One of the great things about medicine is that experts tend to gather together into groups, like say: The North American Menopause Society. This organization of nurses, nurse midwifes, nurse practitioners, pharmacists, physicians, physician assistants, and psychologists is on a mission. That mission is the best possible management of menopause for women as they age. The new issue of their descriptively titled journal, Menopause, contains their position statement on hormone replacement therapy. When I started medical school every woman who complained of an end to her periods and “hot flashes” got hormone therapy. It’s more complicated now. The guidelines were crafted using the latest scientific evidence and clarify areas that many practitioners find confusing. The authors write, “Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both.”
So we’re back to every woman gets hormone replacement therapy (HRT). We used to do it because it appeared to prevent heart disease. It doesn’t. However, osteoporosis and fracture risk goes down for women on HRT and they have fewer hot flashes and other symptoms.
Based on data from the massive Women’s Health Initiative study, it turns out that either low dose estrogen therapy or estrogen with progesterone carry very low risks. When the news came out in the 90s that HRT might not protect against vascular disease there was thinking that disease might actually increase with HRT. It turns out that’s wrong and women can safely use HRT. The authors do note that the jury is out what the best combination of estrogen and progesterone is and what the best way to administer the hormones is. We are waiting of further studies to find out if pills, creams, injections, implants, patches or what-have-you are best.
Regarding cancer, the society feels that HRT probably doesn’t increase the risk of ovarian cancer though the research isn’t absolutely clear. They are confident that any increase in risk that might exist is very low. Older women with lung cancers, though, should avoid HRT as it appears to cause the tumors to grow faster, though women under the age of 60 who smoke may actually get some protection against developing later cancers. The jury is completely out for estrogen replacement in women with breast cancers as to whether the risk of recurrence increases or decreases, and that’s a decision best made by a woman and her doctor.
Sadly, it doesn’t appear that HRT helps at all to prevent cognitive decline or dementia. In fact, women over 65 who start HRT are at greater risk of developing dementia.
The new guidelines make it clear that HRT risks are very low, particularly when started early at the onset of menopause.
