are more coon in women after menopause.
The past
Up until recently, we had placed our confidence in hormone replacement therapy to treat these symptoms to help replace the long term conditions of osteoporosis and heart disease. Recent studies that include the Women;'s Health Initiative (WHI) (women aged 50-79 years) and the HERS Tribal leave us doubting the safety of hormone replacement therapy.
The facts as we know them as related to estrogen replacement (in other words, PremproT 6.25mg equine estrogen/2.5mg medroxyprogesterone acetate)
— A 41 percent increase in stokes: 150 patients that were taking hormone replacement therapy suffered strokes as related to 107 who were taking a placebo (which does not contain any drugs). this means if a group of 10,000 women take E+P for one year, seven more will experience strokes than non-users.
— A 20 percent increase in heart attacks
— A 24 percent increase in total cardiovascular disease: Initially, it was thought that hormone replacement therapy helped to protect women against cardiac disease. The WHI findings suggest that E+P does not protect the heart and may even increase the risk of cardiovascular disease. It was found that if a group of 10,000 women take E+P progesterone for one year, seven more cases of heart disease will occur than in non users. The HERS Tribal also concluded there were no beneficial effects on the heart “in women with a history of heart disease.” After 6.8 years of follow-up, there was no reduction in the risk of heart attacks or death from heart disease.
— Doubling rates of venous thromboembolism (blood clots): If a group of 10,000 women take E+P for one year, 18 more cases will occur than in non users.
— A 26 percent increase in breast cancer: The increased risk of breast cancer due to E+P therapy was eight additional cases of breast cancer for every 10,000 women over one year.
There have been additional studies that show no correlation between E+P use and an increased risk of breast cancer.
Family history does have an impact on the risk of developing breast cancer.
This issue needs to be discussed with your health care provider.
— A 37 percent reduction in cases of colorectal cancer: If a group of 10,000 women takes E+P for one year, 6 fewer cases of colon cancer will occur than in non users.
— A one-third reduction in hip fracture rates.
— A 24 percent reduction in total fracture: E+P can help prevent fractures of the hip, vertebrae and other bones. In a group of 10,000 women, five fewer fractures will occur for those who take E+P. This was true only for those who continued to take E+P throughout their menopausal years.
— A link between estrogen and endometrial cancer: The risk of endometrial cancer taking estrogen plus progesterone is nearly the same as for women not using estrogen. However, some studies have shown increases in endometrial cancer with E+P if the progesterones are used for less than 10 days per month.
— No difference in total mortality (of all causes).
Does the method of administering hormones make a difference?
Most of the information on the long-term health effects of hormones comes from studies where E+P are administered orally in the form of pills. Other ways hormones are given include transdermal patches, gels, vaginal creams and rings. These forms of estrogen are equally effective methods of treating the symptoms of menopause. Several studies show that the benefit of transdermal (patches) products on bone density is comparable to oral therapy. Currently it is not known whether the transdermal method will have different effects than pills on the heart and blood vessels.
The amount of estrogen that enters the bloodstream from vaginal rings and creams depends on the dose. Because the vaginal tissue responds to very low doses of estrogen, only very low doses are needed. Vaginal estrogen therapy does not appear to protect against bone loss.
What are the alternatives for women who choose not to take hormones?
All women can adopt a healthy lifestyle by not smoking, exercising regularly, and eating a healthy diet. A healthy lifestyle helps to decrease women's risk for osteopenia/osteoporosis (bone loss). Your health care provider may also recommend calcium (1000mg-1500mg daily) with Vitamin D (400 IU) daily supplements to help prevent osteoporosis. Other drugs such as alendronate (Fosamax®), raloxifene (Evista®), and risendronate (Actonel®) have been shown to prevent bone loss, and becoming increasingly popular in the treatment of osteoporosis.
Although short term menopause related problems tend to go away on their own, some women choose to seek relief with non-prescription remedies, such as estrogen containing foods (soy products, whole grain cereal, seeds, and certain fruits and vegetables), creams, herbs such as black cohosh (a study now suggests that black cohosh may make an existing breast cancer more aggressive); and vitamin E and B complexes. Keep in mind that although these are considered natural remedies the benefits and risks of most of these agents are unproven, but currently are active areas of research.
In summary
Why so much confusion? Health care is considered an art. With any art you can expect fluctuation and change because new studies are being conducted every day. Fresh information the consumer market on a regular basis. Researchers are continuously working to find out more and more about the human body in an effort to control and prevent disease.
So what does all this mean? It means that we need to make personal choices regarding our health care based on our family and personal histories, our personal health status, and our desires for the future.
We cannot prevent natural aging processes, but we can become an active part by being aware of our bodies' changes, remaining sensitive to emotional changes, and keeping in mind that we can reduce risk factors for disease by changing / maintaining our lifestyles.
How to remain active reducing risk factors for disease:
1. Yearly physical to include PAP smear, in indicated.
2. Weight bearing exercise four to five times weekly.
3. Diet high in fiber and fluids (fruits, vegetables, whole grains, seeds, beans, oatmeal).
