There has been a lot of publicity about HRT over the past 6 months. It is important to put the information into perspective. There are two main areas that have changed in our understanding of HRT over the past few years. The first is data showing that HRT does not reduce the incidence of heart disease or stroke as previously thought. In the past many women started HRT for menopausal symptoms but then chose to continue HRT long term in the hope of reducing their risk of heart disease. Similarly there were limited options for the prevention and treatment of osteoporosis, so many women chose long term HRT as a way to reduce their risk of fracture. Although HRT still has value in reducing fracture risk there are now several more options to choose from for the prevention and treatment of osteoporosis.

There has long been a concern that using HRT may increase the risk of breast cancer. There have been many studies pointing toward a small increased risk in breast cancer with long term use of HRT (generally greater than 5-10 years). Recently the Women's Health Initiative confirmed a small increase incidence in breast cancer in women using conjugated equine estrogen (Premarin) & medroxyprogeterone acetate (Provera) for 5 years. The baseline incidence in breast cancer for woman on the "placebo" (no hormones) was 3 cases per 1,000 women per year. The study subjects taking conjugated equine estrogen .625mg and medroxyprogesterone 2.5 mg daily for 5 years had a slightly higher incidence of 3.8 cases per 1,000 women per year. This would extrapolate to be 8 more cases of breast cancer per 10,000 women per year. This small increase incidence in breast cancer was not seen in the women (without a uterus) taking only Premarin. The branch of the study looking at using conjugated estrogen alone is continuing.

Based on the Women's Health Initiative data if 10,000 women were taking conjugated estrogen .625 mg & medroxyprogesterone acetate 2.5 mg daily for one year there would be 6 fewer cases of colon cancer, 5 fewer hip fractures and 7 more heart attacks, 8 more cases of breast cancer and 18 more incidences of blood clots than a group of women not taking the hormones. For an individual woman using HRT for a limited amount of time to manage symptoms these risks are relatively small. If one looks at women in general being on long term HRT then the potential health risks are significantly greater.

The Woman's Health Initiative only looked at the effects of one dose of conjugated estrogen and synthetic progesterone. It is not known if this data can be extrapolated to other forms of HRT. The WHI data may not apply in the same way or to the same extent to woman on lower doses of bio-identical (natural) estrogen and progesterone.

Not all women have severe symptoms with perimenopause & menopause. For women having only mild symptoms, nutritional and vitamin therapy as well as exercise may be enough support. Others having more moderate symptoms may benefit from herbal therapies, acupuncture, biofeedback or non-hormonal medication for hot flashes, insomnia and mood changes.

If symptoms are primarily vaginal dryness, pain with intercourse or urinary frequency then small amounts of vaginal estrogen can be extremely helpful without raising circulating blood levels of estrogen. For women having severe menopausal symptoms HRT can be extremely helpful. The lowest dose of HRT to manage the symptoms should be prescribed. This dose then can be slowly tapered over time and then stopped.

If a woman is already on HRT it is important to look at the reasons why it was started, the length of time she has been on it, the type of HRT and the dose. For many women it will make sense to slowly taper the dose and eventually stop the HRT.

The most compelling reason to use HRT is for the treatment of menopausal symptoms that are affecting one's day to day quality of life. The overall goal is to use the lowest effective dose for the shortest duration of time. As always the exact dose and length of treatment will vary from individual to individual.

We encourage you to see your doctor with your concerns regarding HRT. Avenues for Health physicians are available for consultations to review your current approach to menopause and to help you look at alternatives and options.

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