Hormone Replacement (R)evolution

Hormone Replacement (R)evolution:

Many women face a challenge when trying to treat menopausal symptoms. On the one hand, some women find their experience at this time to be particularly difficult and are relieved to have prescription hormone options. On the other hand, since the 1990’s, media news reports on hormone therapy have been, at times, confusing, offering little to clarify a patient’s decision process. Women can often feel torn between concern with the risks of treatment vs. concern with the severity of their symptoms. The purpose of this article is to provide information and history about the evolving practice of using hormone replacement, specifically estrogens and progestogens, to treat menopausal symptoms. Hopefully this helps give you a better grasp of the news out there and sparks a more fulfilling discussion with your doctor.

The Past:

Likely every woman over the age of 40 has followed the unfortunate results of the Women’s Health Initiative Trials (WHI http://www.nhlbi.nih.gov/whi/) in the news over the years. It caused a lot of concern and also taught us a lot. The WHI continues to contribute to our understanding of risks and benefits as they evolve.

  • The WHI Trials started in 1991 and studied many things including the risk of breast cancer and cardiovascular disease in healthy postmenopausal women taking hormone replacement therapy (HRT). The HRT used in the trial was estrogens (CEE) from pregnant horse urine paired with or without  progestin (a non-bioidentical substitute for progesterone). It was a big deal and recruited thousands of women from all over the United States.
  • Both hormone portions of the trial were stopped early when researchers found that the CEE plus progestin put these women at increased risk of breast cancer, cardiovascular disease, and pulmonary embolism. CEE alone, without progestin, put these women at increased risk mainly for stroke. For a lot of physicians and their healthy menopausal patients, this meant stopping all hormone replacement prescriptions abruptly.  What followed was a great deal of confusion and fear in the female population regarding HRT.
  • Even with new options on the market, many patients are still not sure what to make of them. Are they the same? Do they have the same risks? What about bioidentical hormones?

The Present and Future:

The WHI Trials remain instrumental in helping us understand the potential risks of a specific set of hormones at a specific dose (CEE and progestin at relatively high doses). Continued analysis of trial data has brought about a radical change in the prescription options available today. For example, did you know that several of the new pharmaceutical HRT options available to you by your conventional physician are actually bioidentical? Additionally, HRT comes in much lower doses. Does this mean there are risk free hormones now? No, but we are getting smarter about what those risks are, and research is accumulating that helps answer questions such as:

  • Who is a safer candidate for therapy?
  • Are there safer ways to take HRT (have we evolved beyond pills)?
  • Is there safer dosing that still helps with symptoms?
  • Are there safer specific hormone combinations (bioidentical vs non-bioidentical, single vs combination therapy)?

Over the next few weeks, in brief installments, we will discuss the evolution of hormone prescribing in menopause. We will touch on each of the questions posed above. Hopefully this helps you have a better discussion with your doctor if the issue of hormone replacement comes up.  Next week we will talk about what the research is teaching us about safer candidates for therapy and length of therapy for menopausal symptoms.

Information in this article is provided for informational purposes only and is not intended as a substitute for the advice provided by your physician or other healthcare professional. You should not use the information on this web site for diagnosing or treating a health problem or disease, or prescribing any medication or other treatment.

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Shannon Hirst