You Asked, We Answered: Questions About Hormone Therapy and Cancer

Dr. JoAnn Manson is one of the authors of a study on the cancer risks of hormone replacement therapy.

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Manson is chief of the Division of Preventive Medicine at Brigham and Women's Hospital and Elizabeth F. Brigham professor of women's health at Harvard Medical School.

Cecilia from Utica, N.Y., asked: "I am now taking Climara Pro patch. Does it have the same risks as traditional hormone replacement therapy?"

Manson: There's mounting evidence that estrogen patches may be less likely to increase the risks of blood clots in the legs and lungs than estrogen in pill form. However, this evidence is not yet conclusive and decisions about pills versus patches often depend on a woman's personal preference. Many women report that estrogen pills are easier to use and patches can occasionally cause skin irritation. Estrogen pills are also better than patches at improving cholesterol levels. However, pills may be more likely than patches to increase blood clots, triglycerides, and markers of inflammation. Knowing about these differences can help you and your doctor choose the therapy type that's best for you. Keep in mind that there are no large-scale rigorous studies comparing the patch versus the pill in terms of heart safety, breast cancer risk and other health outcomes.

Susan from Westfield, N.J., asked: "I am aware of the dangers of traditional hormone therapy. However, my doctor has recommended natural hormone replacement by using hormones compounded specifically for me based on blood tests done every six months.

"Does this type of hormone therapy carry the same risks as the traditional 'one size fits all' therapy? My doctor says it does not and she herself takes compounded hormones."

Manson:"Bioidentical" hormones are a molecular match to the estrogen or progesterone made naturally by our bodies. Proponents of bioidentical hormone therapy (BHT) claim that these products have fewer risks than traditional hormone therapy, but the reality is that few rigorous studies of these medications have been done and it's unknown whether they're any safer or more effective.

Bioidenticals can be purchased at conventional pharmacies in a range of set doses or at compounding pharmacies in "customized" doses. If you'd like to try bioidenticals, it may be best to stick with commercial preparations, which are regulated by the FDA, rather than custom-mixed ones, which aren't (unless you have an allergy to an ingredient or another clear reason to avoid the commercial preparations). Quality control, in terms of ensuring consistency of dose and purity (lack of contamination) is better with the FDA-approved medications. Also, there's no evidence that blood or saliva testing of hormone levels is helpful in adjusting or "balancing" the dosages of estrogen or progesterone.

Pam from Indianapolis asked: "Keeping all the studies in mind, what can someone do who is just beginning to feel the first symptoms of menopause? Should HRT be avoided from the very beginning? Do the risks outweigh the benefits? And are there any alternative therapies with merit? Thank you!"

Manson:The key question is whether your symptoms of menopause (such as hot flashes or night sweats) are severe and frequent enough to disrupt your sleep or quality of life. Only about 20 percent of newly menopausal women report symptoms of this severity. If vaginal dryness is the only symptom, try low-dose vaginal estrogen rather than pills or patches. If you're concerned about bone health, be sure to get adequate calcium, vitamin D, and weight-bearing exercise, and ask your doctor about the expanding list of non-estrogen medications available for preventing osteoporosis. Hormone therapy is best taken for only two to three years and, as a general rule, for no more than five years (unless you had a premature menopause, when it is acceptable to take it somwewhat longer). Hot flashes and night sweats typically subside after the first few years of menopause, so hormone therapy usually isn't needed long-term. Moreover, breast cancer risk climbs with duration of hormone use, particularly combination estrogen plus progestin, which is another reason to avoid long-term use.

Alternative options for menopausal symptoms: Although hormone therapy is the most effective treatment available for hot flashes and night sweats, other options do exist. Lifestyle approaches include layered clothing, portable fans, exercise, and paced respiration or other relaxation techniques, as well as avoiding "triggers" such as cigarettes, caffeine, alcohol, and spicy foods. Although research findings are mixed, some women also report relief from hot flashes with soy, black cohosh, certain antidepressants, or the anti-seizure medication gabapentin. Women should try some of these strategies before considering hormone therapy.

Karen from Bingham Farms, Mich., asked: "Does taking bioidentical hormones have the same risk for breast cancer as taking synthentic hormones?"

Manson: See response above. Although proponents of bioidentical hormone therapy (BHT) claim that these products have fewer risks than traditional hormone therapy, the reality is that few rigorous studies of these medications have been done and it's unknown whether they're any safer or more effective. We don't know whether they're any safer than synthetic hormones in terms of breast cancer risk. However, we do recommend using the lowest effective dose for the shortest duration possible to minimize breast cancer risk. And be vigilant about having regular mammograms and breast exams.

Jill from Warren, Pa., asked:"Is there still an increased risk of low dose estrogen only? I am having a hyterectomy next week and they will remove ovaries also. The gynecologist is recommending estrogen replacement."

Manson: To minimize health risks, use the lowest dose that makes your hot flashes and night sweats bearable. For many women, low-dose preparations are nearly as effective as standard-dose preparations. For example, start with one half or one third of a standard estrogen dose and track your symptoms for 2-3 months. If symptoms are still intolerable, have your doctor adjust the dose slowly upward until they aren't. Although research studies haven't yet shown conclusively that lower doses are safer, most of the professional organizations recommend using the lowest effective dose for the shortest duration possible to minimize risks.

Elaine from Caldwell, Idaho, asked: "I've been on the climara patch 0.05 mg for over 20 years, is there a difference in the patch or pills? Are natural hormones safe? How would I know what a safe dosage would be? If I go off hormones will I have mood swings, fatigue, hot flashes? At age 56 how will I get the right amount of hormones for my body without replacements?"

Manson:Please see above responses about estrogen patches versus pills. Climara and other estrogen patches may be less likely to increase the risks of blood clots in the legs and lungs than estrogen in pill form, but the evidence is not yet conclusive. Decisions about pills versus patches often come down to personal preference. Although estrogen pills are better than patches at improving cholesterol levels, pills may be more likely than patches to increase blood clots, triglycerides, and markers of inflammation. Keep in mind that there are no large-scale rigorous studies comparing the patch vs the pill in terms of heart safety, breast cancer risk, and other health outcomes. Also, although proponents of "bioidentical" hormone therapy claim that these products are safer and more effective than traditional hormone therapy, the reality is that few rigorous studies of these medications have been done and it's unknown whether this is the case. Regarding symptoms after stopping hormone therapy, we found that about half of the women in the WHI who had hot flashes or night sweats at the start of the study had a recurrence of symptoms after stopping hormone therapy.