Introduction
Navigating the challenges that come with menopause can seem overwhelming. While hormone therapy, either estrogen alone or estrogen combined with a progestin, offers real benefits – relief from hot flashes, night sweats and vaginal dryness, and protection against fractures – it also has been linked to higher rates of breast cancer, stroke, blood clots in the legs and lungs, and heart disease in older women. This podcast – featuring Dr. Joann Manson, Chief of Preventive Medicine at Brigham and Women's Hospital, a principal investigator of the Women's Health Initiative, and author of Hot Flashes, Hormones and Your Health – will answer commonly asked questions about hormone therapy, its associated risks, and factors to consider when making your own decision.
What key factors need to be considered when making the decision about hormone therapy?
The key factor to consider is whether you have significant symptoms of menopause, such as moderate-to-severe hot flashes or night sweats that interfere with your sleep and impair your quality-of-life. Other factors to consider are your age, the amount of time since your last menstrual period, whether you are in good cardiovascular health, and your risk factors for breast cancer and osteoporosis. Generally, recently menopausal women in good cardiovascular health are the best candidates.
Does hormone therapy increase breast cancer risk?
Yes, in particular, combination estrogen plus progestin has been linked to an increased risk of breast cancer, and the risk increases with longer duration of use – greater than four to five years. These findings were confirmed in the Women's Health Initiative trial of combination estrogen-progestin, a large study of more than 16,000 healthy postmenopausal women aged 50 to 79 who were followed for an average of 5.6 years. In July 2002, this study (Brigham and Women's Hospital was one of 40 study sites across the country) was stopped prematurely because it showed that there was a slight increase in breast cancer risk among the women who took combination hormone therapy and that the overall risks outweighed the benefits. In contrast, estrogen-alone therapy (in women with hysterectomy) did not increase the risk of breast cancer over seven years, but observational studies suggest that breast cancer risk may increase with longer duration of use.
Is there an increased risk of cardiovascular disease?
Clinical trials suggest that women at high risk of heart disease, or those at least 10 years past menopause, may have a small increased risk of heart attack with hormone therapy. These studies also suggest a slightly increased risk of stroke and blood clots from these hormones. As a result of these studies, hormone therapy is no longer prescribed for the express purpose of reducing the risk of cardiovascular disease. However, recent analyses from the Women's Health Initiative and other studies indicate that younger women who are recently menopausal may have more favorable effects from hormone therapy in terms of heart disease. These findings, together with the relatively low rates of adverse events in younger women, provide some reassurance for recently menopausal women who are considering hormone therapy for treatment of distressing menopausal symptoms.
Additional women's health initiative findings were released recently, weren't they?
The latest findings are a more detailed look at hormone therapy in younger women versus older women. These findings give us a clearer view of how a woman's age and time since menopause impact her health outcomes when she takes hormone therapy. In terms of heart disease risk and mortality, the results were more favorable for younger women and provide more reassurance for recently menopausal women considering hormone therapy for the control of menopausal symptoms.
So short-term hormone therapy is safe?
Well, hormone therapy is still an appropriate option for some – but not all – women. For newly menopausal women – whose final menstrual period took place five or fewer years ago - and who are in good health, estrogen is likely safe to use on a short-term basis (ideally two to three years, and generally no more than five years). Mounting evidence suggests that hormone therapy does not adversely affect the risk of heart disease in younger women and may even confer heart benefits.
What are the side effects of hormone replacement therapy?
The most common side effects of estrogen therapy are breast tenderness, vaginal bleeding, and occasionally nausea and headaches. If these persist, the dose of estrogen may be lowered or hormone therapy can be discontinued. Side effects seen with progestins are breast tenderness, fluid retention, PMS-like symptoms, and irritability. If these occur, changing the frequency from daily to cyclical use might be more acceptable. However, it is not clear that progestin therapy every other month or every third month is as protective to the uterus.
How should a woman make a decision about hormone therapy?
Estrogen use is very effective for the treatment of moderate to severe menopausal symptoms and, for many women close to menopause onset, is probably safe to use on a short-term basis. Although there is no magic formula for deciding whether or not to take hormone therapy, assessing your time since menopause and your personal risk of cardiovascular disease, breast cancer, and osteoporosis can help with this decision. Our book Hot Flashes, Hormones and Your Health provides tools for estimating your risk of these health conditions as an aid to decision making. Your health history should be carefully discussed with your health care provider prior to starting hormone therapy.
What services are available at Brigham and Women’s Hospital?
For more information on hormone therapy and menopause, to make an appointment, or to learn more about the services and programs of Brigham and Women's Hospital, call 1-800-bwh-9999 or visit us at www.brighamandwomens.org.
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