And learns why doctors sometimes make exceptions to the rules.
Anyone who’s approaching menopause — or deep in the throes of The Change — has probably heard about three letters that could make a huge difference in your quality of life: HRT, aka hormone replacement therapy. Experts say that HRT in the form of estrogen supplementation can alleviate the most common menopause symptoms (including mood swings, brain fog, night sweats, reduced sex drive, or those deeply unpleasant and sweaty hot flashes) and generally improve your day-to-day functioning. Sound like a cure-all? It’s not that simple, especially since not every woman is a candidate for this kind of therapy — and because studies show that for some, HRT can increase the risk of strokes or breast cancer.
Katie and her very own OB-GYN, Dr. B, have discussed the many ins and outs of hormonal treatments for menopause in the past, but the advantages and disadvantages of various treatments can be dizzyingly confusing even after reading expert advice.
To help understand the pros and cons of different options, Katie and Dr. B had another candid chat about how and when patients should start Hormone Replacement Therapy. Using questions you submitted, Katie asked Dr. B to explain how hormone treatments interact with other issues like bone loss and cancer, and why timing is key.
Katie Couric: I’ve been pretty open about the fact that I was on hormone replacement therapy for many years prior to my breast cancer diagnosis. You and I have talked about this privately, but have you learned anything about whether hormone replacement therapy can create problems like breast cancer down the road, even if you don’t have a family history?
Dr. B: The majority of women who develop breast cancer (85%!) do not have a family history. During the course of a woman’s lifetime, if we all live long enough, one in eight of us will develop breast cancer. We know that initiating hormone therapy earlier carries less of a risk. But is that risk zero? Possibly not. However, it seems that using what we refer to as bioidentical hormones, hormones that are manufactured but are exactly molecularly identical to what our bodies make, is safer and carries fewer risks.
You shouldn’t take unopposed estrogen because it could increase your risk of uterine cancer, correct?
Correct. It can increase the risk of cancer of the uterine lining or endometrial cancer.
We got a lot of questions from our readers. Here’s a question from Lisa, which I’d like answered, too: “How long can a woman safely be on HRT without putting herself at a higher cancer risk? My doctor suggested I go off them after five years and I miss them so much.” I hear you, Lisa. There are so many mixed messages about this.
There are mixed messages. Data shows that whether or not someone was on estrogen and progesterone or estrogen alone, the safety data was actually very good. There was no increased morbidity or mortality in either group. My feeling is if somebody is well, I will not take them off hormones after five years. There are proven benefits. Now, the United States Preventive Services Task Force just came out with a statement that says hormones are not for primary disease prevention. But we do know that hormones really do help keep a woman’s cardiovascular risk low, particularly when estrogen is used transdermally. In addition, it helps bone health — we know that that’s very important — and also lowers one’s risk of developing type two diabetes.
So I really feel strongly that the use of menopausal hormone therapies absolutely has to be individualized. It’s something I discuss with my patients annually. If someone should develop a contraindication or a reason why they can’t be on hormones, I will take them off them.
I try to really shift my patients — particularly as they’re getting into their 60s — if they’ve been on an oral formulation. I ask them to consider transdermal estradiol because it has a safer profile. We don’t have to worry about changes in lipid profiles, we don’t have to worry about clotting, that data is really, really reassuring. But when I have patients on hormones, I do not have an endpoint in mind. And that five-year rule is passé, if you will.
So perhaps Lisa should talk to her doctor or change doctors if she wants to stay on hormones. Also, there are a lot of other advantages to hormone therapy, and maybe they’re more superficial, but estrogen helps your skin and hair and also helps with brain fog. Estrogen is kind of a wonder hormone if you ask me.
I agree. Earlier in my career, we weren’t really supposed to talk about those things. We wouldn’t let that factor into the discussion we would have with our patients in terms of why someone should go on hormones. But, quite honestly, the discussion of hormones has to do with quality of life. And that has to do with sexual function, cognitive function, sleep, and an overall sense of well-being.
Obviously, we want to take care of our bones, our muscles, and our joints. It’s very interesting because many women start to have joint aches and pains with menopause. You hear of so many women having frozen shoulders. It’s not a coincidence. So I think there are so many benefits that go beyond vasomotor symptoms, yet the FDA-approved hormones for vasomotor symptoms.
The way I would look at it is that hormones affect every single organ system of the body. And it’s really true — we could walk through every organ system of the body and talk about the benefits of being on hormones. But then again, not everyone wants to and not everyone can be. So it clearly has to be individualized. It’s not one size fits all medicine. We have a whole array of options, and what works for one patient may not work for another. And what works for a woman who’s newly menopausal may not work for somebody who is in her 60s.
Chris asks, “What are the pros, cons, risks, and benefits to a woman beginning HRT after being in menopause for 10-plus years? I know there are many benefits of HRT for brain, heart, and bone health. If there’s no family cancer history, does it make sense to begin HRT at this point?”
The current prevailing philosophy regarding starting hormone therapy is to start it within 10 years of one’s final period, and before the age of 60. It’s really unfortunate because in my practice I have 60-year-olds coming in and saying, “Oh my gosh, I missed the boat.”
I’ve made a few exceptions to the rule. Say I have somebody who’s just 60 or 61 who recently went through menopause, and they are healthy as can be, their cholesterol is fine and their blood pressure is fine, we’ll look at their bones and have a discussion weighing the risks and benefits of hormone therapy. But as a rule of thumb, if someone is 10 years out, I won’t.
Unfortunately, there are many young women who went through very early menopause, well before the age of 40, who weren’t offered hormones. The question frequently comes up in my meetings: “Can you then give a woman hormones?” It certainly is up for discussion.
We know if you were to take a 35-year-old, for example, who was treated for a certain type of cancer or had early ovarian insufficiency, hormones at the beginning can keep the risk of cardiovascular disease low. They lower the risk of osteoporosis. These women who go through earlier menopause are at an increased risk of cardiovascular disease and are at an increased risk of bone loss. So the question is always, “If they come to you at 45, is it too late?” We have to weigh the pros and the cons. I would certainly consider the pros in a younger woman. But as for the woman who comes to me in her 60s and is well beyond her final period? We typically don’t do that.
Is there anything that someone like Chris could do, being 10 years out from menopause, that would mitigate some of the symptoms that come from getting older and losing all your hormones?
If she still has vasomotor symptoms, which 10 to 15 percent of women have, there are non-hormonal ways in which we can address those symptoms.
It doesn’t seem to me that Chris has symptoms. I think she’s just talking about the health benefits: Brain, heart, and bone health. If she doesn’t qualify for HRT, are there other ways she can get those benefits?
Yes. There are absolutely non-hormonal things you could do. Being on hormones isn’t a free pass, in terms of taking care of your health. Eating healthfully is so important and having a heart-healthy diet, like the Mediterranean diet, for example, is very important. Also exercise — and it’s just not cardio. A lot of women think cardio alone is sufficient, but it really isn’t, especially as we age. We lose a decent amount of muscle as we age. And I really try to emphasize to my patients, especially the young ones who are doing Pilates and yoga and resistance training, to keep doing it. It is so important — and it’s never too late to start.
