| Hormone Replacement Therapy |
| Hormone Replacement Therapy |
Hormone replacement therapy is in a state of flux. For years, it
was the mainstay of treatment for women suffering from the
new and unexpected experience of menopause. Women did
not hear from their mothers or older sisters about the "change
of life" except in whispered tones, with foreboding. This was not
a time of sharing, and many women did not know what to expect.
There was a honeymoon period, when hormones were felt to
the be the cure-all and could be taken without consideration for
consequences. The heyday of hormone therapy ended with the
Women's Health Initiative, which was an enormous study of
thousands of women. It was stopped before it was completed,
because of the large increase in women who developed
problems from hormone therapy compared with women on
placebo.
This was quite unexpected; for years, studies had
recommended hormone replacement therapy to treat
symptoms of menopause, to prevent menopausal insomnia,
heart disease, osteoporosis, and to prevent the worst of
Altzheimer's disease in women. Practitioners had always
known of the association between estrogen and blood clots,
and had used that association to treat abnormally heavy
bleeding. Most studies at the time were based on studies of
osteoporosis, which could be easily measured, and the
dosages of HRT recommended were based on the lowest
dose that could be demonstrated to prevent osteoporosis.
Physicians knew that some breast cancers were
hormone-sensitive, but not all of them. If a woman had a known
history of breast cancer, she was never offered HRT. If a
woman had a known history of blood clots (thromboembolic
disease or pulmonary embolus) she was never treated wtih
HRT. Just as people who had ulcers should not take aspirin,
women with thromboembolic disease should not take HRT.
Studies became more sophisticated, using more and more
complex statistics, with built-in formulas that could dictate the
actions of the study. One of those pre-determined statistics
kicked out the study of HRT in the Women's Health Initiative,
and the study was stopped early, before it had been completed,
and before the question it set out to answer was clearly settled.
A news release caused an enormous amount of discomfort in
the community and women discontinued their hormone therapy
by the thousands.
was the mainstay of treatment for women suffering from the
new and unexpected experience of menopause. Women did
not hear from their mothers or older sisters about the "change
of life" except in whispered tones, with foreboding. This was not
a time of sharing, and many women did not know what to expect.
There was a honeymoon period, when hormones were felt to
the be the cure-all and could be taken without consideration for
consequences. The heyday of hormone therapy ended with the
Women's Health Initiative, which was an enormous study of
thousands of women. It was stopped before it was completed,
because of the large increase in women who developed
problems from hormone therapy compared with women on
placebo.
This was quite unexpected; for years, studies had
recommended hormone replacement therapy to treat
symptoms of menopause, to prevent menopausal insomnia,
heart disease, osteoporosis, and to prevent the worst of
Altzheimer's disease in women. Practitioners had always
known of the association between estrogen and blood clots,
and had used that association to treat abnormally heavy
bleeding. Most studies at the time were based on studies of
osteoporosis, which could be easily measured, and the
dosages of HRT recommended were based on the lowest
dose that could be demonstrated to prevent osteoporosis.
Physicians knew that some breast cancers were
hormone-sensitive, but not all of them. If a woman had a known
history of breast cancer, she was never offered HRT. If a
woman had a known history of blood clots (thromboembolic
disease or pulmonary embolus) she was never treated wtih
HRT. Just as people who had ulcers should not take aspirin,
women with thromboembolic disease should not take HRT.
Studies became more sophisticated, using more and more
complex statistics, with built-in formulas that could dictate the
actions of the study. One of those pre-determined statistics
kicked out the study of HRT in the Women's Health Initiative,
and the study was stopped early, before it had been completed,
and before the question it set out to answer was clearly settled.
