Are you in menopause and afraid to take estrogen? It's been 10 years since one of the most significant papers in women's health was published -- a study on the risks and benefits of estrogen plus progestin in healthy postmenopausal women. The WHI papers scared the hell out of women and many of their doctors (see below). But during the 10 years since the study was published, new studies have disproven many of the findings. But harm was done for women; the fear prevented many women from taking estrogen that could have prevented terrible symptoms, and those women suffered. I want to help you make sense of these important studies.
First, let's look at what the studies were supposed to do.
At that time, estrogen plus progestin (notice, not progesterone which is the natural hormone, but progestin, a synthetic substance that the woman's body responds to similarly to how it responds to progesterone) were being recommended for all women in menopause to lower the risk of heart disease as well as treat symptoms of menopause such as hot flashes and vaginal dryness. Postmenopausal women ages 50 to 79 (mean age 63) were given different formulations of the most common estrogen and progestin medications in use at the time.
Giving hormones to older women, they thought, would lower their risk of heart disease and so the study didn't take into account how old the women were, how long it had been since they started going through menopause, or if they were at risk for any other diseases. Hormone Therapy (HT) was considered both good and safe.
There were two hormone studies that were started about the same time. The first involved giving some 16,000 women either estrogen and progestin (Prempro -- the most commonly used hormone of this type at the time) or placebo. That study was stopped three years early because the risks were greater than the benefits. Not only did HT not protect women from heart disease, the study reported an increased risk of blood clots, stroke, heart attack and breast cancer. There was however, an equally lower risk of colon cancer and risk of breaking your hip.
The second study also followed a large number of women. But this group of women had their uterus removed (hysterectomy) as well as their ovaries. Women who have their uterus removed do not need to take progesterone or progestin -- only estrogen. Once again, the study was stopped early because the women taking estrogen had an increased risk of stroke compared to those who took a placebo. However, compared to the women in the first study who took estrogen and progestin, these women who took estrogen only didn't have an increase of breast cancer or heart disease.
Postmenopausal women threw away their estrogen in droves and endured a very challenging window of time. So challenging, in fact, that many of my patients who initially went off their hormones called me up and within three to six months wanted to get back on them. But in that year after the WHI was first published, between 25 and 72 percent of women stopped taking HT.
Over the past decade since those initial WHI studies were done, many of their conclusions have changed. Here are my thoughts on the highlights.
- Estrogen and progesterone, now called HT instead of HRT, is still the most effective treatment for symptoms related to menopause.
- HT is a very reasonable and safe treatment for menopausal symptoms for many women, but it can't be the only treatment we offer. Some women, especially those with a history of breast cancer or uterine bleeding or blood clots or who smoke, should talk with their doctors about alternatives to HT.
- If you want to go on HT or consider going on it, there seems to be a critical window of time to start -- the closer to the onset of menopause the better. Ten years after menopause, it may be too late to start HT.
- Treatment must be individualized and not assume that "one size fits all."
- Estrogen taken through the skin seems to be less of a risk for blood clots than estrogen taken by mouth.
- HT works great for preventing osteoporosis or thinning of the bones
- Estrogen only may reduce (not increase) the risk of breast cancer.
- Estrogen may reduce the risk of stroke in certain subgroups of menopausal women.
If you are interested in taking estrogen and/or progesterone or want to consider it as a possible treatment for your symptoms, talk with someone who is knowledgeable about these medications. It isn't the same as going in for an antibiotic -- it will take time for the health professional to understand your personal risks, explain what the benefits and risks are for you, and provide you with an explanation of your options. When I see patients for these types of discussions, I allot nearly an hour to go over everything. Make sure you find the right person to work with you.
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