VOLUME 29 - 6 Hormone Replacement

Health Tips

Hormone Replacement Therapy

What is Menopause?

Menopause, or climacteric, is the time in a woman's life when menstruation ends and the ovaries produce lower levels of the sex hormones-estrogen and progesterone. Progesterone becomes nearly absent, and estrogen levels are reduced to approximately one-tenth of pre-menopause levels. Menopause usually occurs between the ages of 45 and 55, although it varies between individuals. "Surgical menopause," or oophorectomy, occurs when a woman's ovaries are surgically removed.

During menopause, many women experience problems such as hot flashes, night sweats, sleeplessness, mood swings, and vaginal dryness. Bone loss (osteoporosis), angina, and heart attack (coronary artery disease) are also more common in women after menopause.

What Is Hormone Replacement Therapy? To counter some of the problems often associated with menopause or to prevent some long-term conditions that are more common in postmenopausal women, such as osteoporosis, medical doctors may recommend using hormone replacement therapy (HRT)-for a period from one month to five or more years.1

HRT usually involves treatment with either estrogen alone or estrogen in combination with progesterone. Progestin, a synthetic hormone with effects similar to those of progesterone, may be used as a substitute. The use of these substances can effectively double hormone levels in post-menopause women, but this therapy does not produce the natural hormone levels seen before menopause.

Do the Benefits of HRT Outweigh the Risks? The best evidence to date for the risks and benefits of HRT comes from the Women's Health Initiative (WHI) study, in which 16,000 healthy women, ages 50 through 79, took either hormones or a placebo-a pill that does not contain the drug under study. The trial was discontinued early in 2002, when investigators reported that the overall risks of estrogen plus progestin outweighed the benefits.2

According to recent studies, HRT with estrogen plus progestin may increase the risk of: · Dementia, i.e. deterioration of mental abilities resulting in an inability to function, by 50 percent-in women age 65 and older.6

• Blood clots by 50 percent.2
• Stroke by 41 percent.2
• Heart disease by 29 percent.2
• Breast cancer by 26 percent.2 The breast cancers were also slightly larger and more advanced.3 The risk increased with prolonged duration of hormone use and returned to normal five or more years after hormone use was discontinued.4
• Death from ovarian cancer-in women who used estrogens for 10 or more years.7 Benefits of the use of estrogen plus progestin:
• Relief for menopausal symptoms2
• Fewer cases of hip and spine factures2
• Reduction in the risk of developing colon cancer by 37 percent was reported among women using estrogen plus progestin.2 Studies do suggest, however, that to maintain bone density, women must continue taking the hormone.

To date, HRT has not been proven beneficial in older women with pre-existing heart disease.5 Additionally, the use of estrogen plus progestin hasn't been shown to affect post-menopausal women's general health, vitality, mental health, depressive symptoms, or sexual satisfaction.8

The risks and benefits of estrogen-only therapy, the use of different forms of hormones, including experimentation with lower doses, utilization of different hormones-or different routes of administration are currently being researched. Safer and more effective therapies may become available in the future.

Are There Alternative Therapies to HRT? While hormone therapy can have short-term benefits, many short-term menopause-related symptoms will eventually disappear, and many frequently require no treatment. However, although there are substantial concerns about the use of HRT, it has not been proven beneficial for long-term menopausal problems. If you feel that HRT is not a good choice for you, you may want to consider an alternative approach.

Exercising regularly, eating healthy foods, and not smoking is always good. A healthy lifestyle helps to decrease the risk of bone loss. Health professionals also recommend taking calcium and vitamin D supplements to prevent osteoporosis.9 The effect of calcium and vitamin D supplements on hip, spine, and wrist fractures, as well as its effect on colon cancer is being tested.

Some foods and nutritional supplements can be helpful in reducing the symptoms of menopause:

• Estrogen-containing foods: soy-based products, whole-grain cereals, fruits, and vegetables
• Evening primrose
• Black cohosh
• Dong quai
• Vitamin E
• Vitamin B complex
• Hormone creams.

The benefits and risks of most of these agents are not definitively proven, but are being researched. Before taking any dietary supplement, consult with your health care provider.

Lawrence Wyatt, DC, DACBR, clinical sciences professor, Texas Chiropractic College, Writer

Carol Kline, MA, and Nataliya Schetchikova, PhD, Editors David Cundiff, MFA, Art Director

References

1. Brett KM, Madans JH. Use of menopausal hormone replacement therapy: estimates from a nationally representative cohort study. Am J Epidemiology 1997;145(6):536-45.

