In my menopause quest, this is the biggest question. SHOULD YOU DO HORMONE THERAPY? Then there are the ancillary questions: how much, how to give it (orally, transdermal, vaginally), what type, when do you start, what is the underbelly and risks of doing it.
THIS IS NOT MEDICAL ADVICE. The reason I am blogging about this is that I am a woman surgeon. I am seeing these changes. And as a plastic surgeon, I fix a lot of the ravages of aging. In menopausal women, much of what I see has to do with poorer skin quality, relaxed skin tone, and the drooping that comes from that. If hormone therapy can be a tool in my toolbox to help my patients age more gracefully, then I am all for it. But I know there are risks.
I wanted to get informed, and as a doctor for almost 30 years, I have a different filter when I read information. I have done a deep dive on this- looking at multiple sources, talking with multiple ObGyn doctor friends, reading many books by experts, reading original scientific articles.
There are risks and benefits anytime you start to tinker with what occurs naturally. The goal with hormone replacement therapy isn’t to get you back to hormone levels of a 35 year old. It is to help alleviate symptoms of menopause and lower risks of changes we see in menopause (brain, joints, sex, heart) without increasing risks of other things (breast cancer, uterine cancer, blood clots). For each of you this algorithm is different. What are your symptoms? How bad? Do you have a high risk for breast cancer? (family history, big dense breasts)
Fascinating facts:
- Most estrogen is “synthetic” and made from yams and soybeans. (So there is no such thing as “bioidentical” or “natural”)
- Original estrogen therapy caused build up of the uterine lining, and there was a jump in uterine cancers, until progesterone was added
- In the 90s, it was recommended ALL postmenopausal women take hormone replacement.
Then big studies were done on over 100,000 women to look at hormone replacement and its effect on:
- bones/fractures
- heart disease
- breast cancer
- endometrial cancer
- blood clots
- dementia
The initial studies were stopped in 2002, earlier than planned, because the hormone arm showed clear evidence of higher risk of breast cancer and little effect on heart health, if anything a higher rate of heart disease, stroke, and blood clots. But there were issues with this study. They communicated poorly about the risks (a 26% in risk of invasive breast cancer, was only 6 additional women with breast cancer a year for every 10,000 patients who took hormone therapy, so 6/10,000), they didn’t look at the different forms of hormone replacement, the average age was older (63), and there was no change in mortality of these women.
Then in 2007, they did another review of the data.
IF you started hormone therapy within 10 years of your last period, you had a lower risk of heart disease.
There is a society called NAMS (North American Menopause Society). I looked at getting certified. They really have analyzed the data, and they come out with recommending hormone therapy for those who have hot flashes, preventing bone loss, and vaginal issues. It may improve sleep, mood, and type 2 diabetes.
OVER THE AGE OF 60, the benefit of hormone therapy starts to change.
What are the risks?
- 6/10,000 increased breast cancer. With combined hormone (estrogen with progesterone), 6-15/10,000.
- 9/10,000 increased blood clot (*though not increased with transdermal estrogen). This risk goes up with age.
- Worsens triglyceride levels (though lowers cholesterol and improves HDL)
- Increased risk of gallbladder disease (*though not increased with transdermal)
- Heart disease if started after the age of 60
- Stroke 8/10,000
Benefits?
Read all my blogs on the subject. Other interesting factoids I found were reduction in colon cancer, depression, cataract risk, metabolic syndrome and visceral fat, vaginal symptoms, and type 2 diabetes. It slows muscle loss and the changes in the skin (wrinkles, moisture, collagen loss).
My thoughts?
Again, I am NOT a gynecologist or internist. And if you are reading this, and I am not chatting with you about it, I am also not even your doctor and I know nothing about you. Yes, you are all special unique women, and as such, the decision if you should do hormone replacement and how and why is different for all of you.
But before I did this deep dive, I was in the camp of NO WAY would I do any hormone replacement, and now I am in the Hmmm. Let me understand more. I came of age in medicine in the 1990s, and after reading all of this backstory, I think I was trained during the brunt of “all women should have hormone replacement” —-> NO! STOP! It is bad! I think the reality is more nuanced.