Hormone Replacement Therapy

When results from the Women’s Health Initiative (WHI) were published in 2002 65% of women taking hormone therapy (HT) discontinued its use because of concerns over risks to long term health. Since that time 25% of those women restarted HT presumably because of intractable menopausal symptoms. The widely publicized WHI frightened many women and their physicians into not using HT for any indication. To evaluate the benefits and potential risks of HT and other medications in treating menopausal symptoms the American College of Obstetricians and Gynecologists convened a task force of experts to look at all the relevant data and issue recommendations to aid women and their physicians in treating menopausal symptoms and the role of HRT in this treatment.

Approximately two thirds of women will experience menopausal symptoms and 10-20% will find them intolerable, causing a significant adverse impact on their quality of life. Typical symptoms include hot flushes, night sweats, difficulty sleeping, fatigue, moodiness, vaginal dryness, painful intercourse and a feeling of not "being myself." Some, none or all of these symptoms may be present in differing degrees of severity. Estrogen, the active ingredient in HT, remains the most effective therapy in alleviating menopausal symptoms. However as with most medications it does have some risks associated with its use thus each woman, with the help of her physician, needs to decide if it is an appropriate choice for her. This decision should be reviewed on at least an annual basis and certainly if there is a change in health status.

Benefits of HT are an improvement in the symptoms of menopause along with a decrease in the incidence of osteoporosis and subsequent fractures. It also decreases the incidence of colon cancer. In women who take estrogen along with a progestin (to protect the uterus from increased risks of endometrial cancer when estrogen is given alone) there is an increased risk of breast cancer of approximately 20 extra cases per 10,000 women over 5 years of use. There is not an increased risk of breast cancer in those women taking estrogen alone. The risk of blood clots doubles in women on HT although the absolute risk is still low, approximately 7 extra cases of blood clots per 10,000 women taking HT.

HT used to be prescribed in the belief it would prevent the development of cardiovascular disease (stroke and heart attack). Recent studies have not shown this to be the case and it is no longer appropriate to use HT to prevent cardiovascular disease. The WHI did show a slight increase in the rate of stroke and heart attacks in HT users mainly in the first year of use. Primary prevention of cardiovascular disease should include diet, exercise, weight reduction and smoking cessation. Evaluation for other contributing factors such as elevated lipid levels, diabetes and hypertension should be part of routine health surveillance.

Women with menopausal symptoms will often want to try non-hormonal or "natural" preparations for symptom relief. Some anti-depressants are effective for the treatment of hot flushes and night sweats. Black cohosh, red clover and wild yam extract do not have a significant effect on symptoms; studies looking at soy products have had conflicting results on efficacy for hot flushes. None of these preparations have any effect on vaginal symptoms.

There are now many preparations and modes of delivery of HT. It is not known if any of these are better with fewer risks than the standard oral preparations. However with all the available preparations it does allow women and their physicians to design a regimen that is appropriate for their individual symptoms and concerns. One positive note is that it does not appear that HT causes an increase in body weight. Increases in weight around the time of menopause are part of the normal process of aging. As Dr. Deborah Smith points out in an ACOG press release "If we want to lose, we’ve got to move."

In conclusion ACOG states that HT remains an effective therapy for women with hot flushes, night sweats and vaginal symptoms. They recommend that women discuss risks and benefits of HT with their physician at least annually so they can make the best decision for themselves. Future research into HT should look at different preparations and dosages of estrogen and progestin, the effect on quality of life and optimum timing of HT administration.