Is taking estrogen right for you? Is it safe? You've probably heard a lot about hormone replacement therapy (HRT), which may be used to treat the symptoms of menopause and, in some cases, to protect against osteoporosis and colorectal cancer. HRT is a controversial topic, especially now that the results of a major U.S. study (the Women's Health Initiative [WHI] study) have become available. To help sort out the issues, here are some key points that can help you decide what's right for you.
First, you need to speak with your doctor. You may be interested in taking hormone replacement but it's not advised for women with certain health issues. This type of therapy isn't recommended if you have a history of:
- endometrial or breast cancer
- blood clots
- unexplained vaginal bleeding
- active liver disease
Some women ask why they should take hormones for a perfectly natural stage of life. After all, it's not a medical condition, is it? True, menopause is a normal state and doesn't pose any serious health problems on its own. On the other hand, hormone replacement may help certain women in a few ways:
- by helping to get through the worst of their symptoms, including irregular bleeding, hot flashes, night sweats, difficulty sleeping, mood disturbances, and vaginal dryness
- by protecting against osteoporosis: the WHI study found that taking a combination of estrogen plus progestin decreased overall fracture risk by 24% (the risk was reduced from 11.1% in women who did not take active medication to 8.6% in women taking estrogen plus progestin) and hip fracture risk by 33%. Estrogen and progestin also increased bone density in the hip by 3.7% (compared with 0.14% in women who did not take active medication). However, because of the risks of HRT, it is not recommended for preventing osteoporosis. It is not routinely recommended for treating osteoporosis except for cases where the benefits outweigh the risks.
- by reducing the risk of colorectal cancer: the WHI study found that taking a combination of estrogen plus progestin decreased the risk of colorectal cancer by 44%. This translates to six fewer colorectal cancers for every 10,000 women over one year.
- by reducing the risk of diabetes: in the WHI study, women taking a combination of estrogen plus progestin had a 21% lower risk of diabetes. This translates to 15 fewer cases of diabetes for every 10,000 women over one year. However, HRT is not recommended for the sole purpose of preventing diabetes because of its risks.
HRT also has some risks. Some of the side effects can include:
- tender breasts
- abdominal bloating
- vaginal bleeding
- uterine cramps
- weight gain
- mood swings
Estrogen replacement therapy can increase the risk of endometrial (uterine lining) cancer in women with an intact uterus. This is why women who have a uterus are also prescribed a progestin (such as medroxyprogesterone acetate) to protect them from endometrial cancer. Taking a progestin with estrogen replacement therapy reduces the risk of endometrial cancer to a similar (same or lower) level compared with women who are not taking estrogen replacement therapy.
The Women's Health Initiative (WHI) study recently found that the use of a certain combination of estrogen and progestin taken in pill form (a combination of conjugated equine estrogen 0.625 mg plus medroxyprogesterone acetate 2.5 mg) significantly increases the risk of breast cancer, heart disease, and stroke. It is important to note that not all forms of HRT have been linked to an increased risk and that these risks occurred with long-term versus short-term usage. It is also important to note that the group of women studied in the trial had an average age of 63 years (with a range of 50 to 79 years), and none had severe menopause symptoms (many had no symptoms at all). Therefore, it is not known to what extent the results will apply to postmenopausal women who have different characteristics than the study group.
Specifically, initial study findings showed that the hormones increased a healthy woman's risk of:
- heart disease by 29%
- stroke by 41%
- breast cancer by 26%
Although these increases seem high, the actual number of cancers, heart attacks, strokes, and blood clots among the women in the study was small. The study authors say that given the increased risks they found, a group of 10,000 women who took the hormone combination for one year would experience:
- seven additional heart attacks
- eight more breast cancers
- eight additional strokes
- eight more blood clots in the lungs
The Women's Health Initiative (WHI) also studied women taking estrogen alone (women who had had a hysterectomy). For every 10,000 women taking estrogen alone, the risks and benefits for these women were (per year):
- an increased risk of stroke: 12 more cases of stroke
- possibly, an increased risk of blood clots: six more women with blood clots
- a decreased risk of hip fractures: six fewer women with hip fractures
- possibly, a decreased risk of breast cancer: seven fewer breast cancers
As a result of the WHI study, the Society of Obstetricians and Gynecologists of Canada (SOGC) does not recommend that hormone replacement therapy be started or continued for the sole purpose of preventing heart disease, since estrogen plus progestin can actually increase the risk, and estrogen alone does not have any significant effect on the risk. Hormone replacement therapy may be used to treat menopausal symptoms (such as hot flashes), or to protect against osteoporosis and colorectal cancer. However, it is not recommended for women who do not have any menopausal symptoms. The current thought is that the risk of developing breast cancer increases after five years of taking HRT. Because some symptoms of menopause subside after two to three years, a woman should re-evaluate her need for HRT each year. The SOGC recommends that the lowest effective dose of HRT should be used for the shortest period of time needed.
Since each woman's health history is different, it's important that you openly discuss your concerns and needs with a doctor. Together, you can weigh the pros and cons of hormone replacement. If you decide not to take hormone replacement therapy, there are other treatment options for menopausal symptoms and osteoporosis. If you decide to go ahead with hormone replacement, you'll be prescribed a treatment plan that's tailored for you. Hormone replacements come in many forms and dosages, including pills, patches, gels, vaginal preparations, and injections.
The first time hormone therapy is suggested might be while you're still in perimenopause. Some doctors recommend low-dose contraceptive pills to help regulate the menstrual cycle as it becomes more irregular. It's convenient, but the drawback is that you can't tell if your period has stopped completely or not.
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