New Views on Hormone Replacement Therapy

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Hormone replacement therapy (HRT) has been a hot topic of debate for many years. With this year’s release of new and conflicting data about the potential harmful rather than protective effects on the cardiovascular system and increased incidence of invasive breast cancer, most women are more confused than ever before about the pros and cons of HRT.

Let’s review some of the data from the women’s Health Initiative study published in July. They indicate that for every 10,000 women on HRT for the duration of one year, 8 additional women will develop invasive breast cancer compared with those not taking HRT. There will be 7 additional out of the 10,000 who will have a heart attack, 8 additional who will have a stroke and 10 additional who will experience blood clots.

When we take a closer look at these data, we find some confounding elements. It is well known that it takes a certain number of years for breast cancer cells to become detectable via mammogram. It’s possible, therefore, that some of the women in the WHI study who developed invasive breast cancer already had breast cancer at the onset of the study. However, since the cancer would have been non-detectable at that time, how can we effectively screen women for risk factors for HRT? In other words, do the new data offer any new information about the increased incidence of breast cancer in women with no pre-existing cancer cells? According to the study, the breast cancer risk exceeded the predefined boundary for safety after 5.2 years of HRT.

Let’s discuss the mechanisms behind the increased incidence of cardiovascular events. Estrogen can dilate blood vessels and improve the blood flow to the brain and heart. This may explain the increased mental clarity that some women report while taking HRT. When given to a 50 year-old woman with no significant cardiovascular risks, HRT may be an appropriate choice. Estrogen, however, also increases the blood’s ability to clot.

Intuitively we know that thicker blood that clots more easily can be a problem as we age and our blood vessels become stiffer and more narrow. It may therefore be less appropriate as we get older and the blood vessels stiffen and narrow.

Women who initially took HRT for menopausal syndrome can usually be weaned off their medications seamlessly. Even in women with a history of severe menopausal symptoms at or around the time of menopause, symptoms that initially abated with HRT stay in remission when HRT is discontinued. Each woman should be evaluated individually; there is no scientific schedule we adhere to in terms of how we taper HRT. It’s one of the myriad issues we address when considering whether or not to continue HRT.

Osteoporosis prevention and treatment are other possible indications for continuation of HRT. There are many alternative therapies that are beyond the scope of this article. However, it is worth mentioning that HRT can be an extremely effective treatment choice. It might be a more appropriate choice when both osteoporosis treatment and menopausal syndrome are at issue. HRT can effectively prevent bone loss as well as help to replace already diminished bone mass.

Once the strategy to continue HRT is adopted, the patient is faced with the choice to use synthetic one-size-fits-all HRT or natural hormones that can be dosed individually. Let’s look at progesterone first. Natural progesterone is derived from soybeans and yams. These foods are rich in phytoestrogens, which have hormone-like properties, Natural progesterone functions like the progesterone produced by your body. Progestin, the synthetic progesterone found in traditional pharmaceutical HRT, can lower the body’s own production of progesterone which can worsen mood swings, cause headaches, bloating and weight gain. Natural progesterone is considerably less likely to cause these side effects.

We use micronized progesterone because It’s better absorbed by the body and It’s been proven to raise the blood level of progesterone effectively.

Tri-est, or “triple estrogen”, is actually a combination of three hormones: estriol, estrone and estradiol. To a certain extent, estrone and estradiol are converted into estrone in the intestinal tract. The problem is that estrone is the type of estrogen that is thought to increase breast cancer risk. Replacing estriol and estradiol in the form of Bi-est, a natural estrogen replacement medication, is an effective and potentially safer means of both alleviating menopausal symptoms and raising serum estrogen levels. We also use DHEA and testosterone cream when appropriate in order to customize the HRT protocol for each individual patient.

HRT remains a field of expertise wherein there are no black and white guidelines. Careful consideration of pros and cons in addition to regular gynecologic check ups with mammograms should always be undertaken under the guidance of a health professional. When natural HRT is used, dose regulation can help optimize treatment of menopausal syndrome and osteoporosis.

BOTTOM LINE: The “new” news isn’t so new! The decision to continue or discontinue HRT should be made after a comprehensive review of each individual patient’s current status.

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