Hot flashes can strike at the most inconvenient moments, soaking your clothes and melting your makeup...night sweats can steal slumber...and vaginal dryness can make sex a pain. What's a menopausal woman to do?
Surprise: Hormone therapy (HT), nearly a pariah in the field of medicine, may be the best answer for some women. Five years after major studies indicated that HT increased the risk for cardiovascular problems and breast cancer-causing women across the US to toss their HT prescriptions in the trash-HT is on the rise again.
New findings: The latest studies along with reevaluations of earlier research have helped to clarify the benefits and the risks.
Fact: HT remains the most effective treatment for moderate to severe vasomotor symptoms (hot flashes and night sweats).
About 80% of women in the US experience hot flashes during menopause. The typical episode lasts one to five minutes-though hour-long "heat waves" can occur. During a major hot flash, a woman feels as if she's being consumed by an inner fire...her skin turns red and may drip with perspiration...her heart may pound.. she may feel confused and/or light-headed... and she may experience a vague sense of dread. Menopausal women typically have several hot flashes per day, and some have 10 or more. Episodes usually persist for about four years—for a total of up to 15,000 hot flashes. I find that, for about one in four women, symptoms are severe enough to merit treatment.
But Is It Safe?
Among the general public, the term bormone therapy often is used to refer either to estrogen replacement alone or a combination of estrogen and a progesterone-like drug. Many people refer to all progesterone-replacement drugs as progestins, though the accurate all-inclusive term is progestogens (which covers natural and synthetic forms). Women who have had a hysterectomy can take estrogen alone. Otherwise, estrogen is given with a progestogen to protect against uterine cancer.
We have learned that timing is key to the safety of HT. The risks for heart attack, stroke and blood clots related to HT use are low in recently menopausal women who are in good cardiovascular health. Also, the risk for breast cancer does not increase appreciably until a woman has taken hormones for four to five years. Most women don't need HT for that long because menopausal symptoms often abate by then.
Essential factor: The amount of time since your final menstrual period. You reach menopause when you go 12 consecutive months without a period. The farther you are past menopause and the more risk factors you have for heart disease and breast cancer, the riskier HT is. (If you have hot flashes but still menstruate, low-dose oral contraceptives may be an option.)
Based on the large-scale Women's Health Initiative and other studies, here's a summary of the latest thinking…
- Heart disease. Women who began HT within five to 10 years after menopause and took it for five to seven years tended to have a lower risk for heart disease than women taking a placebo. Women who started HT more than 10 years after menopause tended to have an increased risk. The older a woman was, the greater the risk.
- Stroke. At all ages studied, HT increased the risk for stroke—but even so, for younger women, overall risk remained low. Among women who started HT in their 50s, stroke risk increased by about two cases per year for every 10,000 women.
- Breast cancer. Women of all ages who took estrogen with a progestin (a synthetic form of progestogen) had an increased risk for breast cancer after four years of use. The longer they used the combination therapy, the higher their risk. Women who took estrogen alone for seven years did not have an increased risk for breast cancer-however, estrogen-only therapy is appropriate only for women who have had a hysterectomy.
- Bone fractures. Estrogen (taken alone or in combination with a progestogen) clearly reduces bone fracture risk. However, this benefit would require long-term HT, so experts no longer recommend it as the first line of defense against osteoporosis.
If you and your primary-care doctor or gynecologist decide HT is right for you, the next step is to consider the specific options.
- Estrogen. For relief from hot flashes, products include daily pills...or transdermal skin patches worn on the arm, abdomen or buttocks and replaced once or twice weekly...or a transdermal cream, gel or spray applied to the arms, legs or buttocks once or twice daily. Compared with oral estrogen, transdermal estrogen may be less likely to increase the risk for blood clots. Most doctors agree that with oral or transdermal estrogen, a progestogen also is needed unless a woman has had a hysterectomy.
- Progestogen. Oral progestogen may be used daily or taken 10 to 14 days of each month. Topical creams and vaginal gels also are available.
- Vaginal options. For women whose symptoms are limited to vaginal dryness and discomfort during sex, options include vaginal creams, rings or suppositories. In my view, it is prudent either to halt vaginal estrogen use for a few weeks every three to six months or to add a progestogen intermittently.
- Bioidentical hormones. These are laboratory-made hormones with the exact same molecular structure as hormones produced by the human body. Some people believe them to be safer than the more widely used conventional hormones-but no large-scale trials have yet been done to test this belief. If you prefer to use bioidentical hormones, feel free. However, for now it is prudent to assume that all hormone formulations confer a roughly similar balance of benefits and risks.
Usage guidelines: If you decide to use HT, start with the lowest recommended dose. If symptoms do not diminish within four weeks, talk to your doctor. You may need to increase your dose incrementally until you find the dosage that works for you. After one to three years, your doctor may recommend gradually reducing and then discontinuing HT. If symptoms return, resume HT for another six months. I recommend that the total time spent taking HT be less than five years.
Is Hormone Therapy Right for You?
The answer depends on the intensity of the symptoms, how long ago you entered menopause and your overall health.
A good candidate…
- Has hot flashes and/or night sweats severe enough to interfere with sleep or reduce quality of life.
- Had a final menstrual period less than five years ago (some studies suggest up to 10 years).
- Is at low risk (based on personal and fam-ily history) for heart disease. stroke and blood clots.
- Does not have a personal or strong family history of breast cancer. A poor candidate…
- Is more than five years into menopause (some studies say 10).
- Has had, or is at high risk for, heart dis-ease, stroke or blood clots...or breast. uterine or ovarian cancer.
- Currently has unexplained vaginal bleeding, diabetes, or liver or gallbladder disease.
What? Hormone Therapy May Damage Hearing
Women who are on hormone replacement therapy (HRT) with progestin are more prone to a type of hearing loss that makes understanding speech difficult than women on estrogen only or not on hormones.
Self-defense: Women on MT who suffer hearing loss should discuss alternatives with their doctors.