Humana HealthBeat Transcript Archive

One of the big decisions of menopause is whether or not to take hormone therapy. Hormone therapy may not be right for every woman, and it's not one size fits all, either.

As with all decisions, the best choices are made based on good information.

Menopause is technically defined as the absence of a period for 12 months. The average age of menopause is 51 years. The transition to menopause, which can begin several years earlier, is called perimenopause. Symptoms may be caused by the fluctuations in hormone levels during this time.

Estrogen can, in many cases, alleviate the hot flashes, disturbed sleep, and vaginal dryness associated with perimenopause. Estrogen cream may reduce urinary tract infections and incontinence, which may become a problem as the estrogen levels are reduced.

This loss of estrogen can contribute to long-term health problems, such as osteoporosis and heart disease. Estrogen has been proven to prevent bone loss and osteoporosis, though if you stop the therapy, the benefits stop too.

Estrogen, when used alone, has been shown to reduce LDL cholesterol (the "bad" cholesterol) and increase HDL cholesterol (the "good" cholesterol) and triglycerides. The use of progestins to reduce the risk of uterine cancer (see below) also reduces some of estrogen's beneficial effect on cholesterol, depending on the type of progestin used. Hormone therapy may help prevent coronary heart disease in women with no history of the disease, but no large trials have been done to this point to provide conclusive evidence.

Estrogen therapy may also help cognitive function and prevent dementia, but the evidence is not conclusive. Recent studies also suggest that hormone therapy may decrease the risk for colorectal cancer, the third most common cancer in women.

With any medication, come risks. The risks of estrogen therapy given by itself, is uterine cancer. This risk is alleviated with the addition of a progestin, another hormone. If you have had a hysterectomy, you will not need to take a progestin.

Progestins also come in different forms and can be given with the estrogen, or in sequence with the estrogen, which will cause you to have monthly bleeding. Your doctor will give you information about what to expect, and any bleeding patterns that vary should be reported to your physician.

Progestins may cause breast tenderness and mood changes, so some women may choose to take estrogen alone. In that case, the doctor will want to monitor you for any abnormal bleeding and evaluate your uterus on a yearly basis to check for any early signs of uterine cancer.

Other risks of hormone therapy include blood clots and active gallbladder disease, with the greatest risk in older women with known heart disease. The estrogen patch may reduce these risks in appropriate candidates for therapy.

The Heart and Estrogen/Progestin Replacement Study, known as the HERS study, observed women on combination therapy and the effect on heart disease on women with known coronary disease. Women who were treated with conjugated equine estrogen, the kind of estrogen used in Premarin, for example, and medroxyprogesterone acetate were compared with women on placebo (i.e., a "sugar pill"). The conclusions of the study showed that during a follow-up period of about 4 years, treatment with the combined hormone therapy did not reduce the rate of heart disease events in these women. Additionally, there appeared to be an increase in such events in the first two years of therapy, which decreased in later years. This study raises unanswered questions about the effects of estrogen alone, or combination therapy used in sequence, rather than taken together. It also caused a swell of controversy because it seemed to fly in the face of evidence showing the protective effect of hormone therapy on heart disease. At the current time, women with heart disease should discuss the implications of this study with their doctors as they make their decision.

Many women fear hormone therapy as it relates to the risk of breast cancer. What we know is that the evidence shows no increased risk if therapy is used for 5 years or less. For those women who use therapy more than five years, though the risk increases, the chance of getting breast cancer with a more favorable prognosis also increases.

Common side effects of estrogen include nausea, headaches and heavy bleeding. Common side effects of progestin include breast tenderness, mood changes, and headache. Many of these side effects can be reduced by a change in dose, form of therapy, or regimen. Surprising to most folks is that weight gain is not a side effect of estrogen.

