Are Benefits of Hormone Replacement Therapy Greater Than the Risks?

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The number of American women who take medication to manage menopause plunged after 2002.

That’s when news came out that hormone replacement therapy (HRT) could increase the risk of breast cancer, heart disease, stroke, and blood clots.

Yet major medical organizations like the Endocrine Society, North American Menopause Society (NAMS), and the American College of Obstetricians and Gynecologists (ACOG) say that HRT offers more benefits than risks for many women.

Even after the age of 60, American women often experience frequent hot flashes and night sweats, according to a new study of more than eight years of data from the Mayo Clinic in Rochester, Minnesota — and HRT is effective prevention.

The best approach is to ask your gynecologist to evaluate the risks and benefits in your own case, co-author Dr. Paru David told Healthline. “Older women should seek care,” she said.

Beyond hot flashes, a dry vagina after menopause can make sex painful or cause urination problems. Estrogen applied directly to the vagina, which doesn’t pose any risks, helps.

But though approximately a third of all women eventually experience unpleasant dryness, new research shows that only half of them tell their doctors and less than 4 percent get treated with vaginal estrogen.

When do menopause symptoms start and how long do they last?

You’ve entered menopause when you haven’t had a period for 12 months in a row.

That moment ordinarily arrives between the ages of 48 and 55, generally after a transition with inconsistent bleeding.

Up to 80 percent of women experience hot flashes, technically called “vasomotor symptoms.”

Heat rises in the chest, face, and head, followed by flushing, perspiration, and sometimes chills. At night, you might find yourself waking up drenched with sweat.

Those sleep interruptions make fatigue the primary symptom of menopause around the world, Robin Phillips, a New York gynecologist and editor of “The Menopause Bible: The Complete Practical Guide to Managing Your Menopause,” told Healthline.

Doctors previously thought that vasomotor symptoms lasted from six months to two years, but they can last much longer. Half of all women who experience frequent hot flashes live with them for more than seven years, according to another major study.

If your first hot flashes come while you’re still bleeding, the median (half less and half more) is nearly 12 years.

African American women and women with more depression or anxiety also tend to endure symptoms longer.

“We had women coming for help with menopause in their 60s, 70s, and 80s,” David said. “So we looked into the data.”

The Mayo team found that more than 40 percent of women age 60 and up reported “moderate” or “severe” symptoms.

However, David pointed out that 60-plus women who were taking hormones had no hot flashes or night sweats.

Although HRT is the most effective treatment, Dr. JoAnn Pinkerton, executive director of the North American Menopause Society and professor of gynecology at the University of Virginia Health System, warned that it’s not as safe for older women.

“The risks are likely to outweigh the benefits for women starting hormones more than 10 or particularly by 20 years from menopause or over age 60, and certainly starting after 70,” she said.

Patches may be safer

According to Phillips, receiving the hormone through your skin — in a patch or gel, rather than a pill — is much safer.

She points out that the problem with pills is that they’re synthesized through the liver.

Phillips says she discusses transdermal HRT with all her patients, pointing out that HRT may actually protect women against breast cancer, a conclusion from research conducted in Finland.

That research showed that taking estrogen alone, rather than a combination with progesterone, appeared to protect Finnish women against heart disease and stroke.

To get the heart protection, “you have to start within a few years of your last period,” Phillips said. “It’s debatable whether it helps if you start later.”

Pinkerton notes other evidence linking estrogen with fewer cases of heart disease but remains concerned, especially as women age.

“NAMS does not recommend using estrogen therapy (oral or transdermal) to prevent heart disease” she said.

As for stroke, “observational studies show fewer blood clot risks and stroke with transdermal estradiol [a patch], but that is not the same as preventing stroke,” she said.

Phillips and David also point to data showing that taking estrogen may lower the likelihood of dementia, if you start early.

The Cochrane network of researchers, analyzing studies that focused on U.S. data and oral HRT, reported in 2017 that taking estrogen alone lowered the risk of breast cancer and bone fractures and didn’t increase heart disease.

However, in this data it appeared to raise the risk of blood clots, stroke, and gallbladder disease.

Combination therapy also raised the risk of heart attack, breast cancer, gallbladder disease, and death from lung cancer.

Who shouldn’t take HRT?

“We worry about women who are at elevated risk of heart disease, have untreated hypertension, atherosclerotic plaque, or are at high risk for dementia or have changes already present in their brain on MRI scans,” Pinkerton said.

You should also be wary if you have an elevated risk of blood clots or stroke, have had an estrogen-sensitive breast or uterine cancer, or liver issues.

The risks may go up at higher doses, the longer you use a medication, or as you age.

When looking for an alternative to hormones to treat hot flashes, David said, “I tend to pick a drug that will benefit patients in another way. If she has a mood disorder, perhaps Effexor or another SSRI [selective serotonin reuptake inhibitor]. If she has chronic pain, gabapentin.”

Pinkerton also notes that clonidine patches, a high blood pressure treatment, has been helpful “off-label,” meaning it hasn’t been approved for that purpose by the U.S. Food and Drug Administration (FDA).

“Nonprescription therapies that have shown benefit in clinical trials include hypnosis, cognitive behavioral therapy, and possibly acupuncture,” she added.

Beyond hot flashes

About half of all women in menopause end up with vaginal dryness, which is uncomfortable and can make sex painful.

For many, urination becomes an issue — waking up frequently to urinate, leaking while sneezing, or embarrassing accidents.

Estrogen (generic estradiol or Vagifem) pills that are fired with a dispenser into the vagina, helps both dryness and urination problems.

Phillips advises that ring devices that release estrogen in the vagina continually at a low dose for three months can help as well.

Estrogen in the vagina doesn’t pose any risk (or benefit) to the rest of the body, since it isn’t absorbed elsewhere. But you might hear otherwise from one of your doctors.

“Many family doctors, internists, and some oncologists don’t really understand that only a small amount of vaginal estrogen is absorbed if low-dose estrogen is dosed appropriately,” noted Pinkerton. “The boxed warning scares women and their partners, even after we have explained the minimal absorption and that the… risks of systemic estrogen and progestin given to older women do not apply to these low-dose vaginal products.”

A recent study found that the pills did no better at taming dryness than a placebo over three months. But Phillips pointed out that this treatment only works in three months for someone who entered menopause recently.

“The estradiol has to attach to receptors in the vagina and the receptors have to build up, so in some people it can take longer to work. I’ve seen it take two years of treatment for the vagina to completely recover,” she said.

The standard dose is 10 milligrams twice a week. But Phillips said some women need more. “I tell women to go up to three or four times a week until they feel the vagina is where it should be. Then they can go to twice a week for maintenance.”

Should you take hormones?

Only about a quarter of all women in menopause need treatment, Pinkerton noted.

If you do try it, you may not have to continue for long.

“Most women, even if they start hormone therapy, don’t continue as long as a year,” she said.

The bottom line?

Most women can safely take HRT within 10 years of menopause for hot flashes. Also, estrogen in the vagina is an under-used safe remedy for other symptoms.

Talk to your doctor about your own risk and benefit calculation so you can make the decision that’s best for you.

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