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Hormone Replacement Therapy: How Does A Woman Decide?
by Sophia Cariati

Take hormone replacement therapy. Don't take HRT. HRT is safe. HRT is too risky.  Women are constantly bombarded with a flood of seemingly conflicting information on the pros and cons of HRT. So how can you make sense of it all? For the millions of women approaching menopause, deciding whether or not to take HRT to compensate for producing less estrogen can be overwhelming. Unfortunately, there is no simple answer. The results of a slew of recent studies do help clarify the proper use of HRT to treat menopausal symptoms and to reduce the risk of osteoporotic fractures.  However, these data do not support the previously held belief that HRT would provide cardiovascular disease prevention. 

What Do We Know?
While doctors glean bits and pieces of the puzzle from each emerging study, one thing remains clear: Whether to take HRT is a decidedly individual choice with no generic solution. HRT is actually a combination of two hormones: estrogen and progestin. Some women who have had a hysterectomy, can often safely take estrogen alone (ERT), while women with a uterus should take a combination of estrogen and progestin if they have chosen to take HRT. When weighing the risks and benefits, the scales will balance out differently for each woman. So while all post-menopausal women produce much less estrogen, not all need HRT.

While scientists are still unclear about many aspects of HRT, some benefits have been established. Doctors do know that, for most women, HRT relieves many uncomfortable symptoms of estrogen loss including hot flashes, night sweats and vaginal dryness. HRT can also protect against osteoporosis and accompanying bone fractures by maintaining or increasing bone density and reducing fracture risk. The recent Women's Health Initiative (WHI) data also indicate that HRT reduces the risk of colorectal cancer.  Although there is some evidence that HRT can help preserve memory and cognitive function, no general consensus has been reached.

Still Have a Uterus?
What are the known risks of HRT?  This depends on each woman and which type of therapy she takes. Estrogen alone (ERT) alone is not recommended for women whose uterus is intact as it can increase the risk of endometrial hyperplasia (overgrowth of the lining of the uterus or womb) which may lead to uterine or endometrial) cancer. Instead, these women should take estrogen combined with progestin (HRT), to reduce the risk of this form of cancer. Women who have had hysterectomies, however, may take estrogen alone.

Breast Cancer or Blood Clots in the Family?
Women who have had breast cancer or have a family history of the disease are often justifiably cautious. While several studies have shown no increased risk of breast cancer from HRT, other studies have shown an association between HRT and breast cancer risk.  Most recently, the combination estrogen/progestin (Prempro) treatment arm of the WHI showed a small but significantly increased risk of invasive breast cancers in the women taking combination HRT, thus causing this portion of the study to be halted prematurely.  Furthermore, in this study and others, HRT increased the risk of heart attacks, strokes and blood clots.  It has long been known that women with a history of of one type of clots (deep vein thromboses or DVT) should not take HRT.

How Long Should a Woman Take HRT?
Like most medicines, HRT beneficial only as long as it is used. Once a woman stops the therapy, she stops reaping continued benefits. More women than ever are living almost three decades in the post-menopausal phase. Should these women take HRT for the rest of their lives? Is it safe to take hormones for that amount of time?  Only further long-term studies that are well designed and have a large number of participants will provide the answers to those questions.  The WHI combination HRT arm, for example, was stopped after an average follow-up of 5.2 years. . .but this study did not focus on use for menopausal symptoms.

Does HRT Help or Hurt Heart Disease?
Until 1998, health care providers assumed that HRT protected the heart based on compelling yet inconclusive research. Since heart disease is the number one killer of postmenopausal women (and men), many doctors thus recommended that  menopausal women consider taking HRT to reduce their risk of heart disease. 

Times have changed. A recent landmark trial, the WHI showed that combination HRT therapy increased the risk of heart attacks, strokes and blood clots in otherwise healthy, postmenopausal women (average age 63) in the course of 5.2 years of study follow-up.

Another study, the Heart and Estrogen/Progestin Replacement Study ("HERS"), revealed that in women with established, advanced heart disease, HRT did not protect against a recurrent heart attack or heart disease-related death. The Estrogen Replacement and Atherosclerosis (ERA) study similarly found that HRT did not slow the progression of heart disease in older women with cardiovascular disease.  It is unknown whether these data are applicable to women who do not yet have heart disease or if the WHI data are applicable to women just entering menopause. 

The Women's Estrogen for Stroke Trial (WEST), also warns women and their doctors against using HRT to prevent repeat strokes. More than 600 women who had recently suffered a stroke were randomly assigned to take HRT or a placebo and followed for almost 3 years. The findings revealed that HRT did not reduce the risk of recurrent stroke or death. In fact, women who took HRT had a higher risk of dying or suffering more neurological damage from a subsequent stroke.

Based partially on these findings, the American Heart Association (AHA) issued a position paper on not prescribing HRT for preventing heart attack and stroke (July 2001). The AHA warned that women who already have cardiovascular disease should not begin HRT solely to prevent future heart attacks or stroke.

Tips on Making the Choice
In the meantime, the Society for Women's Health Research offers some basic guidelines a woman can follow to make the best decision about HRT:

  • Schedule an appointment with your doctor and communicate clearly any symptoms of menopause or estrogen loss you are experiencing.
  • Have a complete annual pelvic exam including a Pap smear.
  • Have an annual clinical manual breast exam and mammogram.
  • Talk to your doctor about having a lab workup including complete blood count, liver function, blood sugar, cholesterol, triglyceride, calcium and phosphorus levels, TSH for thyroid, and complete urinalysis.
  • Have a bone density test to assess your risk of osteoporosis.
  • Assess your personal and family history of cardiovascular disease, osteoporosis, breast and other cancers.
  • If you and your doctor decide that HRT is right for you, be sure to have your annual check-up and communicate with your doctor about any changes in symptoms or side effects.

The Society for Women's Health Research is the nation's only not-for-profit organization whose sole mission is to improve the health of women through research. Founded in 1990, the Society brought to national attention the need for the appropriate inclusion of women in major medical research studies and the resulting need for more information about conditions affecting women. The Society advocates increased funding for research on women's health, encourages the study of sex differences that may affect the prevention, diagnosis and treatment of disease, and promotes the inclusion of women in medical research studies. Dr. Donnica Moore has been a member of the Society since 1990 and is a past member of its Board of Directors.

For more information on menopause and hormone replacement therapy, click here.

Created: 11/29/2001  -  Sophia Cariati
Reviewed: 7/19/2002  -  Donnica L. Moore, MD

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