Ask Dr. Lauro
Hormone Replacement Therapy
By Dr. L. William Lauro
For many years physicians believed that giving post-menopausal women "hormones" was both desirable and harmless. We believed that by replacing the hormones lost after menopaus, we could reduce the risk of heart attack and stroke, build bone density, and, at the same time, alleviate the many bothersome symptoms of menopause such as hot flashes, mood swings, insomnia, irritability, decreased sex drive and the like. We believed that hormone replacement therapy could put a woman back on the path to pre-menopausal youth and vitality. And we further believed that these "wonder drugs" were basically harmless.
Then about twenty years ago reports started emerging which caused a great deal of concern in the medical community. It seemed that women placed solely on estrogen after menopause were developing uterine cancer at an alarming rate. Researchers discovered that giving estrogen without the other female hormone progesterone set them up for uterine cancer. New guidelines were formulated at that time which seemed to solve the problem. Progesterone was to be added to the estrogen, and this seemed to essentially eliminate the uterine cancer scare. Once again everyone was happy with our "brilliant" post-menopausal regimens.
Then about ten years ago another concerned emerged. It seemed that the post-menopausal women taking hormone replacement medications were developing breast cancer at a slightly higher rate than those women who did not take the medications. Physicians, as well as the public, were once again alarmed; but this time the consensus surrounding the right course to take in view of these disturbing studies was not as clear-cut. Some researchers argued that the studies had been flawed, that there had been too few patients enrolled in the studies, etc. Some physicians were reluctant to even entertain the possibility that these hormones we had been using for years could be causing breast cancer. Other physicians, however, were very concerned that the new studies showing this link between hormones and breast cancer were indeed accurate, and were then left to wonder if they should stop giving hormones altogether.
So ten years ago we were asking ourselves this: in light of all this confusion, what are we to suggest to our post-menopausal patients? Were we to stop giving hormones to all women on the grounds that a few additional breast cancers were being caused each year by taking hormone replacement, while at the same time the drugs were doing so much good, such as reducing heart attack, stroke, and osteoporosis? The answer at that time appeared to be an emphatic no. Medical authorities decided that the hormones should still be offered because of all the good they do, but of course the public should be informed of the slightly increased risk of breast cancer. Then the patients could decide for themselves if they wanted to take this extra risk as a trade off for the good the hormones were doing. Additionally, physicians decided that we would closely monitor women placed on hormone replacement therapy for the very slightest or earliest signs of breast cancer. Once again everyone was fairly happy with the direction of post-menopausal treatment using hormone replacement.
A Major Bombshell
Then a year ago a major bomb shell exploded on the scene when a comprehensive study of post-menopausal women using estrogen and progesterone replacement therapy showed that these drugs did not reduce a women's risk of heart attack and stroke at all. Suddenly one of the major reasons for giving hormones to post-menopausal women had evaporated! And to make matters worse, the study revealed that these drugs not only failed to protect against heart disease and stroke, they actually seemed to increase the risk for heart disease during the first year the women takes the hormones. Yikes!
Now we were really in a quandary. Hormone replacement therapy that we had advocated for years was now found to not only cause an increase in breast cancer rates but also was having a negative impact on the heart as well. And to make matters worse we also discovered that the bone building aspects of these hormones that we had trumpeted for so many years was much more modest than we had hoped for.
Now that we knew these additional facts about estrogen and progesterone, what were we to do? What were we to tell our patients? On the one hand we now knew that hormone replacement was not the safe little miracle pill we had once thought. But we also knew that without them so many women suffer tremendously with menopausal symptoms. And we also knew that these symptoms, unfortunately, don't get a lot better with the passage of time in so many women. Were we finally to the point where we were going to advocate stopping the use of hormones in all post-menopausal women?
All the questions surrounding this debate have come down to this: should those women who are being successfully treated with estrogen at this time stop their medicines and suffer the monstrous effects of estrogen deficiency? And should we prohibit new post-menopausal women from using the medications?
The Current Recommendations:
Here are the current recommendations offered by the American College of Obstetrics and Gynecology regarding hormone replacement therapy, along with my personal opinions:
First of all, if you are newly menopausal (or approaching menopause) and are not too bothered by symptoms, then don't take hormones at all. There is just no long-term benefit to be had and they probably cause more harm than good.
Next, if you are already taking hormones to reduce menopausal hot flashes and mood changes, then take the lowest dose of hormone that you can get by with and still be comfortable with your symptoms. Talk to your doctor about reducing your dose. But don't abruptly stop your medicine without discussing this with your doctor. And, if you find that you can get by without taking hormones at all and survive postmenopausal symptoms, then that is the way to go.
Next consider this: the negative impact that hormones have on the heart seems to disappear after the first year of therapy. So if you want to keep taking your hormone and you have taken hormones longer than a year, you are probably safe with respect to the increased risk of coronary disease seen with these medications. But let me once again stress this advice: take the lowest dose of hormone that you can get by with.
Next, if you have had a hysterectomy and are taking hormone replacement you should not take progesterone along with estrogen. You just do not need it (you have no uterus) and it can cause problems. But if you still have a uterus and decide to take estrogen because of postmenopausal symptoms, then you must take progesterone as well. But be forewarned, breast cancer risk appears to increase even further by adding progesterone to the estrogen.
What Are the Alternatives to Hormones for Menopause?
Many naturopathic physicians have advocated plant-derived estrogen for menopausal symptoms. These are available without a prescription. Unfortunately, studies have not demonstrated that this approach is any better than placebo. But many women swear by these plant estrogens. So my advice is this: since these plant estrogens seem to do no harm (and might even help), then try them. But if you don't get the relief you are seeking, talk to your doctor about other methods.
The best non-hormone approach we have at this time for hot flashes, insomnia, and mood changes associated with menopause are the selective serotonin uptake inhibitors (SSRI-Prozac, Paxil, Lexapro, etc). Unfortunately, while these drugs have been quite effective with menopause symptoms, they can cause a decrease in sex drive in about 25% of patients (great-you already have that problem with menopause, don't you!). Luckily most of these patients will respond to adding a low dose of Wellbutrin to their regimens.
My Final Comment:
Please don't take hormones just because someone tells you that you need it, that it will help your heart (because it won't) or make your bones stronger (because there are other safer ways to do this). Talk to your doctor and make a plan that fits your particular needs. Good luck!
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