HRT: The debate rages on
Years ago, menopause was the rarely discussed uncomfortable transition in a woman’s life. But as baby boomers started to age, menopause joined the vernacular, and became the subject of books and talk shows. It even became the title of a musical comedy, allowing women to laugh at the side effects—hot flashes, mood swings, night sweats, and memory loss—that plague many of them as their fertility slips away, even though they’re anything but funny. After all, who wants to be the hot, crabby woman who can’t complete a sentence?
Doctors routinely prescribed sufferers with hormone replacement therapy (HRT), not only to ease unpleasant symptoms, but also to protect against heart disease and osteoporosis, as the conventional wisdom said it would. But then, in 2002, a large clinical trial, the Women’s Health Initiative, blew apart those long-held beliefs with the revelation that HRT combining estrogen and progestin (a manmade version of progesterone) increased a woman’s chance of developing breast cancer and pulmonary embolism. Suddenly, droves of women opted out of HRT.
Since then, breast cancer deaths have dropped, and there is a significant correlation between the two trends, according to Christine Ambrosone, professor of oncology and chair of the Department of Cancer Prevention and Control at Roswell Park Cancer Institute in Buffalo. She noted that women taking HRT ended up with more breast cancer, and with more aggressive and deadly forms of it. “Breast cancer is very common and women are looking for ways to reduce risk,” Ambrosone says. “One way to reduce risk is not taking HRT.”
Physician opinions continue to differ on the subject, however, and approximately half of all gynecologists still recommend HRT for women in mid-life. Ambrosone points to an article published in PLoS Medicine, a peer-reviewed open-access journal published by the Public Library of Science last March, that lists beliefs behind this. They include assertions that clinical trials should not guide treatment for individuals, the risks associated with HRT have been exaggerated, and the population studied was not representative of the general population of menopausal women. Interestingly, the article also cites a possible conflict of interest between physicians who received payment from the HRT manufacturers for speaking or consulting on articles promoting the use of hormone therapy.
Factors that affect a woman’s level of risk also include her family history, overall health, age, and length of time on the hormones. And some doctors say those should be weighed to figure the benefits of HRT versus the risks.
While the Mayo Clinic no longer recommends long-term HRT for the prevention of postmenopausal symptoms, it does cite evidence that younger women—those in their forties and fifties—who take estrogen and progestin for a short time may gain some protection against colorectal cancer, heart disease and brittle bones.
Jean Wactawski-Wende, professor and associate chair of the University at Buffalo’s Department of Social and Preventive Medicine, notes that women who need HRT to manage moderate to severe menopausal symptoms rather than for disease prevention should take the lowest dosage for the shortest amount of time.
Patients may also choose to take bio-identical HRT, which is identical to the hormones the body produces. Al Muto, owner of Pine Pharmacy in Williamsville, makes such compounds from scratch and works closely with the doctors who prescribe it.
Margaret Mitchell, M.D. and owner of Healthy Transformations, an alternative medical clinic in Amherst, regularly prescribes bio-identical progesterone—usually in the form of a cream that you rub into your skin—for women suffering from hot flashes, libido loss, weight gain, night sweats, or mood swings,
“If you get a person healthy and balanced, she is going to feel better,” Mitchell maintains. However, if lifestyle changes and supplements alone don’t alleviate tough menopausal symptoms quickly enough, Mitchell will prescribe progesterone or a mix of progesterone and estrogen. Rarely, does she prescribe estrogen alone.
“Progesterone makes you feel better,” she explains. “Your body produces more of it in the part of the cycle when women are trying to attract a mate. Progesterone sends receptors to your brain, which is why when women are losing it during menopause that they experience memory loss and fatigue.” Mitchell used progesterone to treat her own difficult menopausal symptoms for a few years. It usually takes two to three months of treatment before everything calms down, she notes, though she has had patients report elevated moods and higher energy levels almost immediately.
Unlike bio-identical HRT, synthetic hormones stick inside cells for weeks, increasing the opportunity for damage. Muto and Mitchell make it clear, however, that even bio-identical HRT is not risk-free.
“We work closely with doctors, and then follow up with patients after three months” Muto says. “Then we pass that information along to doctors and make suggestions to increase or decrease hormone dosages.”
Mitchell says she always gives women a breast cancer risk assessment, which includes a family history and thermography, an infrared picture that uses heat to determine the likelihood of future breast cancer development. If Mitchell sees a high risk, she won’t prescribe the HRT, and seeks alternative solutions.
Ambrosone said she would be reluctant to use any type of HRT even the kind developed from natural sources. “If it works the same, I’d say there are going to be risks.”
Likewise, Wactawski-Wende said women should use caution, as there have not been any clinical trials assessing bio-identical hormones.
Many women feel the same hesitation, and Mitchell suggests that alternative supplements and herbs, such as fish oil, rhubarb, magnesium, and Vitamin E, can help with hot flashes, metabolism and energy lags. Muto also points women to herbs and supplements and notes that diet and stress also play a role in how menopausal symptoms manifest. “In general,” he sums up, “women will do what they can before taking HRT.”
Freelance writer Laurie Kaiser has recently relocated to Western New York.