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Study helps clear up hormone therapy questions

June 13, 2011

Another day, another hormone study. What is a woman to do? If you are like me, you have either given up entirely on the use of hormone therapy or are baffled by the choices. Is the use of estrogen safe?

I have been writing about hormone therapy for 15 years while researchers have plugged through data available through the Women's Health Initiative, or WHI. The Medical College of Wisconsin was part of that study, so many of you readers are part of this history. This was one of the first major studies for and on women. We now know information that wasn't available without a randomized controlled study that had years of collected data. So why is this still relevant today?

A recent study generated from the WHI research showed us that women who did not have a uterus who used estrogen therapy alone had a 23% decrease in breast cancer. The women who started estrogen around menopause up to the age of 59 also had 46% fewer heart attacks. These women were users of estrogen for at least six years and were followed for 10 years.

Let's look back at where we started. First, there were a number of arms to this study. However, it was the summer of 2002 when women who were using estrogen and the progestin Provera were told to stop their hormones because of the increased risk of heart attacks, breast cancer and stroke. Millions of women dumped their drugs.

In retrospect, the average age of women in this study was 62. Women were started on estrogen at any age. The average age of menopause is 51, so many of these women had been without any exposure to their own body's estrogen for long periods of time.

Also, the progestin used in the study is called Provera, which is a c-19 analog of testosterone. We still don't know if the increase in breast cancer risk might be more attributable to this drug vs. the use of a progesterone (Prometrium), which looks like what our own body makes. There is some evidence from an earlier study called the PEPI trial that Prometrium does have less impact on lipids. This drug was not studied but is now being researched in a follow-up trial.

Then in 2006 we found that women taking estrogen only did not increase the risk of breast cancer. A 2007 review of the WHI data showed that if hormone therapy was started around menopause that it may indeed decrease heart risk.

So now we know there is a difference between women who used estrogen alone vs. those using estrogen and Provera, as well as the difference in what time a woman starts using these hormones.

Whew. After a decade we now have the research to help guide women in decision-making about hormone use.

Hormone therapy is an individual choice. We need to look at our own family and individual history, know and understand our symptoms of menopause, and make our best educated decision.

So what is a practical approach toward using hormone therapy? The first question to ask yourself is do you have any contraindications to using estrogen. Simply stated, the risk is not worth the benefit. If you have uncontrolled cardiovascular risk factors such as hypertension, diabetes, elevated cholesterol/lipids or are obese you should think carefully about improving these parameters with lifestyle and medical treatment before introducing any new therapy.

Second, ask yourself if the symptoms you are having are altering your life in such a way as to warrant hormone therapy. Here's an example: A 50-year-old woman who is healthy, with no history of heart disease and is having hot flashes that wake her at night in cold sweats could safely use hormone therapy for a number of years. She may only remember tossing the covers once or twice during the night but actually she is moving in and out of REM sleep so frequently that she awakens in the morning exhausted. It is critical for our emotional and physical spirit to have refreshing sleep.

Many physicians and organizations such as the North American Menopause Society recommend that a woman can use hormone therapy for as many as five to seven years peri- and post-menopause at the lowest dose that minimizes symptoms. The site menopause.org has information about symptoms and treatment during menopause. If you do choose to use hormone therapy it is highly recommended that you use transdermal estradiol, as this minimizes the risk of blood clots. Estradiol can very easily permeate through the skin into your body and sustain excellent levels. If you have a uterus, you must use a progesterone to minimize the risk of uterine cancer. If you are allergic to peanuts you should not use Prometrium (natural micronized progesterone) but rather the same natural progesterone through a compounding pharmacy where olive oil instead of peanut oil is used for the medium in which the progesterone is placed.

What if you don't want to use systemic hormones but are noticing signs of vaginal dryness and painful intercourse? These symptoms certainly can affect one's interest in sexual intimacy. There are now options available that provide minimal if any absorption into your body except locally in the vaginal tissue. Estring is a small silicone ring placed in the vagina and left for up to three months; it slowly releases estradiol to keep the mucosa moist and healthy. Vagifem are small tablets that do the same and are inserted three times a week. Additionally small amounts of estriol or estradiol cream around the urethra can help prevent urinary tract infections, as the bottom third of the urethra is estrogen sensitive. It is believed these medications can be used safely without progesterone by most women.

Kayt Havens is a physician who is an associate professor of internal medicine at the Medical College of Wisconsin and director of women's health at the Zablocki Veterans Affairs Medical Center.