MENOPAUSE MAKEOVER. FOR MY ENTIRE CAREER IN MEDICINE, MYTHS AD MISCONCEPTIONS have shrouded menopause.
And silence.
Here’s actress Susan Sarandon’s observation:
“I think there’s something about not giving up and becoming invisible, which is what our society has a tendency to do. I hear women [of a certain age] talking about becoming invisible. My interpretation of anti-aging means anti-becoming invisible.”
Good News: A Tidal Wave of New Research
Fortunately, we are getting a tidal wave of scientific research rewriting the narrative around menopause.
Fortunately, some of the new research in the realm of hormone replacement therapy (HRT).
In this essay, I’ll debunk some of the biggest HRT myths, explore the latest science, and empower you to make informed decisions about your health and well-being throughout menopause.
What is Hormone Replacement Therapy?
There are two main types of hormone replacement therapy:
- Estrogen-only HRT: This is typically used for women who’ve had a hysterectomy (surgery to remove the uterus).
- Combination HRT: This includes both estrogen and progesterone (often a synthetic kind called progestin). It may be offered to women who still have their uterus.
Why the different types? Estrogen alone can thicken the lining of the uterus, increasing the risk of cancer.
Progesterone added to estrogen helps prevent this thickening.
Taking Hormone Replacement Therapy
How you take it: HRT can come in one combined pill or separate medications.
You can take it continuously (every day) or with a cyclical schedule (like birth control pills).
Largest Study of Women’s Health
I’d like to talk with you about a recent report in JAMA.
The biggest women’s health study in the U.S., the Women’s Health Initiative (WHI), is giving us a clearer picture of how hormone therapy, calcium, vitamin D, and diet changes affect women’s health.
Until recently, many researchers looked at each of these things separately.
Now, this new report combines all that research to give doctors and women a better understanding of what works in real life.
Today, I will focus on hormone replacement therapy for menopausal women.
HRT: An Historical Perspective
One of the most common questions I get is this:
“My hormone replacement therapy (HRT) when I entered menopause caused my breast cancer, right?”
What do you think my answer is?
Do I reply that it is likely that the few years of HRT you took around menopause landed you in my office today?
Or, “Not so fast.
Let’s look more closely at the research that led to newspaper headlines putting fear into the hearts of women with menopausal hot flashes.”
Historical Perspective – Menopause Makeover
In the past, before the connection between HRT and breast cancer was clear, many women used HRT for long periods to manage menopause symptoms and keep their bones strong.
Others turned to hormone replacement therapy to reduce their heart attack, stroke, and dementia risks.
But in 2002, when studies showed a link to breast cancer, stroke, and blood clot risk, the number of women using HRT went way down.
The breast cancer risk appeared to rise by a relative 25 percent if one took hormone replacement therapy.
We based this estimate on a 2002 Women’s Health Initiative report.
WHI Stops Combined HRT Study Arm
You can imagine what happened immediately after the report:
The World Health Organization discontinued the combined (estrogen and progestogen) HRT arm of the study prematurely in light of safety issues, including a small increased risk of breast cancer, heart disease, stroke, and blood clots.
But were we right? Should we have deprived so many of the most effective tools for hot flashes, hormone replacement therapy?
And does HRT increase the risk of chronic diseases such as heart attack? Could it lower it?
Hormones and Cancer Risk
Let’s get to what we got very wrong about hormone replacement therapy and cancer risk.
The updated findings tell a very different story than what many have been telling women:
Women in early menopause (age 60 years) had a lower risk for adverse events from hormone therapy. Generally, they had a more favorable benefit-to-risk profile than women in later menopause.
Age appears to matter. A lot.
Age and HRT
Read this 2019 take:
“HRT may prevent chronic conditions when started in symptomatic women before the age of 60 years or within 10 years of the onset of the menopause, taking into consideration the characteristics and risk profiles of each given woman.”
Newly published findings from the World Health Initiative give me more confidence in the use of estrogen products for many women in early menopause.
Younger women have a low risk for cardiovascular and other chronic conditions when taking hormone therapy.
The risks attributed to HRT were less than one additional adverse event per 1,000 women annually.
Many younger women may get significant quality-of-life improvements with hormone replacement therapy.
Thinking About HRT? Menopause Makeover
Thinking about using hormone replacement therapy to manage menopause symptoms?
