Hormonal Update Volume 1 Number 12

The HRT Controversy

For nearly half a century hormone replacement therapy (HRT) has been available to women. Over the years, a substantial body of scientific evidence has been building to support the use of hormones for reducing the risk of heart disease, osteoporosis, and more recently, Alzheimer’s disease, colon cancer, and tooth decay. And yet, in spite of this important scientific data, a controversy rages around HRT. On the one hand HRT is said to protect against many of the chronic degenerative diseases associated with aging. On the other hand it is reported to increase a woman’s risk for breast cancer. One study shows that women who take hormone replacement tend to live longer than women who do not. Yet another study finds that women who take estrogen and progestin are at increased risk for a cardiovascular event during the first few years they take this form of HRT.

For women who have uncomfortable menopausal symptoms like hot flashes, night sweats, insomnia and mood swings, HRT can provide welcome relief. In fact, it can greatly improve the quality of a woman’s life. But women who take, or consider taking, hormones to relieve menopausal symptoms are often discouraged by all the conflicting reports. The controversy leaves them wondering what they should do. Unfortunately most women either decide to avoid HRT all together or stop taking it if they have already started. What is the truth about hormones? How does a woman determine whether or not she should take them? 

The answer to those questions lies in a better understanding of scientific study results, and in the unique nature of every woman’s hormonal profile. The decision to take hormones is a very personal one and must be made on an individual basis. In this Hormonal Update we are going to try and provide some of the tools women need to make informed decisions about HRT.

Looking Beyond the Headlines

Hormone replacement therapy has become a favorite media topic. Everywhere you look there is a featured article or news segment about hormones — the covers of Time and Newsweek, prime time television shows like 20/20 and Dateline, even your local newspaper all regularly feature the latest hormone replacement therapy studies. 

When a report comes out about a hormone study, often the most sensational aspects receive the most press. The true essence of the study is not always reflected in the headlines. In order to fully understand the results, women must look beyond the sound bytes. For example, a recent Journal of the American Medical Association (JAMA) article (using data from the National Cancer Institute breast screening program), concluded that a woman’s risk for breast cancer increased 8% each year for every year she was on combined HRT therapy. This was compared to 1% per year for women on estrogen alone.  The Nurses’ Health Study showed similar findings with a 9% increase with combined HRT and a 3.3% increase with estrogen alone. 

Just looking at the most widely reported results of these studies doesn’t give you a complete picture of all the variables that have an impact on the study outcome. For example, in the JAMA study the risk increase was significant for thinner women but not for heavier women. One must surmise that there may be other issues of individuality and variability affecting the outcome of the study. 

In addition, in both the NCI program and the Nurses’ Health Study progestin was used. Progestin is the synthetic version of progesterone. Progestin is different in molecular structure than the body’s natural progesterone. While it may work in a similar fashion to progesterone, it is not exactly the same. The 1995 Postmenopausal Estrogen/Progestin Intervention (PEPI) Trial has shown us that natural progesterone works more effectively in maintaining a healthy lipid profile than progestin. In addition, the use of synthetic progestins can result in uncomfortable side effects. More studies need to be done using natural bio-identical progesterone to determine whether or not the molecular structure of the hormone plays a role in increasing breast cancer risk. Clinical studies show that it may be of importance. 

The HERS Study recently reported an increase in the risk of having another cardiac event during the first year of HRT use, even though participants showed improved lipid profiles (better cholesterol and HDL levels). In the second and third year of HRT use, study participants had significantly fewer cardiac events. Again, there are variables to consider in determining whether or not these results are applicable to you. The women in the HERS study represented an older population, up to 80, and already had heart disease. Progestin was used and the women all took the same dose of replacement hormone. 

In most scientific research studies all women are given the same dosage of hormone replacement. We now know that every woman’s hormonal profile is uniquely her own and that the way women respond to hormone replacement is highly individual. Some women metabolize hormones more quickly, others quite slowly. Dosage size has not yet been investigated as a possible causative factor in the additional health risks associated with HRT. However, testing has demonstrated that the standard doses of replacement hormones are often higher than women actually need. 

Women are not statistics. They are living breathing biochemical individuals. Often studies produce dramatic sounding results but they are not necessarily applicable to a vast majority of menopausal women. Many factors can impact the outcome of a study. When reviewing a report about HRT, it is important to consider as many variables as you can. 

Checklist for Evaluating Research Reports

Determining What's Right for You

Ideally HRT helps a woman maintain a level of hormone similar to what she had while she was having regular menstrual cycles. Because the amount of hormone required by a woman’s body to restore her hormone levels can vary greatly from woman to woman, it is always best to determine first what your hormone levels are and then to monitor your response to therapy. This individualized form of HRT ensures that you take only the amount of hormone that is right for you. Many women who experience symptoms have a built-in barometer that tells them they may need supplemental hormones. Other women who have no outward signs, however, may still have hormone levels that are dropping. A saliva hormone level test can tell you whether or not you need replacement hormones. Symptoms can be the result of more than one hormonal deficiency. For example, in some women a decline in progesterone causes hot flashes, in others the culprit is declining estrogen. Along with your medical and family history, and special risk factors, a saliva hormone level test can be an invaluable tool in assessing your hormonal status both before and after therapy begins. 

Individualized HRT is Customized Care