A news release caused an enormous amount of discomfort in
the community and women discontinued their hormone therapy
by the thousands.
| Brenda L. Kehoe, M.D. |
At this time, the parent organization of OB/GYNs across the country, ACOG, has made a statement
that women who have severe symptoms of menopause could be treated for a period of five years
with the lowest possible dose that alleviates their symptoms. There is no current resolution of the
question, and every woman must decide on her own, given the tumultuous state of the hormone
replacement therapy question, whether she needs replacement or not. The question is
compounded by the fact that at the turn of the century, women only lived to 40 to 50 years old, and
didn't go through menopause the way we do now. Women in menopause today can be expected to
live 30-40% of their lives after menopause.
that women who have severe symptoms of menopause could be treated for a period of five years
with the lowest possible dose that alleviates their symptoms. There is no current resolution of the
question, and every woman must decide on her own, given the tumultuous state of the hormone
replacement therapy question, whether she needs replacement or not. The question is
compounded by the fact that at the turn of the century, women only lived to 40 to 50 years old, and
didn't go through menopause the way we do now. Women in menopause today can be expected to
live 30-40% of their lives after menopause.
Many women prefer to go through the stages
of their lives in a natural manner, and decline
HRT for that reason.
of their lives in a natural manner, and decline
HRT for that reason.
What we do know from the WHI is that
women who are older, who have a greater
risk of coronary artery disease, who have
never used hormones, should probably not
start. There are medications, modified
estrogens, that can be used to prevent or
treat osteoporosis. They also have side
effects.
women who are older, who have a greater
risk of coronary artery disease, who have
never used hormones, should probably not
start. There are medications, modified
estrogens, that can be used to prevent or
treat osteoporosis. They also have side
effects.
If menopausal symptoms, including hot
flashes, vaginal dryness, irritability,
insomnia, moodiness, inability to
concentrate and others are too disruptive,
then HRT may be beneficial.
flashes, vaginal dryness, irritability,
insomnia, moodiness, inability to
concentrate and others are too disruptive,
then HRT may be beneficial.
At this time, every woman must decide for herself, and must balance out the risks and benefits.
There is a slightly increased risk of breast cancer and blood clots, e.g., heart attacks and strokes,
in women on hormone therapy. There is a slightly decreased risk of colon cancer and
osteoporosis. The question of Altzheimer's is unknown. The recommendation from ACOG is that
women be treated for severe symptoms at the lowest dose possible, and for 5 years or less.
Estrogen-like natural substances have not been fully tested, but the suspicion remains that if a
substance acts like estrogen to alleviate symptoms, it might also be associated with the same
side effects that plague estrogen.
There is a slightly increased risk of breast cancer and blood clots, e.g., heart attacks and strokes,
in women on hormone therapy. There is a slightly decreased risk of colon cancer and
osteoporosis. The question of Altzheimer's is unknown. The recommendation from ACOG is that
women be treated for severe symptoms at the lowest dose possible, and for 5 years or less.
Estrogen-like natural substances have not been fully tested, but the suspicion remains that if a
substance acts like estrogen to alleviate symptoms, it might also be associated with the same
side effects that plague estrogen.
Every person is an individual and has specific needs, wants, and issues. Women who are
concerned about menopause and other issues should see a health care professional to
personalize her needs and decide on a course of action.
concerned about menopause and other issues should see a health care professional to
personalize her needs and decide on a course of action.
At least six different natural estrogens have been isolated from human female plasma, but only three are present in significant quantities: estrone, beta estradiol, and estriol. They are produced mostly by the ovaries, although the adrenal glands secrete some as well. The liver conjugates the estrogens to form glucuronides and sulfates and about 1/5 of those products are excreted in the bile, while most of the rest are excreted in urine. The liver converts the potent estrogens, estradiol and estrone, into the almost totally impotent estrogen, estriol. The liver does this so well that diminished liver function causes an increase in the activity of estrogens in the body. The estrogenic potency of estradiol is 12 times that of estrone and 80 times that of estriol. Estradiol and estrone are present in large quantities in venous blood coming from the ovaries, while estriol is an oxidative byproduct of the other two. The serum level of estradiol in post-menopausal women is about 20 pg/ml, and estrone is about 30 pg/ml. Generally bioidentical hormones are compounded specifically based on saliva or blood testing. There is a great deal of controversy about the use of bioidentical hormones because compounded amounts vary remarkably, are not tested, and often are prescribed in very high doses. Insurance often does not cover compounded substances. |
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