Here’s what to consider about breast cancer:
- Combination HRT slightly increases breast cancer risk: Taking both estrogen and progesterone in HRT can slightly increase your chances of getting breast cancer. This risk gets higher the longer you take it, but it goes down again after you stop. The longer you’re on it, the longer it takes for that risk to disappear completely.
- Estrogen-only HRT slightly lowers breast cancer risk: This type of HRT seems to have a slightly lower risk compared to combination HRT. However, it’s important to note that estrogen-only HRT is usually only recommended for women who’ve had a hysterectomy (surgery to remove the uterus).
Estrogen Alone Decreases Breast Cancer Risk?
The WHI 10-year follow-up showed that estrogen alone, compared to no hormone therapy, decreased breast cancer risk by more than one-third (a relative 37 percent).
Researchers discovered that women who started taking estrogen earlier in life seemed to benefit more from it.
The type of estrogen the women took (conjugated equine estrogen, estradiol, or estrone sulfate) didn’t affect the results.
HRT and Non-Breast Cancers
Does hormone replacement therapy increase the risk of non-breast cancers?
If you use estrogen and progesterone in combination, you might slightly raise your risk of ovarian cancer.
The risk drops after discontinuing the medicine.
Taking combination hormone replacement therapy does not affect your uterus (endometrial) cancer risk.
Menopause Makeover: Can Hormones Prevent Chronic Disease?
The WHI studies looked at whether hormone therapy could help prevent health problems like heart disease, stroke, and dementia after menopause.
It turns out hormone therapy isn’t a good fit for preventing chronic conditions such as cardiovascular disease or dementia.
Medications for prevention need to be very safe, and the WHI studies showed some risks with hormone therapy.
However, the studies also showed that hormone therapy can still help manage menopause symptoms, especially for women who are in early menopause.
Menopause Makeover: Individualization
The JAMA article highlights the importance of talking openly with your doctor about hormone therapy (HRT) during menopause. Here’s why:
Shared decision-making: You and your doctor can discuss your situation and health risks to see if HRT is the right choice.
If you are going to project from the Women’s Health Initiative Study, please remember the entry criteria:
The Women’s Health Initiative study only included women who:
- had already gone through menopause (were postmenopausal)
- didn’t have a uterus (likely due to a hysterectomy)
- never had breast cancer before
- Dad had a recent mammogram with no signs of cancer
The study subjects took estrogen for over seven years in the WHI study. Scientists followed the WHI participants for more than 20 years.
Menopause Makeover: You Decide with Your Doctor
The Women’s Health Initiative research looked at the safety of taking estrogen alone (without progesterone) after menopause to manage symptoms.
The surprising finding was that women with typical breast cancer risk who took just estrogen had a lower chance of getting breast cancer compared to those who didn’t take any hormone replacement at all.
It’s important to note that this is just one finding, and we must consider other factors. Before making any decisions, it’s important to talk to your doctor about the risks and benefits of hormone replacement therapy.
The authors of one review emphasize that choosing hormone therapy (HRT) during menopause is a decision you make together with your healthcare provider. Here’s why:
- Age is a factor: If you’re under 60 and have a low to average risk of heart disease and breast cancer, HRT might be more beneficial than risky.
- Balancing pros and cons: For women in early menopause with severe symptoms like hot flashes and night sweats, HRT could offer more relief than potential downsides.
- Working together: You and your doctor can discuss your unique situation and health risks to determine whether HRT suits you.
Remember: HRT isn’t a one-size-fits-all solution. Talking openly with your doctor allows you to make an informed decision about managing your menopause journey.
Of course, I can only advocate for HRT for those who do not have a contraindication to its use.
My Take – Menopause Makeover
The World Health Initiative study findings support using hormone therapy for the management of moderate to severe hot flashes, night sweats, and other menopausal symptoms for selected women in early menopause.
We can no longer categorically reject hormone therapy use for those in early menopause with bothersome vasomotor symptoms (such as hot flashes) or other menopausal problems.
HRT risks vary by whether it is estrogen alone versus a combination of estrogen and progesterone.
Final Thoughts – Menopause Makeover
The evolution of hormone replacement therapy is a great example of how medical research can change what doctors recommend and how patients make decisions about their health.
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