Q&A: The ‘ifs’ and ‘buts’ of hormone therapy

Q: Last year, I tapered off hormone-replacement therapy after reading about the health concerns. Since then, I’ve aged 10 years! I’m considering going back on it, but I am confused and worried. What are the alternatives?

A: Taking hormones should be considered a quality-of-life issue. It sounds like you are not happy with you how feel off hormone-replacement therapy.

There has been major concern about the safety of hormone-replacement therapy (HRT) since the 2002 announcement that the HRT portion of the Women’s Health Initiative (WHI) was being halted. (The WHI is a government study of the health of post-menopausal women.) Many women stopped taking their hormones.

But this study is not the final word on all hormone use. It has left many questions unanswered.

Premarin is the form of estrogen most prescribed in the U.S. and most used in studies. It is derived from the urine of pregnant mares.

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One branch of the study looked at the effects of Prempro, which is Premarin combined with Provera, a synthetic progestin.

The results showed that, over the course of a year, if 10,000 women taking Prempro were compared with 10,000 not taking this HRT:

• 8 more would develop invasive breast cancer
• 7 more would have a heart attack
• 8 more would have a stroke
• 8 more would have blood clots in their lungs.

The increased risk of breast cancer didn’t appear in the first four years, whereas the risk of blood clots was greatest in the first two years.

But — and there always seems to be a “but” — there were some positive outcomes:

• 5 fewer would have hip fractures
• 6 fewer would get colorectal cancer.

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There are more “buts.” Some of the women did not continue taking their hormones during the study, many were overweight and some smoked.

What’s more, the study looked at older women (average age 63), so it didn’t address the issue of HRT at the onset of menopause.

More recently, information on the Premarin-only branch of the study was released. There was no increased risk of breast cancer, but there was an increased risk of stroke — 12 per 10,000 women. This and other studies have made it clear we should not take estrogen to prevent or treat heart disease.

“Aging” is not considered a reason to medicate you. If, however, after going off HRT you have severe hot flashes, night sweats, short-term memory loss or sleep problems, you may want to do something about these symptoms.

If you have heart disease or are at high risk for stroke or breast cancer, there are other medications you can consider, such as antidepressants and anti-seizure medications.

In scientific studies, most herbs and soy supplements have not lived up to their hype, though black cohosh has been found to be slightly better than placebo. The brand most tested is Remifemin.

If you have no underlying risk factors for heart disease, stroke or breast cancer, you can consider going back on HRT, but at a lower dose. The FDA has released a warning about all forms of HRT, stating that “the lowest amount should be used for the shortest time to reach your treatment goals”.

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If you are leery of Premarin, there are other types of estrogens and delivery methods worth considering. These include transdermal estrogen (a patch) and transvaginal estrogen (a ring). Both provide estradiol, the form of estrogen made by the ovaries, which is released over time.

Because this non-oral route lets the estrogen be absorbed without first passing through the liver, it is less likely to increase clotting factors or lipids such as triglyceride. Many doctors believe this is a safer way to provide a steady level of estrogen.

The so-called “bio-identical” hormones are derived from plants and are generally supplied through compounding pharmacies. They include estradiol plus weaker estrogens found in the body.

Bio-identical, however, does not mean bio-better. I always prefer medications under FDA regulation. Those made by compounding pharmacies — pharmacies that mix drugs to create new formulations — do not have the same oversight as those made by pharmaceutical companies. There can be variations among batches, along with contaminants.

Dr. Reichman’s Bottom Line: If lack of hormones diminishes your quality of life, you don’t have to suffer. Consider alternatives, different doses and different delivery methods. When it comes to HRT, one size does not fit all.

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You willl find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published by William Morrow, a division of HarperCollins.

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