Ask Your Ob-Gyn: “What’s New in Hormone Replacement Therapy? (HRT)”

In the early 1990s, 40% of American women who had reached menopause used hormone replacement therapy (HRT) to treat disagreeable symptoms like hot flashes, sleep problems, and discomfort during intercourse. At one time, Premarin® (brand name for oral estrogen) was the most commonly prescribed drug in the U.S.

In 1993 the U.S. government invested over $600 million to study whether hormone replacement protected women from heart disease. That study, the Women’s Health Initiative (WHI), changed women’s lives for sure. But was this a change for the better?

In 2002 the Women’s Health Initiative made a dramatic announcement. The HRT study would end early because the participants taking estrogen with progesterone were having higher rates of breast cancer, heart disease, and stroke. The news created havoc among women using hormones; nearly half of them gave up their prescriptions within months. Women whose menopausal symptoms reduced their quality of life resigned themselves to suffer in silence.

In the fifteen years since that announcement, we have come to realize that the panic was unnecessary. Dr. JoAnn Manson, lead investigator of the WHI, has commented that “The pendulum has swung so widely, from ‘hormone therapy is good for all women’ to ‘it’s bad for all women’ to now somewhere in between. This really does seem to be the appropriate place for the pendulum to come to rest.”

We now realize that the WHI’s early conclusion resulted from an incomplete understanding of the issues. Still, the WHI has provided us with reliable data that has led to a much better understanding of the benefits and risks of HRT than we had in 2002.

I have had a professional interest in HRT beginning many years before the WHI study. As a member of the North American Menopause Society, I maintain an up-to-date understanding of new evidence and share it with my patients. There is no one-size-fits-all answer to the HRT question. The menopause experience is unique for each woman. She has individual risk factors and health issues. My recommendations are based on those personal factors, on the latest medical evidence, and on the careful consideration I would give to a family member.

HRT is a complex subject—difficult to summarize in a short blog post. But new information and new products are now available to tailor treatment to each woman’s needs.

Here are some key facts:

  • HRT is the most effective treatment for hot flashes and vaginal dryness, and it has been shown to reduce bone loss and fractures.
  • For women age 60 or younger or those who are within 10 years of the start of menopause (excluding women with special risk factors), the benefits of HRT make it a good choice when symptoms interfere with quality of life. In this age group, the risks of HRT are low.
  • The WHI set out to find out whether estrogen protected older women from heart disease. Seventy-five percent of participants were age 60 to 79 (average age 65). The study was not designed to answer whether HRT would provide health benefits to women in their 50s having an uncomfortable menopausal transition. We now believe that including older women in the study, some who already had heart disease, probably led to the heart-related incidents that ended the WHI.
  • With most estrogen replacement, women who have not had a hysterectomy need an additional medication (progesterone) to protect the uterus from stimulation, a risk for endometrial cancer.
  • The Women’s Health Initiative only found an increased risk of breast cancer in women who were taking the estrogen/progesterone combination. The women who, because of a previous hysterectomy, were taking estrogen alone (oral Premarin®) actually had fewer breast cancer cases.
  • We now have a new estrogen medication (Duavee®) that can protect the uterus without progesterone, therefore, without increasing the risk of breast cancer.
  • We choose treatment based on your individual needs. For some women symptoms like hot flashes are not very bothersome. If vaginal dryness is your primary concern, we can recommend an estrogen cream instead of a medication (e.g. pill, patch, gel) that acts on all of your body’s estrogen receptors.
  • If you are not having an uncomfortable menopause, but your bone density puts you at risk for fractures, we can offer a SERM (selective estrogen receptor modulator). SERMs activate some specific estrogen receptors in the body and block others. For example, Raloxifene (Evista®) activates receptors in bone but blocks them in the uterus and breasts.
  • We now have a combination medication—an estrogen that reduces hot flashes, vaginal dryness, and bone loss, along with a SERM (bazedoxifene) that blocks estrogen receptors in the breast and uterus. This medication is marketed under the brand name Duavee®. It may be a good choice for women whose risk factors include breast cancer.
  • Some women find non-estrogen medications will improve menopausal symptoms. SSRIs (anti-depressants) can help if mood changes are your primary concern. If you are taking over-the-counter supplements, such as herbal supplements, please keep us up-to-date. We want to inform you of anything that may interfere with other medications.

Above all, I recommend that you discuss concerns about menopause with your women’s health specialist (Ob-Gyn), whether or not you are considering HRT. We understand the process of menopause and current scientific evidence about treatment. We will talk to you about your symptoms, your risk factors, and your preferences. We can offer many options—both estrogen and non-estrogen choices—and discuss the risks and benefits of each. This complicated subject is not a primary area of expertise for other providers such as internists and family practitioners. We have learned a lot since 2002. For most women, the menopausal transition is temporary. We will re-evaluate your situation periodically. But if your quality of life is compromised by menopause, you do not need to suffer in silence!