Learn about hormone therapy including estrogen for treating menopause symptoms and hot flashes, during menopause and into the postmenopausal period.

Many women hesitate to treat menopausal symptoms with hormone therapy or avoid it all together. That’s because of the concerns that were raised by the landmark Women’s Health Initiative (WHI) trial back in 2002. But a follow-up study in 2017 found that hormone therapy wasn’t as bad for women as it once was thought to be. Hormone therapy includes pills, patches, or vaginal creams.

Women’s Health Initiative (WHI) 2002

The WHI was a clinical trial. More than 27,000 women, ages 50 to 70, were randomly assigned to receive either oral estrogen plus progestin, estrogen alone, or a placebo, for an average of five to seven years.

Here are the most notable findings:

• Hormone therapy slightly increased the risks of strokes and blood clots.
• When combined hormones were taken for more than three to five years, it increased the risk of breast cancer.
• The increase in breast cancer was about one extra case per 1,000 users a year.

After the first WHI results came out in 2002, millions of women stopped hormone therapy or never started. That included many who would have benefited from its effective treatment of hot flashes and other symptoms. Now that may change.

WHI follow-up study 2017

Researchers continued to follow the surviving participants. In 2017, they concluded¹ that the use of hormone therapy was not linked with increased or decreased death rates. That was true of the women who took estrogen plus progestin, as well as those taking estrogen alone.

• The findings support the guidelines endorsing use of hormone therapy for recently menopausal women with moderate-to-severe symptoms.
• Yet, the findings do not support the use of estrogen/progestin for the prevention of chronic diseases.
• For women with troubling symptoms, premature menopause, or early-onset osteoporosis, hormone therapy appears to be both safe and effective.

Two things to keep in mind:

• First. Hormones used today (such as patches, gels, and sprays) are different from the ones used in the WHI trial. They will require more long-term testing. But the new hormones are often in lower doses. And because of that, they are thought to be just as safe—or safer.
• Second. For women who have had their uteruses removed, estrogen alone has a better risk/benefit ratio than estrogen plus progestin. But a woman with an intact uterus cannot opt for estrogen alone. That is because it can cause uterine cancer, as was discovered in the 1960s and 1970s. Progestin is added in order to counter this risk.

Hormone advice from the North American Menopause Society

Here’s a summary of advice from the North American Menopause Society.

• For the treatment of menopausal symptoms such as hot flashes, the sooner after the onset of menopause a woman starts oral hormone therapy, the lower her risk of adverse events such as stroke and blood clots.
• The longer a woman waits, the greater the risks.
• The point at which these risks outweigh the benefits of hormone therapy depends on many factors such as the following examples:
  • Risk factors for cancer and heart disease
  • Medical history
  • Severity of her menopausal symptoms
• But the turning point is often reached somewhere between 10 and 20 years after the onset of menopause, or between ages 60 and 70, whichever occurs first.
• Treatment should be individualized. A woman thinking about hormone therapy should discuss the pros and cons with her doctor.
• Reasons to withhold estrogen/progestin therapy include:
  • Unexplained vaginal bleeding
  • Coronary heart disease
  • Stroke
  • Thromboembolic disease
  • Certain types of breast and uterine cancers

Your doctor will review your medical history to make sure you don’t have these, or any other conditions that could cause problems, before starting hormone therapy.

Vaginal estrogen

Vaginal estrogen is prescribed for the genital and urinary symptoms of menopause. Some 20% to 45% of menopausal women have had the following symptoms:

• Vaginal dryness, burning, and pain during sex, due to thinning of the vaginal lining
• Urinary symptoms such as frequent or painful urination and recurrent urinary tract infections

Low-dose vaginal estrogen is available in creams, tablets, or an estradiol ring. It reverses the thinning of the vaginal lining and other vulvovaginal symptoms. It can be prescribed as an effective alternative to hormone therapy. But it doesn’t treat hot flashes.

 

Reference:

1. JoAnn Manson. JAMA, September, 2017.