Helpful? Haphazard? Be in the know—BLAIR TELLERS
“If you took them away, I would kill you.”
That’s what Christine Hoffman said when we asked her about hormones.
Hoffman is 58, works as Community Relations Director at Riverview Retirement Community, and says Hormone Replacement Therapy (HRT) has granted her sanity through hellish hot flashes and unbearable insomnia.
“Until you experience it, it’s like having a newborn baby and being up all night,” she says.
When weighing risk against benefit, Hoffman says the decision to remain on HRT—a medication containing hormones to replace what is no longer being produced by the body—became a quality of life matter.
Before 2002, replacement hormones were the standard combatants for pacifying the proverbial menopause symptoms.
That was until a data resource, called the Women’s Health Initiative, published a study that concluded the risks of estrogen plus progestin (risks that included increased breast cancer, heart attacks, strokes, and blood clots in the lungs and legs) outweigh the advantages (fewer hip fractures and colon cancers).
These findings fueled a substantial decrease in the use of HRT in the United States, as reported by the New England Journal of Medicine.
Edie Ward, Registered Pharmacist, Certified Menopause Practitioner and Director of Clinical Education at Riverpoint Pharmacy, believes that panic was slightly excessive.
“If you look at the actual numbers, you would see the risk of breast cancer is still relatively low,” she says.
Ward is referring to 8 more cases of breast cancer, 7 more cases of heart attack, 8 more cases of stroke, and 18 more cases of blood clots in the lungs or legs (for every 10,000 women taking estrogen plus progestin pills in one year).
Not to imply those numbers are trite.
“I would never say those numbers are insignificant,” says Ward. “However, those numbers are still very small. HRT is not something that can just be indiscriminately given. It needs to be given responsibly, and done in a way that takes in as many aspects of individual needs as possible.”
Susan D. Reed, MD, MPH, professor of Obstetrics & Gynecology at the University of Washington, says the data actually suggests risks for women aged 50-59 are minimal to nil—if the woman is healthy, and has normal lipid profile.
“The WHI gave us very good information regarding what happens when you give those types of hormones to women who are above average age, and may have been well off hormones for up to ten years, or even longer periods of time,” she says.
What it didn’t tell us, says Reed—and what we need to know—is how concerned we should be for the use of HRT in women who are predominately aged anywhere from 46 to 60, since those are the women that tend to be more symptomatic.
There’s also been a time lapse. A new Endocrine Society scientific statement on Postmenopausal Hormone Therapy, published July 2010 in the Journal of Clinical Endocrinology Metabolism, points out the original purpose of the WHI study was to determine “whether HRT truly protected against heart disease, and whether or not it increased breast cancer risk.”
The Society’s statement highlights statistical factors, noting, “the average age of participants was 63, and only 3.5 percent of the women were 50-54 years old, the age when women usually make a decision regarding initiation of HRT. In addition, the WHI did not address the major indication for HRT use, relief of symptoms.”
So who risks the most by taking HRT? That’s relative, says Ward, and uses Osteoporosis as an example: Your chances of getting it increase—without hormones.
“If you have a broken hip, the statistics on recovery after a hip fracture are far worse than having breast cancer from taking hormone therapy,” she says.
Dr. Reed doesn’t recommend HRT for women who are older, have a personal or family risk of breast cancer, have a BMI (body mass index) greater than 30, have had a stroke, or have experienced pulmonary complications.
Debra Ravasia, MD, FACOG, founder of Women’s Health Connection in Spokane, says she no longer feels comfortable offering “traditional HRT” (i.e., pharmaceutical strength estradiol and synthetic progestins),” to patients, since she herself would not be comfortable taking it. She says it’s important to emphasize focus on the individual, as everyone produces and metabolizes hormones differently.
The route of treatment, on that note, is far from overarching.
“As such, I strongly favor measuring actual levels of hormones, and replacing only what is low or missing,” says Ravasia. “Not the supraphysiologic levels that are often reached by synthetic pharmaceutical hormones.”
She says there’s no such thing as a “one size fits all.”
Bio-identical hormones, substances that have been chemically synthesized to be identical to hormones the body makes naturally, operate on this platform.
“The main benefit from bio-identical hormone therapy, is that it’s created especially to match your needs,” says Ward.
Kind of like a hormone cocktail.
“When you use something that is commercially available, there are a lot of options, so you have the ability to make changes—but you may not be able to fine-tune it, as well,” says Ward. “Custom compounding fine-tunes it to the exact person. So it’s nice for people who have tried many therapies, without benefit or luck.”
Do keep in mind: “Bio-identical” doesn’t automatically make a product safer.
“It’s still vital that it is in the right balance, for the right reasons, in the right amount for the right candidate,” says Ravasia. “Bio-identical hormones can be just as dangerous as synthetic ones when used inappropriately or prescribed in too high of doses.”
Ravasia recommends paying attention to the source, and making sure your pharmacy is accredited by the Pharmacy Compounding Accreditation Board.
In terms of trends, Dr. Reed says there’s a strong movement towards taking the lowest dose possible, particularly through transdermal modes, like gels, patches and rings.
“For this reason, I commonly use the Mirena intrauterine device, since it gives minimal concentration to the breast, and goes right to the uterus,” she says. “My patients are all on a low, or ultra-low dose, transdermal regime.”
Noel S. Weiss, MD, DrPH, professor of Epidemiology at the University of Washington, reiterates that less is better. He says the current recommendation for a woman taking combined hormone therapy is to do so for as short as period of possible—no more than a couple of years.
“It’s to try and get her though the time that she needs it,” he says.
Some parting thoughts “Do your homework beforehand,” says Ward. “Really be armed with your symptoms and journal them as closely as possible. When you decide if this is something you want to pursue, make sure all of the symptoms are in fact hormone related, and not related to something else entirely.”
“It’s very individualized,” says Reed. “Each woman needs to speak with her physician, and remember that when the [WHI study] came out. We have way more data, now, and we are able to give more individualized information. I would encourage each woman to do that with her physician. That initial scare may not be right for her.”
“I think the biggest take home message is that there are lots of ways to come through menopause healthier and more energized than when you entered it, without exposing yourself to the risks of traditional prescription HRT,” says Ravasia. “It can be a tolerable, and even a good experience. If you decide to use natural hormones, they still have some very real risks if used incorrectly, so you should still have careful MD supervision from a physician who is very familiar with them, and with you, and tailors them for your specific needs.”
Further Reading (as recommended by Dr. Ravasia)
Awakening Athena by Kenna Stephenson, MD
From Hormone Hell to Hormone Well by CW Randolph Jr., MD, and Genie James, MMSc