Common questions about hormone therapy.

Q Are there any definite rules at this point for who should and shouldn't use hormone therapy?

A Hormone therapy is not a 'one-size-fits-all' solution. It is important for women and their health care providers to determine whether hormone therapy is an appropriate treatment option. This decision should be based on a woman's menopausal symptoms and her medical history.

There is, however, one very clear rule at this point: Hormone therapy should not be started or continued for the express purpose of preventing cardiovascular disease, a common clinical practice in the past.

Based on the research to date, there is no apparent benefit to hormone therapy for cardiovascular disease, and there is even an increased risk for stroke with either estrogen alone or with estrogen and progestin. Generally, beginning hormone therapy at age 60, 70 or even later is not advisable. And, women at high risk for cardiovascular disease should also avoid it. Hormone therapy still has a role in the short-term treatment of menopausal symptoms, but the lowest effective dose should be used for the shortest duration necessary.

Q I know that hormone therapy has often been prescribed to prevent osteoporosis. How does it compare with other osteoporosis medications?

A So far, results from the Women's Health Initiative find that estrogen, either alone or with progestin, helps decrease the risk of hip fracture and other osteoporotic fractures in women. As more women stop taking hormone therapy, however, they are looking for alternatives to protect their bones. Today, several medications are available for the prevention or treatment of osteoporosis, such as Evista (raloxifene), a selective estrogen receptor modulator, or SERM, which is protective against vertebral fractures. However, studies find that estrogen, either alone or combined with progestin, is about twice as powerful in preventing osteoporosis as Evista. Bisphosphonates, a class of drugs including Fosamax (alendronate) and Actonel (risedronate) that is used in the treatment of osteoporosis, are at least as effective as hormone therapy for this purpose.

Q When are hot flashes at their worst?

A Generally, hot flashes are at their worst within the first two years of menopause. They gradually taper off after menopause in most women. A small percentage of women will have long-term, severe hot flashes that can be controlled with only hormone therapy. The wide variety of options now available can help relieve discomfort and minimize the negative impact hot flashes can have on women's lives, such as disrupting sleep.

References

1 NHLBI Stops Trial of Estrogen Plus Progestin Due to Increased Breast Cancer Risk, Lack of Overall Benefit. [Press release]. National Heart, Lung and Blood Institute. http://www.nhlbi.nih.gov.

2 Ettinger B, Grady D, Tosteson AN, et al. Effect of the Women's Health Initiative on women's decisions to discontinue postmenopausal hormone therapy. Obstet Gynecol. 2003 Dec;102(6):1225-32.

3 FDA Orders Warning on all Estrogen Labels, New York Times. Jan. 9, 2003.

4 Female Ob-Gyns Support Menstrual Suppression, Are Divided on Elective Cesareans, and Half Use Hormone Therapy During Menopause. [Press release]. American College of Obstetrics and Gynecology. Available at: http://www.acog.org.

5 Grady D, Ettinger B, Tosteson AN, et al. Predictors of difficulty when discontinuing postmenopausal hormone therapy. Obstet Gynecol. 2003 Dec;102(6):1233-9.

6 Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002 Jul 17;288(3):321-33.

7 Rapp SR, Espeland MA, Shumaker SA et al. WHIMS Investigators. Effect of estrogen plus progestin on global cognitive function in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled trial. JAMA. 2003 May 28;289(20):2663-72.

8 Estrogen and progestogen use in peri- and postmenopausal women: September 2003 position statement of The North American Menopause Society. http://www.menopause.org.

9 Hays J, Ockene JK, Brunner RL, et al. Women's Health Initiative Investigators. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med. 2003 May 8;348(19):1839-54.

10 FDA letter of approval to Solvay Pharmaceuticals. http://www.fda.gov/cder/approval/index.htm.

11 Menopausal Hormone Therapy Survey Results. National Women's Health Resource Center. September 24, 2003-October 15, 2003.

12 Loprinzi L, Barton DL, Sloan JA, et al. Pilot evaluation of gabapentin for treating hot flashes. Mayo Clin Proc. 2002 Nov;77(11):1159-63.

13 Eichholz, A, Mahavni, V, Sood, A. Allopathic and Complementary Alternatives to Hormone Replacement Therapy, Expert Opin Pharmacother. 2002 Jul;3(7):949-55.

14 Shargil AA. Hormone replacement therapy in perimenopausal women with a triphasic contraceptive compound: a three-year prospective study. Int J Fertil. 1985;30(1):15, 18-28.

15 Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled trials. Ann Intern Med. 2002 Nov 19;137(10):805-13. Review.

16 Younus J, Simpson I, Collins A et al. Mind control of menopause. Womens Health Issues. 2003 Mar-Apr;13(2):74-8.

17 Blatt MH, Wiesbader H, Kupperman HS. Vitamin E and climacteric syndrome; failure of effective control as measured by menopausal index. AMA Arch Intern Med. 1953 Jun;91(6):792-9. No abstract available.

18 Barton DL, Lopnnzi CL, Quella SK, Sloan JA, Veeder MH, Egner JR, Fidler P, Stella PJ, Swan DK, Vaught NL, Norotny P. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors.

19 J Clin Oncol. 1998 Feb;16(2):495-500.

20 North American Menopause Society. Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society. Menopause. 2004 Jan-Feb;11(1):11-33.

21 Cohen, Rousseau, & Carey (2003) Can Acupuncture ease the symptoms of menopause? Holistic Nsg Px, 17(6), 295-299.

22 Cutson TM, Meuleman E. Managing menopause. Am Fam Physician. 2000 Mar 1;61(5):1391-400, 1405-6. Review.

--JoAnn E. Manson, MD, DrPH

Elizabeth F. Brigham Professor of Women's Health, Harvard Medical School, Chief of Preventive Medicine at Brigham and Women's Hospital Boston, MA

A principal investigator of the Women's Health Initiative