If you’re struggling with hot flashes, night sweats, and vaginal symptoms, is hormone therapy right for you? You may be hesitant to use it to treat symptoms of menopause because of the health risks that have been reported in the past.
Back in 2002, preliminary findings from the Women’s Health Initiative (WHI) sounded an alarm against hormone therapy. Among the widely publicized concerns were that hormone therapy slightly increased the risks of strokes, blood clots, and breast cancer.
That clinical trial randomly assigned more than 27,000 women, ages 50 to 70, to receive either oral estrogen plus progestin, estrogen alone, or a placebo for an average of five to seven years. The researchers, however, continued to follow the women involved in that trial for a total of 18 years. And the results, which were published in September 2017 in the Journal of the American Medical Associationmade doctors rethink their advice. The researchers concluded that the use of hormone therapy was not associated with either increased or decreased death rates.
Medical groups weigh in
The North American Menopause Society (NAMS) updated its guidelines for hormone therapy use in July 2017. That same month the American Association of Clinical Endocrinologists (AACE) and American College of Endodrinology. updated its position statement on hormone therapy for menopause.
Based on the reanalysis of data, it turns out that the benefits of symptom relief can outweigh the risks for certain healthy women. (See if you’re in that group, below.)
Because of a small increased risk of breast cancer for women who use estrogen combined with progestin, AACE recommends that women take hormone therapy for less than five years (with regular evaluations). However, NAMS believes that lower doses and newer formulations of hormone therapy allow for more flexibility in deciding how long to continue it.
Additionally, the AACE says women who experience severe hot flashes and night sweats but who have a higher chance of side effects from hormone therapy should consider asking their doctor about the use of selective serotonin re-uptake inhibitors (SSRIs) and other non-hormonal therapies, which are still effective and may be safer.
To sort through the new guidelines, HealthCentral talked to JoAnn V. Pinkerton, M.D., executive director of the North American Menopause Society.
Q: If I’m considering hormone therapy, when is the best time to start?
Dr. Pinkerton: We found many benefits, beyond just helping with hot flashes, when hormone therapy for symptoms of menopause is started under age 60 or within 10 years of the onset of menopause. These benefits include a better sleep pattern and improved mood.
Q. Who benefits the most from hormone therapy?
Dr. Pinkterton: Women who are at high risk of bone loss or fracture, and who have bothersome hot flashes, night sweats, and sleep disruption will benefit the most. We found that there are many newer hormone therapy options for menopausal women, such as lower doses, non-oral regimens (as in vaginal creams, skin patches, and suppositories), and regimens that don’t require progestogen, even in women with a uterus. Individualization is key.
NAMS encourages doctors and other providers to work with their patients so that they can decide together whether hormone therapy is right for them. Women can learn how to minimize their risks by talking about the best dose, type of hormone, delivery method, and how long to continue using it.
Q. What if I have vaginal dryness?
Dr. Pinkterton: If you have only vaginal complaints, low-dose vaginal estrogen and other tested therapies, such as the new intravaginal hormone DHEA, are recommended in lieu of oral or systemic hormone therapy.
Q. What dose should I take and for how long?
Dr. Pinkterton: The American Congress of Obstetricians and Gynecologists (ACOG) continues to recommend the lowest effective dose of hormone therapy be given for the shortest period of time for the relief of hot flashes and other menopausal symptoms. But the North American Menopause Society says this may be inadequate or harmful for some women. We recommend a dose that provides the most benefit with a minimal amount of risk, with decisions made by doctors on a case-by-case basis.
NAMS also supports the use of hormone therapy beyond age 65 if unrelenting symptoms of menopause persist or women can’t take other bone-supporting medicine and are at high risk of bone loss or fracture. That recommendation includes ongoing, close surveillance and careful monitoring to identify potential health risks.
Q. What’s the update on bioidentical hormones?
Dr. Pinkerton: All major medical organizations do not recommend the use of non-government approved compounded bioidentical therapies. Compounded hormone therapies lack safety and efficacy data, are not monitored or regulated by the government, and have unique risks associated with compounding itself. These include concerns about sterility, impurities, over- or under-dosing, which could increase cancer risk, and lack of a label providing warnings about potential risks.
Q. What about the use of hormone therapy to prevent heart disease?
Dr. Pinkterton: None of the three organizations (ACOG, NAMS, and the endocrinologists) support the use of hormone therapy at the time of menopause to prevent heart disease, even though they recognize that fewer heart events and fewer deaths have been seen in the women who started hormone therapy between ages 50 and 59 in the large Women’s Health Initiative trial.
Q. What’s the link between the use of hormone therapy and breast cancer risk?
Dr. Pinkerton: The relationship between estrogen and the breast is complex. For women under age 60 or those within 10 years of menopause, the risk of breast cancer was low when using estrogen combined with progestin, as seen in the Women’s Health Initiative study. However, fewer cases of breast cancer were seen in women who received estrogen alone. And in observational studies, the micronized form of progesterone appears to pose less risk of breast cancer. Longer use of estrogen alone may increase the risk of breast cancer, but it may take 15 or 20 years to be significantly different from not using it.
What else you should know
Once you begin hormone replacement therapy, you should regularly visit with your provider to assess how the therapy is working and discuss whether to continue using it for another year.
Your provider should inform you of the potential of increased risk of breast cancer during hormone therapy as well as after you discontinue it. He or she should set up a breast cancer screening schedule for you to follow. Also, be sure to let your provider know about any unusual vaginal bleeding you may have experienced or any bothersome side effects or concerns.
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Known as The HealthGal, expert contributor Amy Hendel is a popular medical and lifestyle reporter, nutrition and fitness expert, columnist, and brand ambassador, as well as a health coach. Trained as a physician assistant, she maintains a health coach private practice in New York and Los Angeles. Author of The Four Habits of Healthy Families, you can find her on Twitter @HealthGal1103 and on Facebook at TheHealthGal. Her personal mantra is “Fix it first with food, fitness, and lifestyle.”