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Menopause Miracle or Madness?
Estrogen Replacement Therapy Could Help Ease The Transition, But It’s Not Without Risk


July 2nd, 2004

By Louis Wittig : eCureMe Staff Writer
July 1st, 2004 : Physician Reviewed



If you’re trying to decide whether to ask your doctor about estrogen replacement therapy chances are you haven’t had it easy. Last month, researchers writing in the Journal of the American Medical Association announced that estrogen supplement use doesn’t offer any protection against the onset of Alzheimer's Disease (AD) in older women, and may actually increase the likelihood that some will develop dementia. The results are just the latest in a series of findings that, over the past few years, have turned what was once almost considered a panacea for the problems of aging in menopausal and post-menopausal women into a risky option.


Yet, even as the FDA is urging women to minimize their use of extra estrogen, it’s also sticking to the line that replacing lost estrogen is as effective a treatment for hot flashes and night sweats as currently exists. Furthermore, some scientists are saying that estrogen replacement therapy doesn’t deserve the bad rap it’s gotten and just needs a little more research.

Menopause Miracle or Madness?


Menopause


Estrogen therapy (also known as hormone replacement therapy, or HRT, or menopausal hormone therapy, MHT) becomes an issue for many women as they go through menopause later in mid-life. During menopause the levels of estrogen, a female sex hormone, in a woman’s blood stream drop dramatically and it’s not a pleasant ride.


As estrogen levels decline, 75%of women experience hot flashes: sudden, intense and uncomfortable sensations of heat that can leave them flush and sweaty. Hot flashes can occur several times a month or several times a day, depending on the woman. Additionally, menopausal women can experience night sweats, sleeplessness, irritability and irregular periods. Vaginal dryness can also occur, which can make sex uncomfortable. Eventually a woman’s menstrual cycle will stop all together. At that point menopause is technically over, but its effects linger on. After menopause, women are at a greater risk for osteoporosis, a condition that dangerously weakens bone structure. Post-menopausal women are also at a higher risk for heart disease.


In an attempt to ease the discomfort, and reduce the more serious health risks associated with menopause, HRT essentially attempts to put back what nature takes out. For years a variety of pills, patches, creams and injections have all been available to replace the estrogen that diminishes naturally over time.


Some women take supplements that add only estrogen to their system. However, scientists have found that estrogen alone can thicken the lining of the uterus, called the endometrium, and thus increase the risk of uterine cancer. Many other women are prescribed a cocktail of estrogen and progestin. Progestin, a synthetic version of another female sex hormone, progesterone, counteracts the increased risk of uterine cancer.


Up until 2002 both forms of the therapy were popular, but there wasn’t any definitive data on their reliability or long-term effects. Eye-opening evidence from an important study changed everything.




Results of the Women’s Health Initiative


In 1991, curious about the benefits and risks of HRT, the National Institutes of Health launched a multi-year study of 161,000 women who were on a long-term estrogen replacement regimen. The study, known as the Women’s Health Initiative (WHI), looked at both women who took only estrogen and those who were on a popular estrogen and progestin combo called Prempro.


In 2002 those in charge of the Prempro section of the study abruptly called it off, more than three years before they’d planned to conclude. Initial results had found that while many women did report small, but noticeable, improvements in uncomfortable symptoms their risk of certain, often life threatening conditions, increased beyond the point at which it was safe to continue the experiment. Researchers found that women on long-term Prempro had a 111% greater chance of developing dangerous blood clots than women who weren’t. Some scientists had thought beforehand that HRT might raise blood clot risk. More unexpected were the findings of a 29% increased risk of heart disease among Prempro users, as well as the 41% increased risk of stroke and 26% greater chance of contracting breast cancer.


Following the results, doctors and potential patients became more wary of the treatment and its popularity declined. There wasn’t much to change women’s’ minds when the results from the estrogen only trials were released. While not as risky as Prempro, estrogen alone therapy resulted in higher risks for stroke and deep vein thrombosis.


A subsection of the WHI that focused on HRT’s effects on memory found more discouraging data. Estrogen and progestin therapy increased the risk of developing dementia in women over 65, and didn’t slow down any mental decline that came with age. Similar results, released in June, were found for estrogen alone therapy. Taken as a whole, the risks of HRT fit with the Food and Drug Administration’s advice that women who choose to replenish their estrogen levels do so at as low a dose as possible for as short a period of time as possible.




A Rebounding Image?


Still, for all this bad news, the FDA seems almost as confused as patients when it comes to the relative merits of HRT. At the same time it cautions against too much estrogen, its published materials admit, "hormone therapy is the most effective FDA approved medicine for the relief of hot flashes, night sweats or vaginal dryness." Even after the negative results from the WHI were made public, the FDA has approved at least two new estrogen replacement treatments that deliver reduced doses of the hormone.


And while the WHI did find that the risks associated with long term estrogen use outweighed the benefits, there were some benefits. Women on HRT had less of a risk of contracting colorectal cancer than women who weren’t, and they were less likely to fracture their hips (a sign that HRT is at least somewhat effective in strengthening bones and combating osteoporosis). Furthermore, the WHI’s results, good or bad, don’t apply to women who go on HRT for less than three years.


In spite of the lack of clear evidence to support HRT, perhaps even because of it, some researchers are stepping forward to urge that it needs to be more thoroughly considered before science gives up on it. Writing in the May 28thedition of the journal Science, Dr. Judith L. Turgeon, a professor of internal medicine at the University of California Davis and colleagues from Duke and Harvard note that only one type of estrogen was tested by the WHI. Since there are many types of estrogens, and they can all effect the body in different ways, they contend that more effort needs to be put into finding the kind of estrogen that will yield the most benefit. In addition, they note that the WHI only tested estrogen in pill form, ignoring cremes, patches and injections.


"More fundamental research on the roles of hormones in specific tissues are needed," Turgeon said in a UC Davis press release, "and more clinical studies of different formulations and ways of administering the drugs are essential."


Until those studies take place, the conversations you have with your doctor about possibly getting onto an estrogen regimen will likely be long ones.


Contact Louis Wittig at louis@eCureMe.com




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