By Kari Bohlke, ScD
Menopause—when menstrual cycles end and ovarian hormone production drops dramatically—produces such symptoms as hot flashes and night sweats in up to 80 percent of women.1 When these symptoms are severe, they can have a profound effect on a woman’s quality of life and ability to function.
For many years hormone therapy with estrogen (with or without progestin) has provided an effective way for women to manage menopausal symptoms. Studies over the past several years, however, have raised some concerns about the health effects of hormone therapy. In the Women’s Health Initiative (WHI) clinical trial of estrogen plus progestin, hormone use decreased the risks of fracture and colorectal cancer but increased the risks of heart disease, breast cancer, stroke, and blood clots.2 More recent reports suggest that combined hormone therapy may also increase lung cancer mortality.3
Estrogen alone does not appear to increase the risk of breast or lung cancer but does increase risk of stroke.4
What’s a woman to do? The answer depends in part on your age and the severity of your symptoms.
Age Matters
An important point to keep in mind about the WHI studies is that many of the study participants were older women who were more than a decade past menopause. The balance of risks and benefits among older women may differ from that among younger women. For example, in a secondary analysis of the WHI hormone trials, the increased risk of heart disease among hormone users was apparent only among older women.5
“Women who are younger and close to the onset of menopause tend to have a low risk of adverse effects of hormone therapy and may be more likely to benefit through the management of their hot flashes and night sweats,” says JoAnn Manson, MD, DrPH, chief of the Division of Preventive Medicine at Brigham and Women’s Hospital in Boston, professor of medicine at Harvard Medical School, and one of the principal investigators for the WHI studies.
Nevertheless, hormone therapy should be reserved for women who truly need it. “We do not recommend that women begin taking hormone therapy unless they have a clear indication, such as moderate-to-severe menopausal symptoms,” says Dr. Manson. “But for women with these symptoms, hormone therapy still has a clinical role.”
Avoid Long-Term Use
If Possible
To reduce the risks, women who choose to use hormone therapy are often advised to use it for the shortest period of time necessary.1 “We generally recommend less than five years of use,” says Dr. Manson. “In a younger, recently menopausal woman who has moderate-to-severe hot flashes or other menopausal symptoms, the benefits of short-term hormone therapy use would be likely to outweigh the risks. This is just for women who have symptoms that are severe enough to affect their quality of life.”
Seek Other Options for Managing Chronic Disease
As effective as it is for managing severe menopausal symptoms, hormone therapy does not have a clear role in the prevention or treatment of other health conditions. In 2005 the US Preventive Services Task Force recommended against the routine use of hormone therapy for the prevention of chronic disease in postmenopausal women.6 “These hormones should not be used for prevention of chronic diseases such as heart disease or cognitive decline,” agrees Dr. Manson. “And even when you’re talking about osteoporosis and prevention of fracture, you would be relegating a woman to a very long duration of treatment in order to achieve those benefits.” Because fracture risk increases substantially when women are in their seventies and eighties, women would have to take hormone therapy for more than 20 years to derive a bone benefit when fracture risk is greatest. “For combination estrogen plus progestin, in particular, that’s a duration that would put women at substantially increased risk of breast cancer and possibly even lung cancer,” says Dr. Manson.
Confusion over “Bioidentical” Hormones
The term bioidentical hormone therapy is often used to refer to custom-mixed (custom-compounded) drugs that use hormones that are structurally identical to the hormones produced by a woman’s body. Women who are considering these compounded drugs should use caution.
“It’s a marketing term,” says Dr. Manson. “There is no rigorous evidence that bioidentical hormone therapy is any safer or more effective than traditional hormone therapy. And until proven otherwise, we have to assume that the risks are comparable. What’s very concerning is that many women who are taking compounded hormone therapy are being led to believe that it’s safer, and they’re not getting the important information about health risks that they would get with FDA-approved products.”
Another myth about compounded hormone therapy is that the dose can be individualized based on the results of a saliva hormone test. According to information from the US Food and Drug Administration (FDA), “Hormone levels in saliva do not accurately reflect the amount of hormones a woman has in her body for the purpose of adjusting hormone therapy dose levels. A woman’s hormone levels change throughout the day, and from day to day.”7
Finally, women should be aware that compounding isn’t the only way to get hormones that are structurally identical to naturally occurring hormones. Several FDA-approved products contain “bioidentical” hormones and offer the advantage of extensive prior testing for purity (lack of contamination) and dose consistency. Compounded products do not undergo similar testing and review.
Additional Ways to Manage Menopause
Regardless of what you decide about hormone use, several other simple steps can help you manage menopausal symptoms. To reduce the frequency and the severity of hot flashes, turn down the thermostat, wear layers of clothing that can be removed, engage in regular physical activity, and avoid common triggers of hot flashes such as tobacco, alcohol, hot beverages, and spicy foods.
Some nonhormonal prescription medications may also help manage menopausal symptoms. These include certain drugs used to treat depression and neurologic conditions.
Talk with Your Doctor
If you find that menopausal symptoms are severely affecting your quality of life or ability to function, talk with your doctor. Short-term use of hormone therapy remains an effective option. And if you choose not to use hormones or can’t use hormones because of other health conditions, there are other ways to manage menopausal symptoms.
References
1. Shifren JL, Schiff I. Role of hormone therapy in the management of menopause. Obstetrics and Gynecology. 2010;115(4):839-55.
2. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial.Journal of the American Medical Association. 2002;288(3):321-33.
3. Chlebowski RT, Schwartz AG, Wakelee H, et al. Oestrogen plus progestin and lung cancer in postmenopausal women (Women’s Health Initiative trial): a post-hoc analysis of a randomised controlled trial. Lancet. 2009;374(9697):1243-51.
4. Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association. 2004;291(14):1701-12.
5. Rossouw JE, Prentice RL, Manson JE, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. Journal of the American Medical Association. 2007;297(13):1465-77.
6. US Preventive Services Task Force. Hormone therapy for the prevention of chronic conditions in postmenopausal women: recommendations from the US Preventive Services Task Force. Annals of Internal Medicine. 2005:142(10):855-60.
7. US Department of Health and Human Services. Bio-Identicals: Sorting Myths from Facts. US Food and Drug Administration website. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm049311.htm.
Managing Vaginal Symptoms
Vaginal dryness and other vaginal symptoms affect many women after menopause. Unlike some menopausal symptoms, however, vaginal symptoms do not improve with time and can grow progressively worse. Hormone therapy taken orally or transdermally (through a patch on the skin) effectively manages vaginal symptoms as well as symptoms such as hot flashes. If vaginal symptoms are the primary problem and systemic (whole-body) estrogen isn’t necessary, estrogen-containing vaginal creams, tablets, or rings are also effective.1 Nonhormonal vaginal moisturizers and lubricants may also provide relief.
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