Evaluating Hormone Therapy

There are two big things that continue to cause confusion over the value of hormone therapy. One is the lingering effect of 2002 communications from Women's Health Initiative study, which got some things wrong and overstated other things. The end result was that "the medical professionals, in their concern about what turn out to be small risks for some women, are overlooking the overwhelming evidence of estrogen's very large benefits for most women," as the coauthors of Estrogen Matters said.

The second thing is that hormone therapy is not right or wrong. Instead, it's right for some women, and not right for others. It all depends on your risk factors. That's why it's important to talk to your medical professional.

I keep up with the latest research and thinking on menopause, including hormone therapy. Given what all that research to date says, I think there are only two conditions that would definitely exclude you from being a candidate for HT: 1) estrogen-receptor-positive breast cancer and 2) cardiovascular disease with plaque present.

If you don't have those conditions, there are still important considerations. Age is one. The age at which a woman reaches menopause plays a part in breast cancer risk; the risk from hormone therapy is roughly the same as the increased risk that happens naturally if a woman's menopause happens five years later—because of the longer exposure to her own natural estrogen and progesterone. This is, in particular, an area where more research is needed, to tease apart some complicated interactions.

Timing is another consideration. Recent research suggests that there's a window within which hormone therapy can be introduced to provide more benefit than risk. Because arteries become less elastic after menopause, hormone therapy should begin before age 60 or within 10 years of entering menopause (unless you've already been diagnosed with either of the two conditions mentioned above). Within that window, hormone therapy significantly reduces coronary artery disease and overall mortality, adding three or four years to your life.

Composition and delivery are also important. Hormone therapy for women who have not undergone a hysterectomy (who still have a uterus) is usually estrogen plus progestin/progesterone because progestin/progesterone protects against endometrial cancer. Women without a uterus can safely take estrogen alone. Hormone therapy can be delivered in a pill, patch, gel, skin spray or vaginal ring. The method of delivery can impact risks, so a conversation with your provider is important (and, again, more research is needed).

If menopausal symptoms are making you miserable, talk to your health care provider. Together you can look at your entire health picture, including your medical history, your weight, how active you are, and your diet, and decide what your options are for dealing with your symptoms, considering hormone therapy and some great non-hormone options, too!

Barb DePree, MD, has been a gynecologist for 30 years, specializing in menopause care for the past 10. Dr. DePree was named the Certified Menopause Practitioner of the Year in 2013 by the North American Menopause Society. The award particularly recognized the outreach, communication and education she does throughMiddlesexMD, a website she founded and where this blog first appeared. She also is director of the Women's Midlife Services at Holland Hospital, Holland, Michigan.