Hormone therapy update: where are we now?

Hormone therapy has been debated in public for five years, with contradictory media headlines confusing us about our health risks. With such differing messages, how do we make sense of the latest studies, and understand the risks and benefits, so that we know what’s right for us?

Women across the globe have been unsure about what is right for them. Until 2002 hormone therapy was the standard treatment for menopausal symptoms, used for hot flushes and vaginal dryness, and it was believed to offer protection against osteoporosis and potentially heart disease.

In 2002 researchers stopped the US Government funded Women’s Health Initiative (WHI) study because of early indications that women who took oestrogen were at increased risk of heart disease, stroke, blood clots and breast cancer. Millions of women worldwide stopped taking hormone therapy as a result.

As researchers have analysed the WHI data, it has become increasingly clear that the picture is much more complex than initial headlines indicated. Mostly though, women have become more confused as new reports from the study become public.

Initial results found that for every 10,000 women using oestrogen and progestin, there would be 37 heart attacks per year compared with 30 in every 10,000 women who were not using these hormones.

“The problem with these findings is they were looking at women with an average age of 63,” says Jean Hailes director Professor Henry Burger.

“The results are not relevant for women taking hormone therapy for symptom relief at menopause, and who are on average 13 years younger.”

“The media response caused much anxiety. Many women immediately stopped using hormone therapy, which had a detrimental effect in some,” Professor Burger says. “Further analysis of the findings, taking the age of the women into account, is helping to balance the view.”

Age and timing

Studies now indicate that the age at which a woman starts hormone therapy may make a significant difference.

A more complete data analysis from the oestrogenalone arm of the WHI suggests there is less risk of heart disease if you take oestrogen early in your postmenopausal years as compared with having no treatment. The data analysis showed participants in their 50s who took oestrogen experienced fewer heart attacks and deaths from coronary artery disease than study participants who took a placebo (dummy or sugar pill) and there were less cases of coronary heart disease.

What we know about hormone therapy for otherwise healthy women under 60

	Benefits	Risks	No Change	Uncertain
Combined oestrogen & progestin therapy (for women with a uterus)	Symptom relief Decreased risk of: – Diabetes onset – Fracture – Colorectal cancer	Increased risk of: Deep vein thrombosis Breast cancer after > 5 years treatment (particularly in thinner women)	Stroke	Dementia Memory Heart attack*
Oestrogen alone therapy (for women without a uterus)	Symptom relief Decreased risk of: – Heart attack – Breast cancer – Diabetes onset – Fracture – Stroke	Increased risk of: Deep vein thrombosis	Bowel cancer	Dementia Memory

* It appears that in younger women (less than 60 years) there may be a reduction in heart attacks but more research is needed. Note: Hormone therapy should not be primarily used to decrease other health risks.

Many questions regarding younger postmenopausal women and hormone therapy exist. To address some of these issues, other studies, including a randomised, controlled clinical trial — the Kronos Early Estrogen Prevention Study (KEEPS) — exploring oestrogen use and heart disease in younger postmenopausal women are under way, but won’t be completed for a number of years.

Hormone therapy risks in perspective

The WHI study has shown a 20 per cent increase in breast cancer for women aged 55 to 59 who take oestrogen and progestin for more than five years. While this increase may sound alarming, it is important to understand what this means in real terms.

The study showed that without hormone therapy, 26 of every 10,000 women in this age group will develop breast cancer in a year. With hormone therapy, 31 out of 10,000 will do so.

The 20 per cent relative increase is only a very small actual risk, representing five more breast cancers per 10,000 women, per year. In fact, among the women who had not used hormone therapy before starting in the trial (about three quarters) there was no increase at all in breast cancer risk.

According to Professor Burger, hormone therapy risk needs to be seen in perspective. “Drinking more than two standard drinks a day, having your first baby at a later age or being overweight or obese will all put you at a higher risk of breast cancer than taking hormone therapy,” he says.

How long is it safe to use hormone therapy?

