What to do about hormone replacement therapy

Hormone replacement therapy, which is estrogen with or without a progestin, is used by more than 13 million post-menopausal woman in the United States. Its use became popular with the release of Dr. Robert Wilson's book, "Feminine Forever," in 1966. Around that time, the benefits of HRT were starting to be noticed by pharmacists and physicians. Women were told HRT would give them relief from the symptoms of menopause. Since then, one of the most popular drugs has become Premarin, which contains estrogen from pregnant mares' urine. Last year about 45 million prescriptions for Premarin were filled in the United States.

There have been many HRT studies over the years. From these studies, we thought HRT was good, not only for treating menopausal symptoms, but also for protecting the heart and preventing bone loss. But everyone had his or her attention on a huge government study that was going to tell us once and for all about HRT. It was supposed to last for eight years; but part of the study was stopped after only five years because too many problems were seen in the women taking Prempro (a combination of Premarin and a progestin). The women taking only estrogen didn't have the same problems, so that group will continue with the study.

Cardiovascular disease

For years, we thought HRT might reduce a woman's risk for heart disease. But women in this new study who took Prempro were more likely to have a heart attack, stroke, or clotting problems within the first two years of use.

As a result, it's no longer recommended that women take HRT to prevent heart disease, especially now that there are other good drugs for prevention. Also, you can do a lot on your own to reduce your risk of heart disease, such as exercise, eat right, watch your weight, and don't smoke.

The new study also showed that HRT increased the risk of invasive breast cancer if it was used for over four years. This risk seems to be greater with the use of combination HRT (estrogen plus progestin) than with estrogen alone. Since most of the risk factors for breast cancer cannot be changed, finding cancer early is important. Monthly breast self-exams, yearly visits to your health care professional, and regular mammograms are recommended.

HRT might also increase the risk of ovarian cancer in women using estrogen alone for 10 or more years. There is not enough information to say if combination HRT will have this same risk. There is some good news though. HRT has been shown to reduce the risk of colorectal cancer.

Osteoporosis

The loss of bone that occurs during menopause can lead to osteoporosis. HRT helps bones stay strong, but this effect only lasts as long as you take HRT. Because of the risks from using HRT, it is no longer recommended for osteoporosis prevention. Your health care professional can recommend other ways to prevent or treat osteoporosis. Things you can do to keep your bones strong include exercise, stop smoking, and get enough calcium and vitamin D through food and supplements. You should aim for 1,200 mg to 1,500 mg of elemental calcium and 400 to 800 IU of vitamin D every day.

HRT is very effective at reducing symptoms of menopause such as hot flashes, vaginal dryness, night sweats, and difficulty sleeping. HRT is used for a short time (several years or less) to decrease menopausal symptoms. If you choose not to take HRT, some other options to treat hot flashes are clonidine, certain antidepressants, or dietary soy. Estrogen creams are useful for vaginal dryness. It is also useful to avoid hot flashes caused by triggers such as hot or spicy food and drinks, alcohol and caffeine.

Should I take HRT?

This is an individual decision. Ask your pharmacist to help you understand the new findings, and talk with your physician about what would be best for you. Experts say using HRT for less than four years to relieve menopausal symptoms is safe for most women. If you decide to stop HRT, check with your health care professional for the best way to do this. Some women will need to slowly reduce the amount of their HRT over several months to prevent hot flashes from returning. HRT is usually not recommended for women who have a current or past history of breast cancer, history of uterine cancer, current or past history of blood clots in the legs or the lung, vaginal bleeding of an unknown cause, or liver disease.