Menopausal hormone replacement therapy (MHT) was once routinely used to relieve symptoms of menopause and protect against osteoporosis, heart disease, and possibly Alzheimer’s disease. It was thought that it generally preserved health and quality of life. That all changed in 2002 with the publication of the large “definitive” study, the Women’s Health Initiative (WHI), which cautioned that the risks of MHT outweighed the benefits.
The unfavorable findings led many medical authorities to abruptly reverse their recommendations regarding MHT. The standard of care changed. Women were no longer necessarily offered hormones to relieve their hot flashes and other menopausal symptoms.
Some physicians, including myself, questioned the new recommendations based on the study’s design and findings of harm that were overly generalized to all menopausal women regardless of age, clinical situation, and the specific MHT regimen prescribed. The promotion and interpretation of the findings were misinterpreted, exaggerated, and misleading. The authors inexplicably appeared bent on portraying a negative view of hormone therapy.
The potential benefits of hormone therapy are due to the effect of estrogen. Progesterone must be added to protect against uterine cancer from the effects of unopposed estrogen in women with a uterus. But progesterone is primarily responsible for many of the negative effects of MHT.
Importantly, the average age of women initiating MHT in the WHI was 63 years. The study included relatively few women in their late 40s and early 50s, the typical age at the beginning of menopause and initiation of hormone therapy. It appears that MHT has a very different safety profile when initiated at or near the beginning of menopause rather than at older ages as was done in the WHI.
The WHI study did show an increased risk of coronary artery disease with combined estrogen/progesterone therapy initiated in older women; younger women did not manifest such an increase. Only the oldest women initiating estrogen alone experienced some adverse cardiovascular effects.
The risk for stroke, thromboembolic events, and dementia with MHT was slightly increased for both estrogen/progesterone and estrogen alone, especially in older women. Breast cancer was also slightly increased with combination therapy but not with estrogen alone.
Beneficial aspects of hormone therapy include reduced hip fractures, improved bone density, and possibly decreases in colon cancer and diabetes.
I always thought the pendulum would swing back in favor of wider use of hormone therapy. That pendulum has indeed swung with the publication of a recent Journal of the American Medical Association article and other articles in the medical literature in recent years reevaluating the WHI findings. Here’s my take on this complex and somewhat controversial clinical situation:
Women with vasomotor symptoms (such as hot flashes), aged 50 to 59 or within 10 years of the start of menopause, should not be discouraged from initiating MHT. In these age groups, there is no significant increase in cardiovascular risk with estrogen alone or with combination estrogen/progesterone. Some caution should be exercised for initiating therapy in the 60s and avoided for women in their 70s as cardiovascular risk is demonstrated at age 70 and older. I am hesitant to continue MHT as patients approach age 70.
MHT should be initiated for menopausal vasomotor and other menopausal symptoms but not for chronic disease prevention. I still believe that increased cardiovascular risk and the risk of breast cancer are greatest with estrogen/progesterone combination therapy.
Consult your physician about what is appropriate for you after consideration of your specific clinical situation and health and chronic disease status.
Richard D. Feldman, M.D. is an Indianapolis family physician and former Indiana State Health Commissioner who served in the administration of Governor Frank O’Bannon.