HORMONE REPLACEMENT THERAPY: WERE WE WRONG? HRT (in the form of estrogen, with or without progesterone) appears beneficial for women 65 and older. HRT does not necessarily increase cancer or early mortality risk.
New study results may be surprising to many, as in 2002, the landmark Women’s Health Initiative (WHI) reported disturbing news about hormone replacement therapy. The negative news about estrogen plus progestin therapy created long-lasting fear about HRT.
The concerns about HRT have lingered, despite subsequent statistical corrections and a 2004 Women’s Health Initiative study showing several benefits for estrogen alone (that is, without progestin).
Hormone replacement therapy: Basics
We once routinely used hormone replacement therapy (HRT) to help manage menopausal symptoms and protect long-term health. Negative results from large clinical trials changed the practice.
Hormone replacement therapy (HRT) is a medication containing so-called female hormones. The medicine replaces the estrogen that women’s bodies cease making during menopause.
HRT can relieve menopausal symptoms, including hot flashes, trouble sleeping, vaginal discomfort, and more.
Moreover, hormone replacement therapy can prevent bone loss and lower the future chances of suffering a bone fracture.
Let’s be clear: There are risks associated with hormone replacement therapy. The potential side effects vary by the type of hormone therapy, the dose, the length of use, and an individual’s health risks.
The largest clinical trial — The Women’s Health Initiative — showed that HRT that contains both estrogen and progestin increased the chances of serious health conditions, including heart disease, stroke, blood clots, and breast cancer.
Researchers confirmed these findings through a meta-analysis of 22 clinical studies and an updated United States Preventative Services Task Force meta-analysis of 18 studies. These overviews included the World Health Initiative study, and the subjects were over 60 years on average.
As a result of these analyses, the US Preventative Services Task Force continues to recommend against the use of combined estrogen-progestin and estrogen alone (the latter for women who have removed their uterus) to prevent chronic conditions.
Unfortunately, the Task Force did not address the use of menopausal hormone replacement therapy for menopausal symptoms. It also did not present data showing the low absolute risks of menopausal hormone replacement therapy in younger menopausal women.
Hormone replacement therapy: Who might benefit?
The Mayo Clinic (USA) suggests that the benefits of hormone replacement therapy may outweigh the risks if you are healthy and you:
- Have moderate to severe hot flashes.
- Have other symptoms of menopause.
- Need to prevent bone loss or fractures. Estrogen helps protect against osteoporosis, a bone-thinning condition. However, doctors usually recommend medicines known as bisphosphonates to treat osteoporosis. But estrogen therapy may help if you can’t tolerate or are not benefiting from other management approaches.
- Experience early menopause or have estrogen deficiency.
Menopausal hormone therapy: New data
The long-term effects of menopausal hormone replacement therapy remain uncertain, given the early stopping of randomized clinical trials and conflicting findings from observational studies.
In this context, researchers examined the 2007 to 2019 enrollment records of Medicare insurance beneficiaries in the United States. They identified seven million enrollees at least 65 years of age. The study investigators identified estrogen’s type, strength, and delivery route.
The researchers examined 13 patient outcomes, including all-cause mortality, five cancers (breast, uterus, lung, colorectal, and ovarian), six cardiovascular conditions (including ischemic heart diseases, heart failure, blood clots in veins, stroke, atrial fibrillation, and heart attacks), and dementia.
Here are the new study findings:
- Estrogen and mortality. Estrogen alone (without progestin) showed a one-fifth drop in early mortality.
- Estrogen type and mortality. The reduction in mortality appeared greatest with estradiol, followed by an estrogen preparation known as conjugated estrogen, then vaginal estrogen, oral, and skin-based (transdermal) preparations.
- Estrogen and cancer. Estrogen alone also appeared associated with risk reductions for all study cancers, with breast cancer risk dropping by nearly one-fifth. Lung, colorectal, and ovarian cancer risks dropped by 13 percent, 14 percent, and 17 percent, respectively. Note that the combination estrogen/progestin approach raised breast cancer rates by about one-tenth, while progestogen alone also led to a higher breast cancer risk.
- Ischemic heart disease. Overall, estrogen therapy increased risk by three percent; however, low-dose preparations did not appear associated with a higher risk of heart disease.
- Dementia. Oral hormone replacement therapy appeared associated with a moderate increase in dementia risk.
The study authors concluded that among female Medical beneficiaries 65 or older, estrogen alone (without progestin) is beneficial.
Menopausal HRT: My take
The current study is a preprint and has not yet been peer-reviewed. We should not yet use this new medical research to guide clinical practice. Still pending review, the study suggests that we may have overestimated the perils of estrogen alone in managing menopausal symptoms.
Please talk with your healthcare provider about your symptoms and general health to determine if hormone replacement therapy is an appropriate management option. Please keep the dialog open throughout your menopausal years.
If you elect to take hormone replacement therapy, you may reduce the chances of harm through these approaches:
- Look for your best product and delivery method. Estrogen comes in pill, patch, gel, vaginal cream, or slow-releasing vaginal suppository or ring forms. Suppose you experience only vaginal symptoms related to menopause. In that case, estrogen in a low-dose vaginal cream, tablet, or ring is usually better than a skin path or an oral pill.
- Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed.
- Get regular follow-up care. See your healthcare provider regularly to ensure that the hormone therapy benefits continue to outweigh the risks. Get clinically indicated screenings such as pelvic examinations and mammograms.
- Make healthy lifestyle choices. Get some exercise and other forms of physical activity, eat well, keep a healthy weight, don’t smoke, watch the alcohol, manage stress, and manage chronic health conditions (for example, high cholesterol or high blood pressure).
Thank you for joining me in this look at “Hormone Replacement Therapy: Were We Wrong?”
The information I provided in this blog is for educational purposes only and does not substitute for professional medical advice. Please consult a medical professional or healthcare provider if you seek medical advice, diagnoses, or treatment. I am not liable for risks or issues associated with using or acting upon the information in this blog.
