Many women of perimenopausal and menopausal age are faced with a fear factor around hormone therapy. I hear this all the time in my practice, and in my community. I was one of them, being a 54 year old woman! Fortunately, there is updated information out there that is dismantling the disinformation and fear mongering around hormones that have misled women since the early 2000s. This was one of the outcomes of the publication of the Women’s Health Initiative’s (WHI) study. I want to get this information out there for not only my patients, but women in general who could benefit from the use of hormones but have been resistant because of fears. This is intended to be a good foundation for understanding when and how we decide to use hormone therapy, what information those decisions are based on, and for you to feel more empowered in that treatment.
When we are discussing hormone replacement therapy, we are generally referring to Estrogen and Progesterone. Testosterone is an important hormone for women, but it is not an FDA approved drug formulation for women, therefore not the focus of this article, as there are no testosterone formulations available to women from a standard pharmacy. Starting around 40, men and women’s hormones start changing and decreasing which can lead to signs and symptoms such as hot flashes, fatigue, brain fog, memory issues, mood changes, skin changes, loss of bone health, increase in cholesterol, muscle and joint pains, poor sleep or sleep interruption, heart palpitations, vaginal dryness, and a decrease in sexual performance and enjoyment. It is not uncommon for women to feel unheard or unseen when they go to their doctors for help. Sometimes being told that it is just a “normal” part of aging, Please know, that some of this response is because the practitioners themselves do not feel educated enough to know how to properly prescribe hormone replacement therapy, or they are relying on outdated research and media hype that not only discouraged hormone therapy use, but made them fear it. I am grateful that some doctors do admit their knowledge gap, and refer to those of us that have the education and experience.
In 2022, the North American Menopause Society (NAMS) published an updated Position Statement. An advisory panel was created to re-examine their 2017 position statement, and evaluate and analyze new literature and evidence, and come up with an updated recommendation. This brings us to our most current recommendations and guidelines for using hormone replacement therapy in women.
Here are the most noteworthy developments from their paper. These bullet points do not list the uses of HRT, nor a list of contraindications for HRT use, but they all come directly from the Position Paper ( link above and below).
What is approved by the FDA for the use of Hormone Therapy?
- Treatment for hot flashes, night sweats and vaginal symptoms. They also state that it can help improve sleep quality, fatigue, mood, and overall quality of life.
- Hormone therapy can reduce the risk of broken bones from osteoporosis, especially in women who have hypoestrogenism (from surgical removal of ovaries, hypogonadism, or primary ovarian insufficiency).
- Hormone Therapy can treat vaginal dryness, painful intercourse, and recurrent UTIs.
- Observational studies have shown to help with heart disease and cognitive decline or dementia.
What about cancer? What are the updated guidelines with Cancer?
- For women with a family history of breast cancer, HRT does NOT increase their risk of breast cancer.
- There can be a very slight increase in risk of breast cancer if hormones are taken longer than 4 years. However, at the time of diagnosis, it is likely to be a lower stage and lower chance of death than women NOT on hormone therapy.
- For women WITHOUT a uterus, there is no increased risk of breast cancer for the first 7 years, but the risk may increase slightly if used longer.
When is the best time to start and end hormone use?
- The best timing to use HRT is younger than 60 or within 10 years of menopause, as long as there are no contraindications.
- For women who initiate hormone therapy more than 10 years from menopause onset or who are aged older than 60 years, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism (blood clot), and dementia.
- Longer therapy past 60 can be continued if vasomotor symptoms persist, and there is shared decision making and regular evaluations with your provider.
What are some of the downfalls of that original WHI study that misled women’s health care?
- The women used in the study were 50-79 years old. And, at the time this study was done, hormones were given orally, and in high doses.
- Currently, there are more types and more likely safer forms of hormone replacements than used in the WHI study. The form of estrogen used in the study was Conjugated Equine Estrogens (CEE). These are a concentrated formula manufactured from the urine of pregnant horses, which typically contain more than 10 different forms of estrogen, and mainly estrone (the most harmful estrogen of the 3), and smaller amounts of estradiol.
- When you look at the actual numbers of what caused the breast cancer scare, it is really not as inflated as it seemed in the paper and publicizing of it. In reality, it was found that only 8 women per 10,000 generated breast cancer from hormone use. Of those that developed cancer, the risk emerged after 5 years of hormone treatment. And, 20 years later, the mortality of the women taking hormones was no higher than that of the placebo group.
- For women that did not have a uterus and only took estrogen there were 7 FEWER cancer deaths.
So, let your fear rest and do not be afraid to explore hormone therapy with your healthcare provider. The benefits of taking hormones, given at lower doses, in the right forms, during the right window of time, generally outweigh the risks. If following the right parameters, hormones are in fact beneficial in symptom relief, increasing quality of life, and even protective to brain, bone, and heart health. “Hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syn- drome of menopause and has been shown to prevent bone loss and fracture. The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing therapy”. (NAMS Position Statement)
Some other helpful resources:
-Estrogen Matters, by Avrum Bluming , MD and Carol Tarvis, PhD, published 2018
-The Menopause Brain, by Dr. Lisa Mosconi, published 2024
-The New Menopause, Mary Claire Haver, MD , published 2024