Changing the conversation about hormone replacement therapy

I see so much misinformation and fear among women and health care providers over menopause and HRT. We need to change the conversation, and base it on facts and evidence. But first we as providers also need to start the conversation with women about menopause ! I see so many women who have needlessly suffered with peri-menopause and menopause because their providers told them to just "deal" with it or gave them outdated misinformation that scared them . I have also found that many women feel reluctant to complain about their symptoms , or feel embarrassed to talk about things like the sexual dysfunction that can occur. 

Here is a follow up post in regards to risks and HRT. I follow the North American Menopause Society guidelines for my HRT recommendations as well as my years of clinical practice and personal experience with menopause, when counseling my patients.  Decisions about HRT should be based on:
1. Most importantly the UNIQUE health risks and symptoms of each individual
2. The age and time from menopause
3. The goals of therapy

The evidence from extensive research shows us that for menopausal women younger then 60, or within 10 years of the onset of menopause, who do not have contraindications to HRT, that systemic HRT benefits outweigh risks for relief of menopause photoflashes and sleep disturbances and for prevention of bone loss. There are risks however to anything we do, so let's review what the latest research shows. We have come a long way from 2002 when the Women's Health Initiative (WHI) study was released. It caused needless widespread panic and concern among women ( and providers)  taking  ( and prescribing) HRT. It showed increase risks in heart disease, stroke and breast cancer. BUT THE DEVIL IS THE DETAILS! In the past 15 years since the headline grabbing initial results, additional studies, further analysis of the data and continued longer term follow up has been done. The picture has become much clearer and now we know that in younger menopausal women, near the age of menopause, using low dose and transdermal HRT in particular, that the benefits outweigh the risks in symptomatic women. A very important fact to point out about the WHI was that on average women were 63 years old and were 13 YEARS from the onset of menopause and MOST women did not have any symptoms of menopause. The women were given synthetic equine estrogen in the form of  oral Prempro. That is different from more modern offerings of estradiol  transdermal patches with an oral progesterone or a progestin combined in the patch. l

Proven benefits of systemic HRT

• Control of menopausal symptoms
• Maintenance bone mineral density and reduced osteoporotic fracture
• Limited studies suggest HRT may improve muscle mass and strength
• Important to note- if you only have vaginal atrophy symptoms ( vaginal dryness, painful sex) then you don't need systemic HRT, and there are very safe options like vaginal estrogen and other products that very effectively treat those symptoms. 

Known Risks of Systemic HRT 

• Endometrial cancer-

Only if uterus still present and only estrogen is being given. Adding a progestogen proved protection

• DVT/PE-

The good news is that the risk of DVT or PE is no higher then the general population when we use low dose trans-dermal risks. The risk of DVT/PE is increased with oral estrogen preparations. 

• Cardio-vascular Disease-

There is no increased risk in women younger then 60 who use HRT. A number of studies suggest that HRT may be good for your heart if you start before the age of 60 or within 10 years of menopause. 

• Breast Cancer-

HRT that combines estrogen and a progestogen may be associated with 1 additional breast cancer cases for every 1,000 women over age 50 AFTER 7.5 years of continuous use. Overall mortality from breast cancer is not increased.  There is a reduction in breast cancer risk when we use estrogen alone ( for instance in women who have had their uterus removed). The risk for combined HRT returns to baseline after stopping HRT. That suggests that HRT acts as a promoter rather than an initiator of breast cancer. It is important  to note the postmenopausal obesity or 2 or more units of alcohol per day is associated with a greater risk then 5 years of combined HRT! 

I hope this post helps clear up some of the myths about HRT. To summarize, it is important to remember that each patient's menopause transition is unique and treatment needs to be tailored to each patients unique needs and risks.

​In the next installment, I will tackle some unique patient issues and HRT, like women with a strong family history, women with premature ovarian  failure, women who are BRCA positive , and women who only have genitourinary symptoms. 

For more information , check out The North American Menopause Society. 
www.menopause.org/docs/default-source/2017/nams-2017-hormone-therapy-position-statement.pdf

Be well!
Dr. Menn

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