Menopause: Questioning Hormone Replacement Therapy

By: Dr. Isadore Rosenfeld

Most recently, virtually everything that was supposed to be good about estrogen has been refuted. Mind you, there were always two schools of thought about hormone replacement. The first (and less vocal) maintained that nature must know what it's doing when it causes the ovaries to stop making hormones and thus permits menopause to set in. They advised against tampering with this normal course of events by taking hormone replacements. If nature had wanted women to continue to have estrogen, the argument went, it would have designed the female body to keep producing the hormone.

The HRT proponents scoffed at this simplistic reasoning. They argued that nature makes lots of mistakes (such as allowing cells to grow wildly and cause cancer) and that menopause is one of them. This natural error, they claimed, is why humans are one of the only mammals that develop menopause. Their solution was to replace the missing estrogen.

Over the years, there were scores of studies (most of which, in retrospect, appear to have been flawed) "proving" that HRT protects menopausal woman from a host of ailments. HRT proponents pointed out that it controls hot flashes, mood swings, dry vaginal tissue, aging skin, and brittle bones and also reduces the risk of heart disease, stroke, and Alzheimer's disease. Yes, these doctors (and I was one of them) admitted that estrogen can cause cancer of the uterus, but that can be prevented by adding progesterone. Breast cancer? We're not convinced by the data, they said, and anyway, if every woman had an annual mammogram, it would detect the cancer early enough to cure the disease. All in all, the estrogen school of thought made HRT look easy -- and the evidence supporting its many benefits seemed incontrovertible. More important, millions of women who took these hormone supplements looked and felt much better.

Then came the statisticians and the epidemiologists. One by one, they proved virtually every claim about estrogen wrong. They showed that this hormone doesn't protect against heart attack and stroke but actually causes them! Doubts that estrogen contributes to breast cancer also disappeared. Its few confirmed benefits, such as reducing the severity of osteoporosis and controlling night sweats and hot flashes, were overshadowed by its many dangers.

Here's What's New
One remaining myth about the benefits of estrogen -- it improves memory and slows progression of Alzheimer's -- was refuted in a large double-blind, randomized, placebo-controlled study in 39 clinical centers throughout the United States. The purpose of this research was to assess the effect of HRT on the incidence of dementia and cognitive impairment in women ages 65 and older. Of the 4,500 women in the trial, about half received the standard estrogen-progestin combination; the other half was given a placebo. Researchers found that women who took the hormones for an average of slightly more than 4 years actually had twice the incidence of Alzheimer's or other forms of dementia compared with those taking a placebo! This increase translates into only 23 more cases among every 10,000 women taking the hormone. It doesn't sound like much -- unless you happen to be one of them! Nor did the HRT protect against mild memory loss.

Another study of 16,000 women ages 50 to 79, followed for an average of 5.6 years, was stopped 3 years early because those receiving HRT had a 44 percent increased risk of stroke compared with those on placebo.

The Bottom Line
These studies did not involve women under 65, and in all cases, the estrogen was being taken along with progestin. Subsequent research has yielded similar results when estrogen was taken alone. And these data constitute a strong case for most women not to use these hormones. This recommendation is further strengthened by the report from the government-supported Women's Health Initiative that women taking hormones do have a higher risk of heart attack, stroke, and breast cancer.

Are there any safe alternatives to help control some of the troubling symptoms of estrogen deprivation? If you are experiencing hot flashes and night sweats, you may want to try one of the newer SSRI antidepressants, such as Paxil (paroxetine). However, do so under close doctor supervision.

Some doctors also recommend that women take natural soy products (such as tofu or soymilk) to help minimize the symptoms of menopause. Because soy contains high amounts of isoflavone, or plant estrogen, it may help protect against osteoporosis and relieve such symptoms as vaginal dryness and hot flashes. If none of the soy products help and only estrogen seems to work, take the lowest effective HRT dose for the shortest possible time. If you have vaginal problems such as dryness or irritation, use the topical estrogen creams. They appear to be safe. For the prevention and treatment of osteoporosis, there are many new drugs that work at least as well as estrogen (see below and page 195).

Evista Benefits

Women who have gone through menopause are at increased risk for bone loss because they no longer benefit from the protective effects of the estrogen their bodies once produced naturally. We used to think that hormone replacement therapy protects postmenopausal women against heart disease and stroke. We now know that it doesn't; in fact, it increases that risk (see page 182). What can women now take to prevent bone loss?

The drug Evista (raloxifene) is a selective estrogen receptor modulator widely used to prevent and treat osteoporosis. Although it's neither estrogen nor a hormone, it has some estrogen-like properties, the most important of which is its ability to reduce bone loss and increase bone density (thus preventing and/or minimizing osteoporosis). It does not adversely affect the breast and uterus the way estrogen does, so it does not cause cancer of those organs, tenderness of the breast, or vaginal bleeding. On the other hand it does not relieve symptoms of menopause, such as hot flashes, either.

Here's What's New
Data from a 4-year study of almost 8,000 postmenopausal women showed that a subset of about 1,000 women with one or more risk factors for cardiovascular disease who were taking Evista to control osteoporosis had a 40 percent lower risk of developing heart disease and a 62 percent reduction in the risk of all fatal and nonfatal strokes. (They also enjoyed a 70 percent decline in the incidence of breast cancer.)

The Bottom Line
Evista does appear to exert a beneficial effect on heart disease, stroke, and breast cancer. It has few adverse effects other than a small increased risk of clot formation in the veins. For that reason, anyone with varicose veins or a history of thrombophlebitis should not use it, nor should those who are premenopausal or pregnant. However, in my opinion, virtually every postmenopausal woman at risk for osteoporosis -- especially those also vulnerable to heart disease, stroke, and breast cancer -- should be taking it.

(Reprinted from Dr. Isadore Rosenfeld's Breakthrough Health 2004: 157 Up-to-the-Minute Medical Discoveries, Treatments, and Cures That Can Save Your Life, from America's Most Trusted Doctor! by Isadore Rosenfeld, M.D. (Rodale Inc., Paperback, $14.95/$21.95CAN; 1-57954-900-4). Permission granted by Rodale, Emmaus, PA 18098. Available wherever books are sold.)

© 2004 Isadore Rosenfeld, M.D.

About the Author - Dr. Isadore Rosenfeld's legions of fans follow his regular column in Parade magazine and his popular Sunday-morning television series Sunday Housecall on FOX News Channel. In addition to his numerous scientific publications and medical textbooks for doctors, he has written nine New York Times bestsellers. He is a distinguished member of the faculty at New York-Presbyterian Hospital/Weill Medical College of Cornell University and attending physician at New York Presbyterian Hospital and Memorial Sloan-Kettering Cancer Center.

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