Article By: Amy Jamieson, Healthline Media - Fact checked by Maria Gifford - READ ORIGINAL ARTICLE
While hormone replacement therapy, referred to as HRT, is frequently prescribed to treat symptoms such as hot flashes, it has also been the subject of debate following a 2002 study that found the therapy can increase a woman’s risk of breast cancer, heart disease, stroke, and other conditions. So, the question remains: Even with these associated risks, are hormones the best treatment for menopause symptoms?
Experts say hormone therapies such as estrogen and progestin are probably still the best treatment for menopause symptoms.
Questions have been raised about these therapies after a 2002 study indicated they can raise the risk of some cancers as well as heart disease.
Experts say hormone therapy is relatively safe if implemented while women are entering menopause and used for a short period of time.
They note there are alternatives that include creams as well as diets.
The symptoms of menopause can be the punch line of jokes, but in reality there’s often nothing funny about them.
“I always say that just calling them a hot flush just really trivializes just how bad they can be. It almost sounds like some pleasant feeling on a cold night — not at all,” said Dr. Hugh Taylor, chair of obstetrics, gynecology, and reproductive sciences at the Yale School of Medicine in Connecticut, who will discuss some of the latest developments in hormone therapy this week at the virtual 2020 pre-meeting symposium of The North American Menopause Society (NAMS).
While hormone replacement therapy, referred to as HRT, is frequently prescribed to treat symptoms such as hot flashes, it has also been the subject of debate following a 2002 study that found the therapy can increase a woman’s risk of breast cancer, heart disease, stroke, and other conditions.
So, the question remains: Even with these associated risks, are hormones the best treatment for menopause symptoms?
Experts say there’s a lot of issues to discuss.
“I think that it’s important to know that some people really do need relief from hot flashes and what we call vasomotor symptoms, the whole constellation of the flashes and night sweats and the heart racing anxiety, sweating, and all the other things that accompany it,” Taylor told Healthline.
“And even if there are small risks, they’re very, very small, and for some people those hot flushes can be truly disabling,” he added.
Healthline asked experts to explain the hormone therapy debate, what symptoms hormone therapy most effectively treats, and to share some alternatives.
The great debate
At the heart of the hormone therapy debate is the 2002 Women’s Health Initiative (WHI) studyTrusted Source that concluded that the overall health risks exceeded the benefits from combined use of estrogen and progestin among healthy postmenopausal women.
If you’re a doctor treating menopausal women, you’re consistently asked about it.
“Every day, yes,” said Taylor, who has studied the molecular mechanisms of estrogen. “I’ve got to say I never get tired of it because I really feel like there’s so much misinformation out there… and I feel like I’m doing something very useful.”
Dr. Wen Shen, an assistant professor of gynecology and obstetrics at Johns Hopkins Medicine in Maryland, concurs.
“Fifty percent of the patients that come in are like yes, yes, yes, give me hormones, I want it, I need it — and are very happy to walk out with prescriptions for it,” Shen told Healthline.
“But the other 50 percent are very leery of hormone therapy, and they would want to try everything else before they go on hormone therapy,” she said. “A big part of my job is to educate patients.”
Experts tell Healthline that the study had some caveats and the results are often misinterpreted.
“A lot of people, yes, are still going on the misinformation that was presented by the WHI,” Shen said. “The amazing thing was that the trial was stopped and was evaluated and scrutinized, so we’re talking about 20 years ago. People are still misunderstanding it.”
The study examined the effects of the combination of estrogen and progestin as well as estrogen alone in postmenopausal women.
The average age of the women in that trial was 65, Shen said, while the average age of women going through menopause is 51.
“When you hit 60, a lot of physiologic changes occur that makes it bad medically for you to start on hormone therapy and especially the only hormone therapy that they used in that trial, which was the oral conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA),” she explained.
“There’s a lot of data that has come out now that shows women who start on hormone therapy very close to their menopause or even during their perimenopause, before they become postmenopausal, actually are healthier and have greater longevity and that is attributed to the beneficial effects of estrogen on heart health, bone health, and brain health, in early stages of menopause,” Shen said.
