Sophia Cariati

Reports of recent studies revealing hormone replacement       therapy (HRT) is associated with health risks have left women scared and       confused about how to stay comfortable and healthy during menopause.       

After decades of seemingly conflicting information on the pros and cons       of HRT, there are finally data from a major clinical trial on one specific       dose and formulation. Last week, a large and well-designed study on the       therapy was halted prematurely when researchers concluded that       post-menopausal women taking a combination of estrogen and progestin were       at a small but significantly increased risk of heart disease, stroke,       blood clots and breast cancer 

 compared with women taking a sugar pill       (placebo). The benefits of therapy, including relief of menopausal       symptoms, reduced risk of hip fractures, and a lower incidence of colon       cancer, Women's Health Initiative researchers decided, were overshadowed       by the risks.


       So should women abandon HRT altogether? "Hardly," say       specialists like Steven R. Goldstein, MD, professor of obsterics and gynecology at the New York Medical Center in Manhattan. Instead,       "every woman should reevaluate exactly why she is on HRT to see       whether the benefits still outweigh the risks," says Dr. Goldstein.       Thus, while medical research has finally provided some hard-fast answers,       even the results of a landmark study can not offer women a       one-size-fits-all answer to the question of whether or not to take HRT.

The right decision hinges on how the scales balance out once a       patient's personal health risks are compared with the potential for HRT to       improve quality of life, according to Dr. Goldstein. For most women,       menopause brings a barrage of uncomfortable symptoms as the body produces       less of the hormone estrogen. Hot flashes, sleeplessness, and vaginal       dryness prevent some women from carrying on day-to-day functions. Others       pass more peacefully through this period. "We need to make decisions       about HRT one patient at a time," says Dr. Goldstein.


       In medical research, risk is averaged out over a large number of study       participants and is presented as a fixed number. Last week's findings were       summarized as follows: over a one year period, among 10,000 postmenopausal       women taking estrogen plus progestin, seven more will have a heart attack,       eight more will suffer a stroke, eight more will develop breast cancer,       and 18 additional will have blood clots compared with a group of 10,000       women not taking HRT.

In real life, however, health risks vary depending upon the       individual's lifestyle and family medical history. Thus, the actual risk       of cardiovascular problems and breast cancer associated with HRT will vary       from woman to woman. "Patients are not statistics, they are       individuals," says Dr. Goldstein.

Consider the case of a 56-year old menopausal woman who goes to her       doctor complaining of hot flashes. "If she is overweight, a smoker,       and doesn't exercise, I might suggest she invest in a personal fan,"       said Dr. Goldstein half-jokingly. In contrast, the same patient with fewer       cardiovascular disease risk factors might be a better candidate for HRT.       After all, experts remind women that the health risks faced by individual       study participants were relatively small. Hence, the benefits of using HRT       for the short-term relief of hot flashes and vaginal dryness will outweigh       the risks for many women.

Women who began HRT solely to promote heart health should reconsider       their decision. While physicians had high hopes that HRT would reduce the       risk of heart disease, last week's results prove otherwise. Instead of       HRT, women concerned with heart health should talk to their doctors about       other methods of reducing the risk of cardiovascular disease including       aspirin, prescription drugs, diet and exercise.

HRT Still the Best Relief for Hot Flashes and Vaginal Dryness


       Last week's landmark report failed to factor in issues of quality of life,       points out Dr. Goldstein. Some patients are desperate for relief when they       visit their doctors. A woman who can't sleep, is sweating profusely, and       can't perform professionally is exactly the kind of person who should       continue on HRT until she is no longer symptomatic, according to Dr.       Goldstein. "How can we give women a blanket response until we've       walked a mile in each of their shoes" asks Dr. Goldstein.

Other women, who began HRT a number of years ago for menopausal       symptoms, might want to consider weaning themselves off the hormones. Hot       flashes and the like generally subside a few years after a woman enters       menopause. "If a patient tapers her dose of HRT over a few months and       she feels okay, I would recommend going off it," says Dr. Goldstein,       "If, on the other hand, she doesn't like the way she feels, she can       have her HRT back."


       What about women with osteoporosis or those at high-risk? Luckily, there       are alternatives to HRT. Raloxifene has been shown to be effective in       preventing and treating osteoporosis and may even reduce the risk of       breast cancer. Bisphosphonates have also been shown to maintain bone       mineral density. The drawback of these medications, according to Dr.       Goldstein, is that neither will relieve the discomfort of menopause.


       Millions of other menopausal women who have had their uteruses removed       have been taking estrogen-alone for the relief of menopausal symptoms,       prevention or treatment of osteoporosis and in hopes of preserving heart       health. How do the latest findings affect them? Unfortunately the relative       risks and benefits of this type of therapy remain to be seen.

Leaders of the Women's Health Initiative study did not halt the part of       the trial comparing estrogen alone with placebo in women with       hysterectomies. When results of that study are revealed in 2005,       researchers will have a better idea of the relative benefits of estrogen       and progestin. In the meantime, experts do know that estrogen alone       increases the risk of uterine cancer, which explains why it is generally       prescribed only to women who have had a hysterectomy.


       While the latest findings provide valuable information, experts caution       that more research into treatments for menopausal symptoms and the       prevention of disease in post-menopausal women is needed. Preliminary       evidence has some experts hoping that so-called "designer       estrogens" or selective estrogen receptor modulators (SERMs) may turn       out to extend long-term health in post-menopausal women much like HRT was       expected to do. Yet only large-scale, well-designed trials on the safety       and effectiveness of these and other drugs in use by postmenopausal women       will determine if these are educated guesses or scientifically sound       answers.

Sophia Cariati
       Society for Women's Health Research

Sophia Cariati is a medical and science writer with a bachelor's of       science degree in biology and a master's degree in scientific and       environmental reporting.

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Reports of recent studies revealing hormone replacement therapy (HRT) is associated with health risks have left women scared and confused about how to stay comfortable and healthy during menopause.

Sophia Cariati

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