More Details in Long-Term Hormone Study

October 2, 2013

News Review From Harvard Medical School -- More Details in Long-Term Hormone Study

Results of a new, longer-term study confirm that women should not take hormone replacement therapy to reduce any disease risk after menopause. But short-term treatment for menopause symptoms seems to be safe. The new results are consistent with advice doctors have been giving for about a decade. The new study is a follow-up to the Women's Health Initiative. That study changed medical practice when it was published in 2002. The study was stopped early when it found that women who were randomly assigned to take estrogen and progestin had higher risks of breast cancer, heart attack, stroke and blood clots. They were compared with women taking placebo (fake) pills. A study of women taking estrogen alone found a slightly higher risk of blood clots and stroke. The new study looked at the women's health after 13 years. It clarified some risks for younger women in the study, those ages 50 to 59. Younger women who were in the estrogen-only study had a slightly lower rate of heart attack and fewer deaths than women who took placebo pills. But blood-clot rates were higher for women of all ages. The Journal of the American Medical Association published the study. HealthDay News wrote about it October 1.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

This time the findings of a new study are consistent with prior advice. Short-term hormone therapy for symptoms of menopause works with minimal risks. The benefits of long-term use to prevent heart disease and other conditions remain questionable at best. For most women, the risks outweigh the benefits.

Those are the findings of the latest analysis from the Women's Health Initiative (WHI). But there is more to learn from this new report. Not all menopausal hormone therapy is the same. The medicine used in the WHI study contained both conjugated estrogen and a progestin (Prempro). Women who had a prior hysterectomy took conjugated estrogen alone.

Prempro was the most widely prescribed hormone therapy at the time women were recruited into the study in the mid-1990s. Estrogen alone increases the risk of cancer of the uterus. Taking a progestin along with the estrogen neutralizes that risk.

Findings from this study again highlight the different benefits and risks of hormone therapy:

• Younger women in early menopause who take estrogen alone (no progesterone) may actually have a slightly reduced risk of invasive breast cancer. This is a very different result from combined estrogen-progestin therapy. The breast cancer risk from combined treatment is well known to be higher.
• Younger women in early menopause who take estrogen alone also have a lower chance of having a heart attack or dying while taking the estrogen. Once it is stopped, those advantages go away over time.
• Women of all ages who take estrogen increase their risk of blood clots in the veins that can travel to the heart. This is true whether or not they take progestin.
• Women of all ages who take estrogen have a lower rate of osteoporosis and fractures.

What Changes Can I Make Now?

Short-term estrogen therapy is clearly the most effective way to manage symptoms of menopause. Common symptoms include hot flashes and  dryness in the vagina. If you have had a hysterectomy, you don't need a progestin.

If you have your uterus, most doctors recommend taking a progestin with the estrogen. This reduces the risk of uterine cancer. However, there is another option. Ask your doctor about having regular ultrasounds to look for thickening of the uterine lining. A thicker lining is linked with a higher cancer risk.

Another question is what type of  estrogen to take. A new study compared conjugated estrogen pills to estradiol pills. The women who took estradiol had a lower risk of blood clots. Previous studies have suggested that estrogen patches might have a lower blood clot risk than any estrogen given as a pill.

If you're not a good candidate for hormone therapy, here are a few other options for treating menopause symptoms.

• Vaginal estrogen -- A tablet, ring or cream delivers a low dose of estrogen into the vagina. This treatment can help relieve dryness, discomfort during sex and some urinary symptoms.
• Relaxation therapy -- There is some evidence that this type of therapy may help with hot flashes. It's a great stress reliever, too.
• Low-dose antidepressants -- Some antidepressant drugs may reduce hot flashes. They include venlafaxine (Effexor), fluoxetine (Prozac), citalopram (Celexa) and escitalopram (Lexapro).
• Gabapentin -- This anti-seizure drug can also help with hot flashes.

What Can I Expect Looking to the Future?

Women entering menopause have already started getting more comfortable with low-dose, short-term estrogen therapy. For now, the message will remain. Take the lowest dose that controls symptoms. Take it only as long as you need it.