Dr JoAnn Pinkerton, the executive director of the North American Menopause Society and Professor of Gynaecology at the University of Virginia, shares some interesting views on hormone therapy and its role in women’s health.
WHY IS HT A HOTLY DEBATED TOPIC?
The biggest impact of the Women’s Health Initiative Trial is that women and their healthcare providers became fearful of oestrogen, and, as a result, many women who would have benefited from hormone therapy were denied safe and effective therapies. Since publication of the Women’s Health Initiative (WHI) large randomised clinical trial, there has been significant disagreement over the risks and benefits of hormone therapy. Despite initial results showing elevated risks of breast cancer, heart disease, stroke, blood clots and dementia, further analysis and newer studies have provided more clarity.
In the NAMS Hormone Therapy Position Statement released in 2017, the advisory panel stated that hormone therapy has more benefits than risks for women who are symptomatic with hot flashes or night sweats, or at elevated risk of osteoporosis if started in women under age 60 or within 10 years of menopause. Thus, hormone therapy is felt safe for healthy women at menopause without contraindications. Age matters, as women who start hormone therapy after age 60 or 70 or more than 10 years from menopause may have more health risks from hormone therapy.
WHAT ARE THE FORMS OF HT?
Currently there are many more FDA approved options for hormone therapy. Type, dose, route of administration and duration of use can be tailored to minimise risks. Women without a uterus can use oestrogen alone, which was not associated with an increased risk of breast cancer at seven years in the WHI when conjugated oestrogen was used.
For women with a uterus, a rare risk (</1000) was seen after 3 to 5 years of using combined oestrogen and synthetic progestin. This risk can be minimised with lower doses, less potent progestin or the use of micronised progesterone. There is a newer therapy, progestogen free, which combines conjugated oestrogen with the SERM (selective oestrogen receptor modulator) bazedoxefine.
Oral therapy has more potential risks of blood clots or stroke as it is metabolised through the liver. Transdermal therapy (patch, gel, spray, lotion, and ring) appears to have less risk of blood clots or stroke, although there are no head-to-head trials comparing oral and transdermal hormone therapies.
WHAT SYMPTOMS DOES IT TREAT?
There is good clinical trial evidence that hormone therapy relieves bothersome hot flashes and night sweats, decreases sleep disruption and prevents bone loss and fracture. There is some evidence that oestrogen given at menopause may reduce coronary heart disease or cognitive changes but the data is not strong enough to recommend the use of hormone therapy to prevent heart disease or dementia.
WHAT ARE SOME COMMON MYTHS ABOUT HT?
1. Local vaginal oestrogen carries the same risks as oral oestrogen.
If blood levels remain low, then topical or vaginal oestrogen does not increase risk for breast cancer, heart disease, stroke or blood clots.
2. Compounded bioidentical hormone therapy is safer and more effective than FDA approved bioidentical hormone therapy.
FDA approved therapies are regulated and monitored for efficacy and safety. Despite media hype, compounded therapies are not safer or more effective than traditional therapy. They are not monitored or regulated by the FDA, have potential for over or under dosing, the possibility of contaminants, concerns about sterility and do not provide information about potential risks as there is no label.
3. Taking oestrogen causes breast cancer.
In reality, most women with breast cancer have not taken oestrogen. More than 80% of women who have breast cancer haven’t taken hormone therapy. In the WHI, conjugated oestrogen alone was not associated with an increased risk of breast cancer. Instead, it was the combination of oestrogen with a potent progestin that appeared to increase the risk of breast cancer, and even that was a small increase in risk. Major risk is the genetic risk, not the use of oestrogen.
4. Hormone therapy has more risks than benefits.
For most healthy women with early menopause or who are symptomatic at menopause, the benefits on relief of menopausal symptoms, prevention of bone loss or improvement in vaginal symptoms outweighs rare risks. However, for women who are starting hormone therapy over age 60 or 70 or more than 10 or 20 years from menopause, the risks of heart disease or dementia may outweigh benefits.
WHAT WERE THE NEW STUDY’S FINDINGS?
One of the most recent studies was a small pilot study which found that a combination of transdermal estradiol and oral progesterone slowed down cognitive decline in postmenopausal women over a 24-month period diagnosed with MCI who are also taking donepezil, a cholinesterase inhibitor. Higher global cognitive function was found for women receiving menopausal hormone therapy compared to placebo.
Based on the small numbers of women, hormone therapy (transdermal oestradiol and progesterone) improved cognitive function in women were early cognitive changers. Larger trials are needed to evaluate the impact of hormone therapy use before the full onset of Alzheimer’s disease to determine if there is a role of hormone therapy in preventing or slowing Alzheimer’s disease.