New Findings on HRT (hormone replacement therapy)

Original Publication Date: 03/02/2009
Last Modified: 03/09/2009
Principal Author: Marcelle Pick, OB/GYN NP

New evidence on the use of hormones for menopause

Here’s a quick overview of what’s new in HRT:

• Coronary heart disease. If HRT is initiated within ten years of menopause or in women under 60, it may help reduce the incidence of coronary heart disease. It appears that estrogen therapy alone delivers better results than combined estrogen and progestin (any hormone that causes progesterone-like effects.) The caveat for women with a uterus, however, is that they do need a form of progesterone to “oppose” potential risks of estrogen alone.
• Breast health. A closer look at the 2002 WHI data revealed that estrogen therapy alone was not associated with an increase in breast cancer risk, but that estrogen together with progestogen (synthetic progesterone) slightly increased the risk of breast cancer. This is still true, but a recent small study suggests that adding testosterone to estrogen and progestogen could help counteract the breast cell proliferation associated with cancer. In addition, the increase in women’s blood estrogen levels when they’re on HRT is associated with increased breast density, but there is also evidence that using bioidentical progesterone instead of synthetic progestin forms lessens breast density.
• Cognitive health. The 2004 WHIMS (Women’s Health Initiative Memory Study) study showed that initiating estrogen therapy or estrogen/progestogen therapy in women over 65 had a negative effect on cognition — particularly if they had already experienced some cognitive decline. But another study looking at younger women, between the ages of 50 and 63, showed that those on hormone therapy had a lower risk of Alzheimer’s disease than those that weren’t.
• Cholesterol and triglycerides. Back in 1997, the PEPI (Postmenopausal Estrogen Progestin Intervention) trial showed that women aged 45–60 on conjugated equine estrogens alone (Premarin) or conjugated equine estrogens and natural progesterone had significant increases in “good” cholesterol, compared to those receiving conjugated equine estrogens with a synthetic progestogen (Prempro). Now, we also know that bioidentical estradiol delivered across the skin reduces triglycerides, rather than increasing triglycerides as do estrogens that are swallowed in pill form — both synthetic and bioidentical.
• Blood clots. In pill forms that are swallowed, the risk for a blood clot (also known as venous thromboembolism) varies by the type of progesterone or progestogen used. The lowest risk comes with using natural progesterone and the highest comes with norpregnane derivatives (synthetic progesterones). Estrogen, on the other hand, if given transdermally (across the skin), comes with no increased risk of blood clot.

What should a woman make of all these findings? Though this new research is promising, much of it still looks at synthetic progesterone and equine estrogen (estrogen derived from a pregnant horse). These hormone forms can be patented by drug companies and are therefore molecularly different from the hormones we make in our bodies. Bioidentical hormones, those that have the same molecular structure as those made in our bodies, have been less studied, but are becoming more popular, especially with Oprah’s recent discussions. We’ve always used bioidentical hormones at Women to Women because we feel they are gentler on the system than synthetics. For more about the differences between synthetic and bioidentical hormones, see our bioidentical hormones article.

Above all we have to remember that hormone therapy, synthetic or bioidentical, is not the right choice for every woman — because we all have our own unique set of circumstances. In my practice, I evaluate each HRT case individually, at each appointment. Every time I see a woman on or considering HRT, we discuss individual risks, look at the recent research, and discuss her quality of life, so each woman can make an informed decision about starting or continuing bHRT on her own terms. And I generally recommend women stay on hormones for fewer than five to seven years.

Risks and benefits of HRT — individuality is central

Do the benefits outweigh the risks for you?

Consider these questions while making your decision about HRT:

• Are you less than 60 years old?
• Are you close to menopause and still having symptoms?
• Does your personal or family medical history include breast cancer, endometrial cancer, or liver disease?
• Is your quality of life being seriously compromised by your symptoms?

When I sit down with a woman considering hormone replacement therapy, I always look at her age, proximity to menopause, medical history, and her quality of life. Quality of life is so important, and it’s something conventional practitioners often dismiss if the research shows any kind of risk associated with a given treatment. I have one patient who was diagnosed with breast cancer years ago, and even after the 2002 WHI results came out, she decided she’d never go back to life without bio-HRT. I’ve always respected her position. (Keep in mind, we’re checking her hormone levels yearly — sometimes twice a year — and she’s taking bioidentical HRT.) Each woman, especially when given the information to make an educated decision, has the right to decide what is best for her body.

Take a look at the questions in the box to the right. Researchers tell us that the risk profile for hormone replacement therapy goes down in women under 60, women less than ten years from menopause, and women who don’t have a history of breast cancer, endometrial cancer, or liver disease. In my opinion, whether or not your hormones are still fluctuating is a more important consideration than whether it’s been less than ten years since you entered menopause. It is safer to introduce HRT when hormones haven’t tapered off yet.

If you think about it logically, reintroducing hormones when the system has adjusted to life without them — like the majority of women enrolled in the WHI study (average age 63) — doesn’t make much sense. Their estrogen and progesterone receptors have most likely diminished in activity, and adding hormones when the body isn’t expecting them or in need of them sends mixed messages. I’ve heard some patients describe menopause and perimenopause like a plane crash — you can feel it coming and then suddenly you hit the ground. I know that your perspective on life can change with the fluctuation of your hormones — after all, the body and mind are intimately connected. But supplementing those hormones as close to menopause as possible can “soften the landing,” so there is less shock to the system.

Each woman has a different set of circumstances that determine her personal risk, but based on the new evidence and what I’ve experienced in practice, the safety of HRT is enhanced if the following guidelines are met:

• It is given to younger women (under 60), who are close to menopause and whose hormones are still fluctuating.
• The woman does not have a history of breast cancer, endometrial cancer, or liver disease.
• The woman uses bioidentical hormones as opposed to synthetic HRT.
• The woman uses transdermal, transvaginal, sublingual, or “melt” forms of HRT instead of pills that need to be swallowed.
• Hormone replacement therapy doesn’t go on for more than five to seven years.