2. Writing Group for the Women's Health Initiative. Risks and benefits of combined estrogen and progestin in healthy menopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321-333.

3. Chlebowski RT, Hendrix SL, Langer RD, Stefanick ML, Gass M, Lane D, et al. Estrogen Plus Progestin Influence on Breast Cancer and Mammography in Healthy Postmenopausal Women in the Women's Health Initiative Randomized Trial. JAMA 2003;289:3243.

4. Schairer C, Lubin J, Troisi R, Sturgeon S, Brinton L, Hoover R. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. JAMA 2000;283(4):485-491.

5. Grady D, Herrington D, Bittner V, Blumenthal R, Davidson M, Hlatky M, et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy. JAMA 2002; 288:49-57.

6. Shumaker, SA, Legault C, Rapp SR, Thal L, Wallace RB, Ockene JK, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. JAMA 2003;289:2651-2662.

7. Rodriguez C, Patel AV, Calle EE, Jacob EJ, Thun MJ. Estrogen replacement therapy and ovarian cancer mortality in a large prospective study of US women. JAMA 2001;285(11):1460-1465.

8. Hays J, Ockene JK, Brunner RL, Kotchen JM, Manson JE, Patterson RE, et al. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med 2003;348: 1839-54.

9. Keller C, Fullerton J, Mobley C. Supplemental and complementary alternatives to hormone replacement therapy. Amer Acac Nurse Pract 1999;11(5):187-98.

Research

Hormone Therapy, C-Reactive Protein, and Progression of Atherosclerosis: Data From the Estrogen Replacement on Progression of Coronary Artery Atherosclerosis (ERA) Trial

Susan G. Lakoski, MD; Bridget Brosnihan, PhD; David M. Herrington, MD, MHS, FAHA Am Heart J. 2005;150(5):907-911.

Objective: To compare the effects of estrogen and estrogen plus progestin on levels of C-reactive protein (CRP) and interleukin-6 (IL-6), and to examine the relationship between these changes and progression of angiographically defined coronary disease.

Methods: Baseline and follow-up (year 1 and year 3) plasma levels of IL-6 and CRP were measured in a subset of 232 patients from the Estrogen Replacement in Atherosclerosis (ERA) trial.

Results: Serial angiograms were also available at baseline and closeout. Estrogen alone increased CRP by 40% at 1 year and 38% at closeout. Estrogen plus medroxyprogesterone acetate increased CRP by 44.7% at 1 year and 54.7% at closeout as compared with baseline levels. There were no significant changes in IL-6 with either treatment. In women in the active treatment arm, change in CRP during the first year was not associated with progression of coronary disease.

Conclusions: Estrogen and estrogen plus medroxyprogesterone significantly raise CRP levels in women with established coronary disease. In contrast, IL-6 levels are not affected by estrogen or estrogen plus progestin. Estrogen-induced changes in CRP are not associated with progression of atherosclerosis.

Do Perceptions of Risk and Quality of Life Affect Use of Hormone Replacement Therapy by Postmenopausal Women?

Dewey C. Scheid, MD, MPH, Mario T. Coleman, MPH, Robert M. Hamm, PhD J Am Board Fam Pract 16(4):270-277, 2003

Background: Although the understanding of the health impact of hormone replacement therapy (HRT) is incomplete, even less is known about the attitudes, perceptions, and motivations of women faced with the decision to use HRT. The purpose of this study was to evaluate the relation between HRT use and women's perceptions of the risk and benefits associated with HRT use.

Methods: A written questionnaire was administered to 387 women, aged 45 years and older, responding to a health plan invitation for free bone mineral density screening. Women were asked to estimate the lifetime probability of developing breast cancer, uterine cancer, osteoporosis, and myocardial infarction when taking HRT and when not taking HRT. Women rated their quality of life in their current state of health, with breast cancer, with uterine cancer, with osteoporosis, and after myocardial infarction.

Results: HRT users perceived a greater risk reduction for osteoporosis and myocardial infarction using HRT compared with HRT nonusers . HRT nonusers perceived a greater risk increase for breast cancer and uterine cancer using HRT as compared to the risk of breast cancer and uterine cancer when not using HRT. HRT users estimated osteoporosis would give them a greater quality-of-life reduction compared with HRT nonusers for osteoporosis .

Conclusions: Regardless of whether they used HRT, women in this study overestimated their risk for all four diseases. HRT users perceived greater benefit and less risk using HRT than nonusers. The results of our study show that continuing efforts are needed to help women understand the risks and benefits of HRT.

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