Education is key to understanding the risks associated with hormone therapy.
“I explain to patients about how not all estrogens and progesterones are created equal,” Shen said.
“There are different side effects and different benefits to the types of estrogens,” she said. “And I explain to them how the estrogen patch is overall much safer and lower in the risks that were found from the WHI.”
Shen believes women can make smart decisions for themselves when they’re “fully apprised of the different pros and cons, instead of harboring misinformation and fears that are unfounded.”
For Dr. Julian Schink, chief of gynecologic oncology for the Cancer Treatment Centers of America in Illinois, hormone therapy is an option for helping women get through menopause, but it’s one that “needs to be taken with a grain of salt.”
“Hormone replacement therapy kind of came to a screeching halt in the early 2000s,” he explained. “The number of prescriptions for hormone therapy dropped significantly, and at that same time the new diagnoses of breast cancer also dropped significantly in the United States.”
The WHI study changed the way Schink treated patients.
“I will freely admit in the 1990s before the WHI data came out, I was an avid proponent of hormone therapy and very strong proponent of it,” he told Healthline. “I changed my opinion. I changed my practice based on those results and have not changed back.”
For many women, especially those with a history of cancer, hormone therapy may not be on the list of options.
“Granted, I’m an oncologist and I practice in a cancer center,” Schink said. “When patients are concerned that the treatment might increase in any way, even the slightest bit, their risk of developing cancer or in particular breast cancer, the vast majority of them have no interest in that treatment.”
While Schink acknowledges that there are critiques of the WHI study, like the average age of the women in the trial, he added, “in the first decade of the 21st century, the number of breast cancer deaths went down in the United States, too, and many have opined that that was because we decreased the amount of hormone therapy we’re doing. (We) can’t say for certain, but it’s a concern.”
Taylor agreed that there are women for whom hormones aren’t an option.
“Anybody who’s had estrogen sensitive cancer, which is typically a breast cancer, should not be taking hormones,” he said.
“There are some clotting disorders that are exacerbated by estrogen,” he added. “So people who’ve had known blood clotting disorders should avoid estrogens.”
What symptoms can hormones treat?
“There’s nothing right now out there that works anywhere near as well as estrogens for controlling those hot flushes, night sweats,” Taylor said. “I think [some] of us, like males who haven’t gone through menopause, probably underestimate how severe these symptoms can be.”
“For some women, yes, hormone therapy definitely is the best answer,” Shen added.
If you’re symptomatic and “your quality of life is in the tank,” she explained, you’re a good candidate.
“(If) you can’t function, you can’t think, you can’t work, you’re irritable, you can’t be intimate with your partner because you have severe vaginal symptoms — if your life is everything I just mentioned then it’s pretty miserable,” Shen said. “So, for women like that, then definitely hormone therapy is the proper treatment.”
A study that’s also being discussed at the NAMS meeting this week concludes that hormone therapy can slow the progression of atherosclerosis.
However, hormone therapy isn’t something that’s recommended for women who are 10 years or more out from their last menstrual period, Shen said.
This is because of physiologic changes that have occurred during that decade that makes starting hormone therapy more tricky, putting women at higher risk for strokes and heart attacks.
“What the research is showing is that the estrogen patch that we now prescribe for most patients do not seem to increase that risk for stroke and heart disease,” she explained. “All that (WHI) data was based on research done on oral combination conjugated equine estrogen and medroxyprogesterone acetate and so there are very different hormone therapies available now that are safer.”
Taylor said that hormone therapy shouldn’t be used for life and reinforced that the treatments “shouldn’t be started in people that are remote from the time of their menopausal transition.”
Schink agreed that hormones are singularly most effective at treating hot flashes, but he stressed that menopause treatment requires an individualized approach and that it’s important to ask yourself several questions first.
“One, is that potential increased risk of breast cancer acceptable to you individually?” he said.