Initially researchers thought that using hormone therapy for five years or less to relieve menopausal symptoms had only a small risk of deep vein thrombosis. The WHI results initially seemed to show that was not the case, but more recent analysis of the 50-59 year age group confirms the original understandings regarding safety.

There is still not enough known about how hormone therapy, particularly in lower doses or different forms, such as creams or patches, might have different effects on the risks of thrombosis and breast cancer. Current guidelines recommend that women who take hormone therapy for menopausal symptoms take the lowest effective dose for the shortest time period to alleviate symptoms. 

Current guidelines recommend that women who take hormone therapy for menopausal symptoms take the lowest effective dose for the shortest time period to alleviate symptoms.

Who should not use hormone therapy?

Women with breast cancer or a history of blood clots should be cautious about taking hormone therapy and would need to discuss with their health practitioner their individual benefits and risks. Hormone therapy should not be used for preventing memory loss, heart disease, heart attacks or strokes.

Talk to your health practitioner about other options, including lifestyle changes, that you can make for long-term protection from these conditions.

Alternatives to hormone therapy

Many women find that simple measures, such as wearing lighter clothing or keeping room temperatures low at night, can make a big difference. These changes won’t eliminate all symptoms, but can make them manageable. Some women may find complementary therapies helpful.

If hot flushes continue to make your life miserable, talk to your health practitioner about the different types of hormone therapy currently available — many of which come in much lower doses than the medication used in the WHI study.

Questions to ask yourself – and your health practitioner

To better understand the benefits and risks associated with taking hormone therapy, it is important to discuss with your health practitioner any history of breast lumps, cancer, heart attack or stroke, blood clots, high blood pressure, cholesterol, diabetes and whether you smoke. While your individual risk for taking hormone therapy may be low, regular checkups are advisable to discuss your ongoing needs. The following questions may be helpful to think about prior to your visit:

 

• Are menopause symptoms affecting your daily life?
• What are the benefits and side effects of taking hormone therapy?
• What are the risks and benefits for you as an individual?
• What new information is there about hormone therapy?
• What else could you take to protect your bones or heart?
• What are the alternatives to help relieve hot flushes or other symptoms?

Points to remember Menopause is a normal part of life – it’s not a disease that has to be treated Not all women will experience symptoms such as hot flushes, night sweats or mood swings during menopause Often these symptoms will last for just a few years There is no ‘one size fits all’ solution There are alternatives to hormone therapy for symptom relief Talk to your health practitioner about your medical history and your individual needs, including risks and benefits If considering hormone therapy, take the lowest effective dose for the shortest period to alleviate symptoms

 

Conclusion

Research is an ongoing process, and information about hormone therapy in particular is changing rapidly. While we now have some clarity to the hormone therapy debate, there are still questions that remain unanswered, such as:

• How long can a woman safely use hormone therapy?
• Are some types of oestrogen or progestin safer than others?
• Is one form of hormone therapy (patch, pill, or cream) better than another?

Talk to your health practitioner about how best to treat or prevent your symptoms or the diseases for which you are at risk. Ask about other options; but remember, these too may have risks and benefits. If you decide to use hormone therapy, the recommendation is to use the lowest dose that works for the shortest time needed.

Professor Burger reminds us that whatever decision you make about using hormone therapy is not final. “You can start or end the treatment at any time,” he says. “If you stop, your risks will lessen over time, but so will the protection.” Discuss your decision about hormone therapy regularly with your health practitioner or whenever you have any concerns.

Each woman is different, so there is no ‘one size fits all’ solution. Further studies offer women and their health practitioners more information to answer the question: Is hormone therapy right for me?

Resources

For more information about hormone therapy please go to www.jeanhailes.org.au

or call 1800 151 441 for information to be sent to you.

Further information is also available at www.healthinsite.gov.au and www.nhmrc.gov.au

© 2007 The Jean Hailes Foundation for Women’s Health

Apart from fair dealing for the purposes of private study, research, criticism or review, as permitted under copyright legislation, no part may be reproduced or reused for any commercial purposes. 

Content updated November 29, 2007