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May 8, 2006
A little history helps. Until a few years ago, many doctors believed that estrogen protected against heart disease, a leading killer of women in developed countries. Large observational studies found lower rates of heart disease and bone fractures in women taking estrogen. Those same studies also identified risks from hormone therapy: higher rates of breast cancer, stroke and blood clots in the legs or lungs. Recently, however, reports from randomized clinical trials, including the Women's Health Initiative, have suggested that hormone therapy might actually increase the risk of heart disease. Because randomized clinical trials provide stronger evidence than observational studies, these findings were major news and persuaded many women (and their doctors) to steer clear of hormone therapy.
In just a few years, the pendulum of public opinion shifted from the position that hormone therapy is good for all to believing that no one should take it. Both views are oversimplifications. As researchers who have conducted in-depth studies of hormone therapy, we believe that the "one size fits all" approach is misguided. Recent research from our group and others strongly suggests that a woman's age and time since menopause, as well as her health history, are the most important factors in the benefit-risk equation. Hormone therapy is more likely to be beneficial if started early in menopause (as in the observational studies that showed favorable results for heart disease) and harmful if started later (generally the case in the randomized trials, which showed negative results).
Why this paradox? Estrogen seems to slow the early stages of atherosclerosis. Once advanced atherosclerotic plaques develop, however, estrogen may make them more fragile and more likely to cause heart attacks by rupturing and forming clots. In many women, advanced plaques begin to form by the age of 60. So a woman who starts hormone therapy when she already has advanced atherosclerosis may be particularly prone to having a heart attack while on estrogen, whereas a younger woman who has healthy blood vessels may receive heart protection. This doesn't mean that newly menopausal women should take hormones specifically to prevent heart disease (they shouldn't), but it does mean that such women who are considering hormone therapy to relieve moderate to severe hot flashes needn't be overly worried about heart risks.
From a medical perspective, you shouldn't consider hormone therapy unless moderate to severe hot flashes or night sweats significantly disrupt your life. If you have only vaginal dryness or discomfort with intercourse, low-dose vaginal estrogen — rather than estrogen pills or patches — may be an option. The best candidates for hormone therapy are younger women who had their final menstrual period within the last five years and who are not at high risk of heart disease, stroke or blood clots in the legs. Older women many years past menopause, who tend to be at higher risk of these cardiovascular conditions, are not good candidates. Women with a history of breast or uterine cancer, or who are at high risk for these cancers, should also avoid hormone therapy.
If you decide to take estrogen, you should choose the lowest effective dose to make your symptoms manageable. Unless you've had a hysterectomy, you should take progestogen along with estrogen to prevent uterine cancer. Hormone therapy should ideally be taken for only two to three years and generally no more than five years (unless the ovaries were surgically removed at a young age).
Why these time limits? Hot flashes and night sweats tend to peak in the two years after your final menstrual period, and then subside, which suggests that most women won't need hormone therapy for symptom control after that time. More important, the risk of breast cancer climbs with longer-term use of hormones (particularly estrogen plus progestogen), which eventually tips the overall benefit-risk balance into unfavorable territory for most women.
If you aren't a candidate for hormone therapy, there are other options for cooling hot flashes, including exercise, relaxation techniques and avoiding cigarettes, caffeine and spicy foods. Certain antidepressants and the anti-seizure medication gabapentin can also be helpful. Soy or black cohosh may be worth a try. Even if you are eligible for hormone therapy, try at least some of these approaches before considering estrogen. If you're still on the fence but would like to help advance health research on hormone therapy, consider participating in a clinical trial. With more research, women will have clearer answers to guide decision-making.
Manson and Bassuk are affiliated with Harvard Medical School and Brigham and Women's Hospital. They are the authors of "Hot Flashes, Hormones and Health" (McGraw-Hill), to be published later this year. For more information on menopause and hormone therapy, go to health.harvard.edu/NEWSWEEK.
© 2006 Newsweek, Inc.
© 2006 MSNBC.com
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Menopause