My Advice on Estrogen (Hormone Replacement Therapy)

For years, millions of women starting menopause listened to their doctors' recommendations about replacing the estrogen their ovaries had largely stopped making. Both women and doctors were delighted with the results. Hot flashes and vaginal dryness were very much lessened. A waning libido often was restored. Mood swings were less troublesome. Skin looked younger. And bones were less apt to become brittle and break due to osteoporosis.

These were all important benefits of hormone replacement therapy (HRT). But the real payoff was in the mortality statistics. It seemed women treated with HRT were having fewer heart attacks and strokes than women without HRT. It even was suggested that HRT could delay or prevent Alzheimer's. There seemed to be no downside to this miraculous and simple treatment.

Then clouds appeared on the horizon. Some women taking estrogen were getting cancer of the uterus. That could be controlled, though. The way to do that was to add another hormone, progestin. So, estrogen was no longer prescribed by itself. Instead, women took estrogen combined with progestin. There was one exception. Women who'd had a hysterectomy did not have a uterus. So they were no longer at risk for uterine cancer.

But then a new concern arose. Data began to show a connection between HRT and a breast cancer. Estrogen was seen as a possible contributing factor to breast cancer. It joined the list with diet, alcohol, genetics, number of pregnancies, and frequency of breastfeeding. Most women were not put off. That’s because no one knew how great the risk really was. And, they felt certain that routine mammography would detect tumors early. Then there would be enough to cure them.

A new study, though, has raised new concerns for women taking HRT. It is the most statistically valid one ever done on this subject. And its findings are alarming. It showed that taking combined estrogen and progestin for many years does not protect against vascular disease. In fact, it increases the risk of

  • heart attacks
  • strokes
  • breast cancer
  • clotting disorders

Plus, other research has found a possible link between estrogen replacement and ovarian cancer.

These risks are not great. But they are real. In fact, they are real enough that the study was stopped in midcourse. The risks from long-term HRT outweighed the benefits. That means they were not offset by fewer hip fractures and colon cancers among hormone users. Nor were control of hot flashes and mood swings and a sense of well-being enough to balance them.

The findings were not conclusive in regards to women who've had a hysterectomy. So studies are still going on to see what the effect of taking estrogen alone is.

So what is a woman in menopause to do? I don't think the final answer is in yet. But here's what I am currently telling my patients:

I prescribe combination HRT for about two years to any woman who recently entered menopause who is troubled by hot flashes and serious mood disorders. These symptoms usually go away or greatly improve by that time. The one exception is I do not prescribe HRT if a woman already has heart disease.

Every female over age 40 should have an annual gynecologic exam and mammogram. Those with a strong family history of breast or ovarian cancer should have gene analysis to determine their vulnerability to these malignancies. If positive, they should consider prophylactic removal of these organs.

Women need to protect themselves against the diseases associated with the aging process. That includes heart attacks and strokes. There is a long list of effective ways to do that. They include:

  • control of weight, blood pressure, and cholesterol
  • other lifestyle changes such as reducing dietary salt
  • regular weight-bearing and aerobic exercise
  • taking such drugs as the statins (Lipitor, Zocor, Lescol and others)

I recommend ACE inhibitors (such as enalapril) for those who already have had a "vascular event." To prevent bone fractures due to osteoporosis, see Second Opinion: "Keep Bones Strong—Without Hormones."

The tips below will help you manage the discomforts of menopause.

Stop Menopausal Woes Without HRT

To control the uncomfortable symptoms of menopause without HRT, I recommend the following:

For hot flashes, night sweats and mood swings:

  • Ask your doctor to prescribe an antidepressant, such as Prozac or Effexor.
  • Reduce your intake of caffeine and alcohol.
  • Stop smoking.
  • Eat smaller meals.
  • Exercise regularly.
  • Enroll in a tai chi or yoga class.

For diminished libido:

  • Try testosterone supplements—your doctor will advise you about dosage.

For vaginal dryness:

  • Use a topical lubricant, such as KY Jelly, Replens Vitamin E oil or topical estrogen (only very small amounts of the hormone are absorbed into the blood stream).

Here's the bottom line. Although right now HRT is in official disfavor, every patient is different. Don't go just by the news reports (or even this column). Check it out with your doctor.