HRT: Rethinking Hormones Again?

I’m approaching menopause and understand that medical thinking about hormone replacement therapy (HRT) has shifted in favor of giving hormones to women in their 50s and that the risks of heart disease and breast cancer aren’t so bad after all. What’s the story?

– August 13, 2012

I don’t think there’s any group consensus yet, but some experts have said that for women who have just reached menopause, the benefits of HRT may exceed the risks. First, some background: in 2002 the Women’s Health Initiative (WHI), a large government study of hormone replacement therapy was shut down after five years, because investigators found that for every 10,000 women on HRT, a combination of the hormones estrogen and progesterone, there were eight more cases of breast cancer, eight more strokes, seven more heart attacks and 18 more blood clots than among 10,000 comparable women who were taking a placebo. The numbers don’t sound huge, but considering that six million American women were on HRT at the time, they represented an unacceptable risk compared to the WHI’s documented benefits: six fewer colorectal cancers and five fewer hip fractures per 10,000 women on HRT than among untreated women. (For women who took estrogen alone in the WHI, the rate of breast cancer was lower than it was in women on a placebo. Progesterone is added to estrogen to prevent uterine cancer in women who have not had hysterectomies.)

What has changed in the intervening years is the understanding that the risks seen in the WHI 2002 findings applied to women in their 60s or 70s who started taking HRT an average of 12 years or so after menopause. Since then, analysis of the data has shown that women in their 50s on HRT had lower rates of heart disease than the women taking a placebo and that HRT is more protective against heart disease in this age group than aspirin or statins.

HRT also remains the most reliable means of relief for hot flashes and the vaginal thinning and dryness that accompany menopause (and can cause pain during sex).

Based on what has been learned from the mining of the WHI data, HRT may be an acceptable option for women in their 50s, particularly if they’re suffering from hot flashes and night sweats that haven’t been relieved by other measures. While the data do show a slight increase in the risk of stroke and embolism in women who start on HRT right after menopause, some studies suggest that these risks occur when HRT is taken in pill form but not when it is given via a skin patch.

I have never believed that all women need hormone replacement after menopause; my usual advice is to do a careful risk/benefit analysis before starting this therapy.

There are other options. You can protect against bone loss with weight bearing exercise and strength training; by making sure you get up to 1,200 mg of calcium plus 2,000 IU of vitamin D daily; by not smoking; by minimizing your intake of caffeine and sodas; and by avoiding excessive consumption of protein. Many women get relief from hot flashes and other menopausal discomforts with black cohosh (Cimicifuga racemosa) plus 800 IUs of vitamin E daily. Two to three daily servings of whole soy foods (tofu, tempeh, edamame, and soymilk) provide some safe plant estrogen (phytoestrogens) that also may help relieve symptoms.

Andrew Weil, M.D.

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