There are some women who are not appropriate candidates for hormone replacement therapy. Women, who are pregnant, have unexplained vaginal bleeding, liver disease, history of breast or endometrial cancer, or recent blood clot are generally advised against this treatment. Women with high triglycerides, a history of blood clots, a family history of breast cancer, gallbladder disease, migraines, fibroids, or a seizure disorder should have a detailed conversation with their physicians about the relative risks and benefits of using hormone therapy.

So if you're trying to make the decision, consider these factors:

Do you want to take hormone therapy for symptoms and then quit once they are resolved, or are you taking it for the long-term benefits of osteoporosis prevention, as well?
What is your relative risk/benefit profile? In other words, what are the benefits to you given your medical history and risk for osteoporosis, heart disease, and breast cancer, compared with the potential risks of therapy?
What's most important to you; will you feel better knowing you are taking a medicine that can potentially prevent a disease, such as osteoporosis, or will you worry about the side effects and risks of taking the medication, even if the risk is small?
What is your preference regarding how you take the medicine? Would you rather take a pill, use the patch, or use a vaginal cream? Ask your doctor about side effects, and relative benefits of these options.

Remember, there is no wrong decision. And you can change your mind, or your therapy, at any time. Just make sure you speak with your physician before you make any changes, and don't stop medication abruptly unless advised to do so by your doctor.

January 21
Hormone Therapy
	One of the big decisions of menopause is whether or not to take hormone therapy. Hormone therapy may not be right for every woman, and it's not one size fits all, either. As with all decisions, the best choices are made based on good information. Menopause is technically defined as the absence of a period for 12 months. The average age of menopause is 51 years. The transition to menopause, which can begin several years earlier, is called perimenopause. Symptoms may be caused by the fluctuations in hormone levels during this time. Estrogen can, in many cases, alleviate the hot flashes, disturbed sleep, and vaginal dryness associated with perimenopause. Estrogen cream may reduce urinary tract infections and incontinence, which may become a problem as the estrogen levels are reduced. This loss of estrogen can contribute to long-term health problems, such as osteoporosis and heart disease. Estrogen has been proven to prevent bone loss and osteoporosis, though if you stop the therapy, the benefits stop too. Estrogen, when used alone, has been shown to reduce LDL cholesterol (the "bad" cholesterol) and increase HDL cholesterol (the "good" cholesterol) and triglycerides. The use of progestins to reduce the risk of uterine cancer (see below) also reduces some of estrogen's beneficial effect on cholesterol, depending on the type of progestin used. Hormone therapy may help prevent coronary heart disease in women with no history of the disease, but no large trials have been done to this point to provide conclusive evidence. Estrogen therapy may also help cognitive function and prevent dementia, but the evidence is not conclusive. Recent studies also suggest that hormone therapy may decrease the risk for colorectal cancer, the third most common cancer in women. With any medication, come risks. The risks of estrogen therapy given by itself, is uterine cancer. This risk is alleviated with the addition of a progestin, another hormone. If you have had a hysterectomy, you will not need to take a progestin. Progestins also come in different forms and can be given with the estrogen, or in sequence with the estrogen, which will cause you to have monthly bleeding. Your doctor will give you information about what to expect, and any bleeding patterns that vary should be reported to your physician. Progestins may cause breast tenderness and mood changes, so some women may choose to take estrogen alone. In that case, the doctor will want to monitor you for any abnormal bleeding and evaluate your uterus on a yearly basis to check for any early signs of uterine cancer. Other risks of hormone therapy include blood clots and active gallbladder disease, with the greatest risk in older women with known heart disease. The estrogen patch may reduce these risks in appropriate candidates for therapy. The Heart and Estrogen/Progestin Replacement Study, known as the HERS study, observed women on combination therapy and the effect on heart disease on women with known coronary disease. Women who were treated with conjugated equine estrogen, the kind of estrogen used in Premarin, for example, and medroxyprogesterone acetate were compared with women on placebo (i.e., a "sugar pill"). The conclusions of the study showed that during a follow-up period of about 4 years, treatment with the combined hormone therapy did not reduce the rate of heart disease events in these women. Additionally, there appeared to be an increase in such events in the first two years of therapy, which decreased in later years. This study raises unanswered questions about the effects of estrogen alone, or combination therapy used in sequence, rather than taken together. It also caused a swell of controversy because it seemed to fly in the face of evidence showing the protective effect of hormone therapy on heart disease. At the current time, women with heart disease should discuss the implications of this study with their doctors as they make their decision. Many women fear hormone therapy as it relates to the risk of breast cancer. What we know is that the evidence shows no increased risk if therapy is used for 5 years or less. For those women who use therapy more than five years, though the risk increases, the chance of getting breast cancer with a more favorable prognosis also increases. Common side effects of estrogen include nausea, headaches and heavy bleeding. Common side effects of progestin include breast tenderness, mood changes, and headache. Many of these side effects can be reduced by a change in dose, form of therapy, or regimen. Surprising to most folks is that weight gain is not a side effect of estrogen. There are some women who are not appropriate candidates for hormone replacement therapy. Women, who are pregnant, have unexplained vaginal bleeding, liver disease, history of breast or endometrial cancer, or recent blood clot are generally advised against this treatment. Women with high triglycerides, a history of blood clots, a family history of breast cancer, gallbladder disease, migraines, fibroids, or a seizure disorder should have a detailed conversation with their physicians about the relative risks and benefits of using hormone therapy. So if you're trying to make the decision, consider these factors: Do you want to take hormone therapy for symptoms and then quit once they are resolved, or are you taking it for the long-term benefits of osteoporosis prevention, as well? What is your relative risk/benefit profile? In other words, what are the benefits to you given your medical history and risk for osteoporosis, heart disease, and breast cancer, compared with the potential risks of therapy? What's most important to you; will you feel better knowing you are taking a medicine that can potentially prevent a disease, such as osteoporosis, or will you worry about the side effects and risks of taking the medication, even if the risk is small? What is your preference regarding how you take the medicine? Would you rather take a pill, use the patch, or use a vaginal cream? Ask your doctor about side effects, and relative benefits of these options. Remember, there is no wrong decision. And you can change your mind, or your therapy, at any time. Just make sure you speak with your physician before you make any changes, and don't stop medication abruptly unless advised to do so by your doctor.

