Hormone Replacement: What You Should Know

In 2002, both women’s and the medical community’s perception of hormonal replacement was turned upside down due to risks published through a study called the Women’s Health Initiative (WHI) . The study led to great panic and an immediate squelching of the widespread use of hormones. Since 2002, many studies have evolved.  Studies have reinforced the findings of the WHI, and other studies have shed light on the limitations of the WHI study.

It is important to note that although the WHI study demonstrated an increased risk of breast cancer, it was predominately due to the combination of Estrogen with Provera, a very strong Progesterone. With this combination, the risk rose by 8/10,000 patients, and the risk of heart disease rose minimally.  In both cases, patients who were taking Estrogen alone did not have an increased risk of breast or heart disease.

Two other factors which reduced the relevance of the study must be kept in mind:

1. The mean age of patients studied was 63-years-old.
2. 50% of the patients either had or were actively smoking.

The study also neglected to emphasize the improvement in bone structure, reduction in life threatening fractures, reduction in colon cancer, and improvement in quality of life for those with symptoms presented.

It is essential to consider risks in proper context.  As an example, the overall risk of breast cancer over one’s lifetime is 1/10, and the risk of breast cancer in women who do not get adequate exercise is increased by 35/10,000, much greater than the minimal risk of hormone therapy.

In order to explore the real worth of hormone treatment we must consider several variables including:

1. How age might affect the risks and benefits
2. The theoretical and practical advantages of one type of therapy over another.

What we know today:

• Estrogen and Provera (very strong progesterone used in the WHI study) resulted in minimal increased risks in breast cancer and minimal risk of heart disease.
• Estrogen use alone does not cause an increase in breast cancer.
• Estrogen alone, especially transdermal, in early menopause reduces the risk of heart disease.
• Estrogen mildly reduces the risk of colon cancer
• Estrogen combats bone loss and life threatening fractures
• Estrogen protects the aging and thinning of the vaginal mucosa
• Estrogen improves the quality of life in symptomatic people.
• Certain studies have shown a decrease in overall mortality of 30% in early menopausal users of Estrogen treatment

What we don’t know yet is how combinations of weaker progesterone along with Estrogen will affect risks.

Take home message:

The benefits of Estrogen therapy in early menopause (under age 65) certainly outweigh the risks and should be considered for patients whose symptoms warrant treatment. If the patient does not have symptoms that warrant Estrogen treatment, she should discuss the benefits with her physician before empirically taking hormone therapy because there may be alternative medications that can be used for patients with mild or few symptoms. At this point in time there is not enough information about the combination of Estrogen and weaker progesterone to give clear cut answers to patients.  Patients who have severe symptoms should consult their doctor and review the small risks that may exist against the benefits they may receive. At present, it appears that Estrogen trans-dermal (absorbed through the skin) is the optimal way of taking treatment.