Expert talks about the very real option of hormone replacement therapy

Hormone treatment may not deserve its bad rap, at least for women in their 50s.

Use of the therapy for relief of menopausal symptoms plummeted 80% after results of the Women’s Health Initiative’s first long-term study were published in 2003. The findings implicated estrogen plus a progestin — the hormones of choice for treating menopausal symptoms such as hot flashes — in an increased risk of breast cancer, heart disease, stroke, blood clots and dementia. Estrogens alone (used by women who have had a hysterectomy) were consider to have the same effects.

Richard Santen, an endocrinologist at the University of Virginia in Charlottesville, co-wrote a statement by the Endocrine Society that attempted to set the record straight on postmenopausal hormone therapy. That statement was published in the July 2010 issue of the Journal of Clinical Endocrinology and Metabolism.

Santen, also an expert in breast cancer research, elaborated on that research in this edited interview conducted April 1.


What does the Endocrine Society’s scientific statement tell us about hormone therapy for menopausal women?

The major message is that the average age of women in the WHI study was 63. Only 4% of women were between the ages of 50 and 55, which is the time when women go through menopause and are deciding about hormone therapy.

Therefore, what we really needed to do was to try to review in a scientific and rigorous fashion the information about risks and benefits in women who are just starting hormonal therapy, so, in other words, women in the 50 to 59 range but predominantly 50 to 55. We consider that women would continue on it for five years.

When you look at it that way, there is no increased risk of heart disease and probably even a benefit with combined hormone therapy. There is only a minimal increased risk of stroke. There’s no increased risk of dementia. And with estrogen alone, as opposed to a combination of estrogen plus a progestin, there’s no increased risk of breast cancer. But there is a small increased risk of breast cancer in women taking estrogen plus a progestin.

So now we know that the premise was wrong, because the older women are the ones who get the side effects and the stroke, heart disease and so on.

We’ve seen a surge in the use of ‘bio-identical hormones’ largely because of the scare about estrogen. How do we know whether those are safe?

Bio-identicals have gotten an enormous amount of hype. It’s been proposed that they are safer and better, but there really is no evidence that they are safer than regular hormones. We believe bio-identicals do everything that the other hormones do.

And many physicians prescribe bio-identical hormones simply because you can measure them in the blood and see just how much of this hormone somebody has. It’s a little bit like a snake oil — if you get your progesterone from a cactus, which is where [bio-identical progesterone] comes from, somebody’s going to say that’s a natural hormone, so it can’t be harmful. So some influential women have written and talked about this and pushed it. But those of us in the scientific community think this is balderdash.


How do you weigh the risks versus benefits of hormone therapy? What are the primary benefits?

Hormone therapy can relieve hot flashes, improve atrophy of the vagina and eliminate pain during intimacy, reduce fractures of the bones and improve quality of life.

The bottom line is that if you don’t have a family history or a high risk of breast cancer, and you have severe symptoms (such as menopausal hot flashes and vaginal atrophy), that hormone therapy would be a good choice for you under those circumstances.

If you’ve had a hysterectomy, you would take estrogen alone, which is actually safer because then you don’t have the increased risk of breast cancer. If you haven’t had your uterus removed, you would take estrogen plus a progestin.


If your underlying risk of breast cancer is quite low and you take estrogen plus a progestin, your potential risk with that is also quite low.

On the other hand, if your mother, grandmother and sister had breast cancer, therefore your underlying risk is quite high, then you shouldn’t be taking estrogen plus a progestin. We’ve got to individualize the therapy to the individual patient.

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