	What about "designer estrogens"? Selective estrogen-receptor modulators, or SERMS, are compounds that bind to specific receptors on cells that usually bind to estrogen. When the SERM binds to these receptors, they can cause an estrogen- like effect, or the opposite effect to estrogen, depending on the type of tissue. The SERM Tamoxifen's anti-estrogen activity has been shown to reduce the risk of breast cancer in high-risk women and the recurrence of breast cancer in women with known breast cancer. But it also acts like an estrogen, with its increased risk of blood clots and uterine cancer. Furthermore, it has not been shown to reduce the risk of osteoporosis or heart disease. A newer SERM, Raloxifene, is approved for the prevention of osteoporosis due to its ability to reduce the risk of fractures in menopausal women. It did so without increasing the risk of uterine cancer. Raloxifene has also been shown to reduce the risk of breast cancer and improve LDL cholesterol levels without increasing triglyceride levels. What about soy as a source of estrogen? Soy is high in plant estrogens. Some studies suggest that a diet high in soy may reduce hot flashes in some women, but usually not to the extent that they respond with estrogen therapy. Other studies show that 25 grams a soy per day may reduce cholesterol levels. Beyond that, there are no conclusive studies on other benefits. There's a great deal of interest in this area, so we may have more information in the near future. References and Resources: McNagny, SE. Prescribing Hormone Replacement Therapy for Menopausal Symptoms. Annals of Internal Medicine, 1999; 131:605-616 Menopause (1992 publication) National Institute on Aging http://www.nih.gov/health/chip/nia/menop/men1.htm National Institute on Aging Age Page: Hormone Replacement Therapy: Should You Take It Administration on Aging www.aoa.dhhs.gov/aoa/pages/agepages/hormone.html