“Two, would you need to have estrogen alone, or would it be estrogen or progesterone?” he continued. “If you have a uterus, then you should have estrogen and progesterone, otherwise the lining of the uterus gets overly stimulated and you have a risk of uterine cancer, if you just take estrogen alone.”
If your uterus has been removed for some nonuterine cancer-related reason, which is true for a significant percentage of postmenopausal women in the United States, Schink said that you can be treated with estrogen alone and get symptomatic benefits.
“There are subsets of women, especially women who don’t have a uterus, where estrogen alone may be a relatively safe option,” he added.
“It’s all about individualized therapy for the patient, recognizing that you first have to ask that question: What problem are you trying to solve? Are you trying [to] address a patient’s symptoms? Are you trying to address osteoporosis, vaginal dryness?” Schink said.
“Because each of those symptoms also has an alternative therapy as well, which is why it’s further complicated over the last 20 years,” he said.
Dr. Jordin Wiggins, a naturopathic doctor and sexologist, said she may prescribe hormone replacement therapy after assessing a woman’s risk and needs.
“Hormone therapy can cause a major improvement in the quality of life for the women that I treat,” she told Healthline. “Some women say they feel better than they have since they were in their 20s with the right hormone balance.”
“They are able to get back to their activities of daily living, back to enjoying sex, and repair relationships that were negatively impacted by mood and mental health,” she said.
There are alternatives
Hormone therapy is one of many treatments available to women, according to experts.
“It represents one of many options to deal with the many side effects, symptomatic side effects, and physiologic side effect of menopause. It’s one option, but there are many others,” Schink explained.
For vasomotor symptoms such as night sweats and hot flashes, Schink said selective serotonin reuptake inhibitors (SSRIs) may be considered.
“We have found that SSRI drugs, which were developed for the treatment of depression but also have the side effect of decreasing — not preventing — but decreasing the severity of hot flashes,” he said. “So that can help mitigate the side effects and some women choose to take those and find them to be helpful.”
Raloxifene, bisphosphonates, and other IV medications that are taken once a year can effectively treat postmenopausal osteoporosis, Schink said.
For vaginal atrophy — thinning of the walls of the vagina — Schink said topical estrogen is an option “that most people feel is not a significant risk of causing breast cancer or contributing in any way to breast cancer risk.”
Certain plants, said Wiggins, can be safely used to modulate hormones. She suggested nutritional therapy as an alternative, too.
“We use a 3-month program, the Hormone Code, to balance hormones/reduce symptoms, decrease inflammation, and optimize metabolism,” Wiggins explained. “Many women who are committed to a lifestyle change will see staggering improvements in their hormonal symptoms with the right direction and support.”
For vaginal dryness, urinary urgency, and painful intercourse, Shen suggested dehydroepiandrosterone (DHEA), as well as vaginal estrogens, and oral selective estrogen receptor modulators (SERMS) — the latter she considers one of the more promising developments right now.
“I think the most promising developments are all the research that’s going on for SERMS and tissue selective estrogen complex (TSEC). These are very selective estrogen receptor modulating compounds that can specifically target organs in the body,” she explained.
“For example, there are SERMS that specifically will target the breast and the uterus but nothing else and there are specific SERMS that can help with a woman’s vaginal symptoms and maybe even help increase her bone density but will not stimulate the hormone receptors in her breast or in her uterus,” she said.
“Being able to specifically target organs like that, I think will be very helpful because a lot of women during aging develop different medical issues,” she added.
In his presentation this week, Taylor will spotlight fetal estrogens as a promising new development in the years to come.
“The fetal estrogens aren’t there yet, but I think for the young newly menopausal woman, she should still feel that if she’s systematic that she can safely use hormones, but knowing that in the next few years we’ll probably have some safer ones for maintenance long term,” he explained.
“I think again, the consensus is women should still feel safe [taking hormones] but even better stuff is on the way — and somebody who starts on these traditional preparations may be able to switch over to one of these newer ones when they become commercially available,” he said.