Updates on Hormone Therapy in Menopause

As a practicing ob-gyn for the last 35 years, I have certainly seen the “hormone wars.” As is true in so many subjects in medicine, studies are presented that demonstrate a significant benefit of a drug or supplement, only to be challenged months or years later with the opposite findings, leading to confusion and angst, and concerns about the harm that this intervention might have had.

Most women remember the sensational presentation of the Women’s Health Initiative (WHI)  findings in July, 2002. Hormone replacement therapy caused breast cancer, heart attacks, strokes, and blood clots. Many, many women stopped their hormones that day, and some were miserable. To this day, I find that the overall negativity of hormone replacement still persists, and I am told by many women that their physicians will not prescribe hormones for them despite incapacitating menopausal symptoms. I, after years of observation, was convinced of the benefits for so many of my patients who experienced hot flashes and night sweats, sleeplessness, depression, decreased cognitive function, painful intercourse, and many other symptoms that significantly affected their family and work lives.

I attended the meeting of the North American Menopause Society last fall to hear the latest data, for it has been 15 years since the WHI results were reported.

For context, the NIH began the WHI study in 1994 to assess the benefits of hormone therapy on the cardiovascular disease in women ages 50-79. There were many previous studies that demonstrated a benefit on the heart, and the NIH wanted to see if giving women hormones in their later years would prevent heart attacks and strokes. When they found more heart attacks and strokes in this age group, they were surprised and abruptly ended the study, which led to many women abruptly stopping therapy.

In the studies which followed, scientists looks at what is called “the timing hypothesis”. The theory is that it truly matters if hormones are begun soon after menopause, or many years later. In reality, hormones are most often prescribed soon after the cessation of the last menstrual cycle, and this was found to be very safe. The data actually demonstrates that women who take hormones in their 50’s, within 10 years of the onset of menopause, have a decreased all-cause mortality of 30%. Women in their 60’s, within 20 years of menopause, had no increased or decreased mortality, and women in their 70’s had increased risks. Now, women must be chosen carefully, since those with cardiac risk factors, diabetics, and those with a history of blood clots should not take hormones at any age. But the reality is that most healthy women in their 50’s can truly benefit from hormones, and the risk is very low.

Here are some of the “pearls” learned from the conference. Hormone therapy reduces the risk of new onset diabetes, and one study demonstrated a reduction in congestive heart failure by showing a benefit in the small blood vessels of the heart. Studies did not show an increase in stroke in the first 10 years of hormone therapy. Hormones improved sexual function, and topical vaginal products for vaginal dryness and painful intercourse were very, very safe, even in breast cancer survivors, except those taking aromatase inhibitors. Women who experience early menopause, with an average age of menopause being 51 years old, especially with surgical menopause, should consider hormones because this group of women experience more osteoporosis and depression, and cardiac risks.

Estrogen alone, without progesterone, demonstrated a decreased risk of breast cancer and heart disease. Women have have a uterus are given progesterone along with estrogen to prevent uterine cancer. Using transdermal estrogen, a patch, gel or aerosol spray is safer than oral therapy. When hormones are taken orally, they pass through the digestive system and the liver, and clotting factors are increased.  These increased clotting factors can increase the risk of heart attacks, strokes, blood clots, and pulmonary embolism Transdermal products are absorbed directly into the bloodstream, and do not increase the clotting factors. The latest data demonstrates that transdermal estrogen and bio-identical micronized progesterone are safer than the estrogen and progesterone which were used in the WHI.

Dr. James Simon, Past President of the North American Menopause Society, even ventured that if the WHI had used transdermal estrogen and bio-identical progesterone, that the results of the WHI would have been very, very different.

Once again, what goes around, comes around.

P.S. A decision about hormone therapy should be made by a knowledgeable physician, taking into account a patient’s past medical history, family history, and physical examination.