Weighing the Odds When It Comes to Hormone Therapy During Menopause, Every Woman Is Different

When Dr. Timothy Fitzpatrick started practicing as an ob/gyn in the mid-1980s, hormone-replacement therapy was almost universally recognized as an acceptable treatment for menopause symptoms such as hot flashes, but also as a preventative measure against heart disease and osteoporosis.

“But this came into clinical practice without any large studies that looked at a large group of women over time to try to determine the risks,” said Fitzpatrick, chief of the medical staff at Mercy Medical Center. “In retrospect, that information would have been helpful.”

Then came 2002.

That was the year a large clinical trial called the Women’s Health Initiative (WHI) reported that hormone therapy actually posed more health risks than benefits for women, including increased risks of heart disease and breast cancer. Almost overnight, doctors became less likely to prescribe it, and up to two-thirds of women on the therapy discontinued its use, often without talking to their doctors.

“They enrolled women between age 55 and 65 and studied them for five years,” Fitzpatrick said. According to the study, over one year, 10,000 women taking estrogen plus progestin compared with a placebo might experience seven more cases of heart disease, eight more cases of breast cancer, eight more cases of stroke, and 18 more cases of blood clots.

For women taking estrogen alone, the WHI found no increased risk of breast cancer or heart disease. But researchers did find that over one year, 10,000 women taking estrogen compared with a placebo might experience 12 more cases of stroke and six more cases of blood clots in the legs, plus an increase in mammography abnormalities.

Based on those numbers, the increased health risk to any individual woman is minuscule. But the story soon became a public-health concern.

“In 2002, many women decided the small risk was not worth the benefits, and that started a tidal wave of change in opinion on hormone replacement therapy,” Fitzpatrick said. “It was a large and statistically very powerful study.

“But since that time,” he continued, “a lot of work has been done re-analyzing some of the subgroups within that study, and as a result, we have a more-nuanced understanding of what the data tells us. The situation is somewhat more complicated.”

Second Look

Take, for instance, the WHI study result that women taking long-term estrogen-progestin combination therapy are at higher risk of heart disease. A 2006 study published in the Journal of Women’s Health suggests that these findings may be applicable only to older women, and that, in fact, hormone therapy with estrogen only seems to decrease the risk of heart disease when undertaken by younger women, those just beginning menopause.

Dr. Elizabeth Lee Vliet, author of It’s My Ovaries, Stupid and a nationally recognized speaker on women’s health issues, says negative reports from WHI and the concurrent Heart and Estrogen/Progestin Replacement Study “hit the media like a nuclear explosion” in the summer of 2002.

However, she writes, “each of these clinical trials used only one form of estrogen — Premarin — derived from the urine of horses, and a synthetic progestin — Provera — both hormones not at all identical to anything our bodies ever made naturally, a point rarely mentioned in the coverage. There are many well-studied, alternative, bioidentical, or ‘natural’ forms of hormones available, with fewer negative side effects.

“Why don’t we get a full picture of the studies?” she continues. “Why are the negative results trumpeted and crucial positive findings downplayed or ignored? The press shouted that there was a 26{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} increase in risk of breast cancer. What they didn’t say was that statistical increase was minute. The alarmist headlines made it appear that more women died taking hormones. This was not so.”

“In a nutshell,” Fitzpatrick asserted, “it’s clear that estrogen has a modest protective effect,” which is why it’s in common use once again to fight the effects of menopause. However, it’s no longer a universal remedy, but instead something doctors consider on a case-by-case basis.

That makes sense, he said, because while the average age for menopause onset is 51, symptoms can strike different women in different levels of intensity.

“Some women get through this and have no hot flashes, and for some women, it’s torture,” he said. “These are the ones who should consider hormone-replacement therapy for a short duration. We recognize that some women go through menopause very gracefully, and hormone-replacement therapy is for people who really struggle with significant side effects, which can include sleep disturbance and other problems.”

Vliet echoes Fitzpatrick in arguing against a “cookie-cutter approach” to hormone therapy. She notes that one form of estrogen derived from pregnant horse’s urine has been used for about 85{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all hormone-replacement prescriptions, despite the fact that bioidentical hormones have been available since the 1970s. “‘One size fits all’ is no longer acceptable. Women are individuals, with individual body chemistries.”

Eva Martin, who works at Down to Earth, a natural-foods store in Hawaii, and was a participant in the WHI study, also touts more natural alternatives to synthetic hormones.

“If a study of this magnitude had been conducted on the combination of a healthy lifestyle, natural supplements, and the natural hormone progesterone made from Mexican wild yam, we probably would have seen impressive benefits,” she writes.

“Progesterone protects the body in so many ways that they are too numerous to list here. And plant estrogens go to the same receptors as the dangerous estrogens and replace them. In addition, many wonderful supplements such as flax oil, multivitamin-mineral combinations, and special menopausal herbal formulas are now available. They may not relieve all hot flashes, but I’d rather have some of those than worry I might suddenly have a stroke or discover a lump in my breast!”

Starting Young

In any case, said Fitzpatrick, it seems that the earlier women begin hormone-therapy treatments, the better. More education is never a bad thing either, he added.

“We must strip away the myths surrounding hormones and hormone therapy,” Vliet wrote, “including such misconceptions as ‘hormones cause cancer,’ ‘all estrogens are the same,’ ‘all progestins are the same,’ and ‘how you take hormones doesn’t matter.’”

It certainly does matter, doctors say. And the more the medical community learns, the safer and more effective future hormone-replacement therapy will be.