Hormone therapy (HT) was originally developed to treat symptoms of menopause, including hot flashes, vaginal dryness and pain during intercourse. HT is treatment with estrogen, with or without progesterone. During the 1990s, observations about the health of women who were taking HRT suggested that estrogen hormone supplements could do more than just provide symptom relief. Scientists took interest in the fact that women who took estrogen appeared as a group to have good heart health. Was that from the estrogen? Or was it a coincidence, since women who bothered to take these hormones were, as a group, attentive to their health and habits?
To know the answer, a large study randomly assigned women to take HRT or a placebo pill and watched for true differences in the two groups. This research provided more reliable information about the effects of estrogen and progesterone.
Indeed, estrogen therapy for menopausal women helps to maintain bone health and prevent osteoporosis. And women who take estrogen have a somewhat decreased risk of colon cancer. But reliable research shows that other benefits that we thought estrogen could provide, such as prevention of heart disease or dementia, are not gained from HT. In fact, treatment with an estrogen and progesterone combination actually increases heart attack risk, and estrogen without progesterone appears to have a neutral effect on heart health. Estrogen with or without progesterone increases the risk of stroke and dementia.
Short-term use of estrogen does not noticeably increase the risk of breast cancer, but taking it for more than five years increases the risk slightly. This increase in risk is relatively small, with an estimated eight extra cases per 10,000 women who use hormone supplements for more than five years.
What Should I Do Now
Recommendations for women have come full circle. Women who have menopausal symptoms that are not adequately controlled with other measures can still benefit from estrogen, because it relieves menopause symptoms. If you begin estrogen, though, you should use the lowest dose of estrogen that makes you feel relief. Periodically, attempts should be made to gradually wean yourself off estrogen therapy.
Unless you have had a hysterectomy, you are advised, if you take hormones, to take progesterone along with estrogen to protect the lining of the uterus from becoming too thick. A thickened lining from estrogen is associated with higher rates of cancer of the uterus.
The Osteoporosis Link
On the osteoporosis prevention front, there are alternatives to estrogen. Possibly your best protection is to be physically active. It is preferable that you do weight-bearing exercise every day, or at least three times a week, to help to maintain bone health. Avoid smoking and avoid excessive caffeine. If you don't get enough calcium in your diet, you can take daily supplements to reach the 1,500 milligrams recommended for postmenopausal women. Vitamin D in doses of 400 to 800 international units a day is standardly recommended.
If there is any question about bone density, your doctor can order a simple test to get a reading. Women who have osteoporosis (bones that are thin enough to increase your fracture risk) can consider treatment with medications other than estrogen. There are several options, including bisphosphonates (such as Actonel, Didronel, and Fosamax), nasal calcitonin (Miacalcin), raloxifene, and injections of the parathyroid hormone (Forteo). Side effects are possible from these medicines, and long-term treatment is expensive. For these reasons, many doctors do not recommend them for treatment of very mild bone thinning, called "osteopenia."
The bottom line is that HT is still recommended in the short term to treat symptoms of menopause related to hot flashes and vaginal dryness. But HT doesn’t prevent heart disease, stroke and dementia, and long-term use could be harmful.