HRT Safe? Cutting Through the Confusion

Dr. Marie Savard gets the straight story on hormone replacement therapy.

June 16, 2008 — -- For the millions of women going through menopause, I don't thing there is anything more confusing than the research surrounding hormone therapy. As a postmenopausal woman who uses a small dose of hormones, every new study grabs my attention.

The latest headline suggests hormones have been declared safe. Did I miss something? Has there been new research from randomized trials (the best form of research)?

It turns out that a worldwide meeting of menopause experts in Zurich, Switzerland, reviewed all the available research and concluded that for healthy women in the first 10 years after menopause -- ages 50 to 59 -- taking hormones is safe.

There is no question that for a woman with severe hot flashes, sleep disturbance and an annoyingly dry vagina, nothing else works as well as estrogen. But the risks of breast cancer, stroke and blood clots from estrogen are hard to ignore. These risks are small in a newly postmenopausal woman but not absent altogether. So once again, women are asked to balance the benefits of hormones with the risks and make the best decision for them.

A second headline grabber recently was the news that although oral estrogen causes an increased risk of blood clots, the skin patch form called transdermal estrogen apparently does not.

This news comes from research that looks at many observational studies of hormones, and not from a randomized clinical trial. But the findings make sense. Oral estrogen must first pass through the liver to be metabolized. This first pass through the liver leads to an increase in clotting proteins. Transdermal estrogen provides estrogen in a smaller dose directly to the blood circulation and so bypasses the liver.

The final new news on hormones -- a simple cholesterol test could help women decide whether to take hormones or not. Researchers studying results from the large Women's Health Initiative Study (this was the study stopped in 2002 when the small increased heart risk was discovered in women who were on average 63 years old when they first started taking hormones) found that women with unfavorable cholesterol levels were more likely to develop heart problems while taking hormones, while women with favorable cholesterol levels did not seem to have an increased heart risk.

Specifically, women who had a "bad" LDL to "good" HDL cholesterol ratio less than 2.5 did not appear to have increased heart risk while taking hormones. This speaks yet again to the importance of knowing your cholesterol numbers and sizing up your personal risk of hormones together with your doctor.

So why have I decided to take hormones? Because in addition to annoying hot flashes that awaken me at night, I believe that after sizing up all the evidence, including my own personal family and medical history, that by starting a small dose of estrogen at menopause I will protect my heart and bones and maybe even my brain, colon and eyes. On the other hand there is no question that by starting hormones 10 years or more after menopause it may be too late for estrogen to protect the heart -- and a little more likely it will harm it.

The latest headlines are another reminder that no one-size-fits-all solutions apply for all women. If you are young and considering hormones, talk to your doctor about taking: the lowest possible dose of estrogen, the skin patch form, which bypasses the liver, and a natural form of progesterone rather than the synthetic progestins.

Are you taking hormones? Which hormones have worked for you? What are your major concerns about hormones? Is it fear of developing breast cancer? What are your thoughts about so-called bioidentical hormones?

As always, I welcome your comments and questions to this very confusing matter.


Additional Links:

Global menopause summit concludes HRT is safe for healthy women entering menopause.

Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis

Study Finds It Pays to be Heart Smart if Considering Hormone Therapy

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Dr. Marie Savard is an ABC News medical contributor.

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