Night sweats, hot flashes and mood swings don't seem a fair trade-off for no more periods. So should you go on hormones? Well, contrary to popular opinion, the book on HRT is not closed. But it's been edited, that's for sure.
Remember how the 2002 results of the Women's Health Initiative report into hormone replacement therapy called into question the safety of HRT? What made it especially galling was learning that rather than cutting the risk of disease, taking estrogen and progestin actually increased the risk of developing heart disease, blood clots, stroke and breast cancer.
Before the WHI study results, more than six million North American women took HRT to reduce hot flashes and, so we were told, to protect against heart disease and bone-thinning osteoporosis. As a result of the scare, there was a 50 per cent drop in the number of women taking HRT between 2001 and 2005.
But according to some, new readings of the WHI study show that thousands of postmenopausal women died prematurely over the past decade because they avoided estrogen therapy after having a hysterectomy. A re-reading of the WHI study in 2011 confirmed that estrogen alone for women who had undergone hysterectomy was actually protective.
So where do we stand now?
"Results of the WHI study took awhile to understand, and we found that it could not be applied to every woman. In other words, it was not one size fits all," says Dr. Vivien Brown, a Toronto family doctor and vice-president medical affairs for Medisys Health Group. "A decade of research and analysis has shown that the 2002 WHI report did not apply to all menopausal women and that hormone therapy is an acceptable option for those who are relatively young." Here's how today's hormone therapy differs from 20 years ago:
HRT is Rebranded: "We don't call it HRT anymore," says Dr. Brown who insists it's not a marketing ploy to change HRT to MHT or menopausal hormone therapy. "Because it's not replacement, it's smaller amounts for symptom control." Not everybody needs hormones, she adds: "But if you have disabling hot flashes and cannot sit in a meeting, for example, it may help."
Age Matters: There is a window of opportunity, age-wise, for starting MHT. In the original WHI study findings, women were older and some already had symptoms of heart disease, leading researchers to conclude that starting HRT after the age of 60 may increase heart disease risk. A trial from Denmark reported in 2012 that healthy women taking combined hormones for ten years after menopause had a reduced risk of heart disease and dying form it.
In a re-interpretation of the WHI trials, published last fall, it was noted that women who started hormones between ages 50 to 59 or less than ten years after menopause began actually had less heart disease and less death from any cause, compared to a placebo group. According to the International Menopause Society, starting HRT before the age of 60 (or at the start of menopause) infers very little risk compared to starting HRT later in life. "By the time a woman is in her 60s, she may have plaque in her arteries and hormone therapy can destabilize plaque," explains Dr. Brown.
Different Doses: In the 90's a woman taking HRT took a pill filled with what seems today like a whopping amount of estrogen. Today, oral estrogen is half what it used to be. Dr. Brown likens the change to what happened to the birth control pill: "They used to be four to six times as high as they are now." (It's definitely an improvement, given that in the 20's,women injected themselves with estrogen isolated from the urine of pregnant women.)
Pill, Gel or Patch: Delivery systems have improved so for some, HRT is an easier pill to swallow. "Estrogen in a transdermal patch or topical gel bypasses the liver," says Dr. Brown, adding that doing so protects better against blood clots and stroke. Women who want to treat vaginal dryness on its own can now opt for estrogen vaginal rings or vaginal suppositories inserted twice weekly. "Localized estrogen treatment is extremely safe," says Dr. Brown. "And it protects the bladder from infection and contributes to general bladder health."
Ongoing Research: Early findings of KEEPS (the Kronos Early Estrogen Prevention Study) shows that women who took a daily low-dose amount of estrogen and progesterone found relief from hot flashes and night sweats and also benefited in bone density. HRT had no effect on rates of breast cancer, endometrial cancer, heart attacks, strokes, mini-strokes or blood clots -- but the study is deemed by some to be too small to make definite conclusions.
Alternatives: Dr. Brown recommends lifestyle alternatives such as dressing in layers, exercising regularly, and decreasing alcohol. "What I do not encourage is some of the herbs and vitamins because there is no evidence they are better than placebo." With some herbs, there is potential liver damage or a thickening of the wall of the uterus. "We know the benefits and risks of products regulated by Health Canada, but not the natural alternatives." For disabling hot flashes and mood swings, some doctors may recommend anti-depressants which act on the brain's temperature regulator.
Surveys indicate that up to 80 percent of women going through menopause have symptoms. "Our great grandmothers didn't have to think about these things, but today women live a third of our lives in menopause," she says. "We need to be productive and feeling well, so talk to your doctor about what you may or may not need. Don't go by what you see on TV or what your girlfriends take. Your story counts, too. There are plenty of good options."
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