Hormonal Update Volume 3 Number 8

HRT - A new Perspective

When the Women's Health Initiative (WHI), a significant scientific study involving more than 160,000 women put the brakes on one of its hormone replacement studies ahead of schedule it made headlines around the world. The threat of increased risk for breast cancer and cardiovascular disease compelled researchers to discontinue the study. This news sent scores of women racing to their medicine cabinets to throw out their replacement hormones. Doctor's offices were deluged with calls from concerned women, many demanding to be taken off HRT immediately. Do the results of this study really mean that all women should forgo HRT completely? 
Maybe not.

There are many forms of hormone replacement. HRT can differ both in its delivery system and its dosage level. Hormones can be taking orally, transdermally, and sublingually. Each delivery system brings with it a unique way for the body to metabolize and utilize the hormone. Dosages are also critically important to how a hormone affects the body. Too much of a hormone can be as detrimental as too little. While the WHI findings were alarming, one hormone replacement study cannot possibly determine the safety of all forms of HRT.

Think of it like this: Auto safety tests are conducted on an individual basis. If a particular brand of compact is found to be unsafe in a head-on 25 mph collision, it doesn't necessarily mean that all brands of compacts are unsafe. In addition, it may not even mean that the compact in question is unsafe in a 10 or 15 mph collision. It simply means it could not stand up to that particular test challenge. Contrarily, if a compact is found to be safe in a 25 mph collision it does not mean all compacts are therefore safe in the same circumstance. Nor does it mean that different brands or models of compacts, even though they look similar, can be assumed to be safe - each model needs to be tested individually for safety. Auto safety is determined car by car, challenge by challenge. Determining the safety and efficacy of hormone replacement therapy requires at least the same degree of scrutiny.

In this Hormonal Update we share our perspective on the controversy surrounding the risks versus the benefits of HRT, and provide some helpful guidelines for determining whether or not HRT is an appropriate choice for you and provide some helpful guidelines for determining whether or not HRT is an appropriate choice for you.

The WHI Study - A Closer Look

The Women's Health Initiative actually confirms that hormone replacement therapy is not as simple as one-size fits all. Of note, the dosage amount and oral delivery system used in WHI were the same for each woman. Participants received Prempro™, conjugated equine estrogens, 0.625 mg, plus medroxyprogesterone acetate, 2.5 mg, in 1 tablet, or a placebo. This begs the question, "Did all the participants need these hormones, in these doses?" 

Even though women all have the same hormones, their hormonal profiles are distinctively individual. A woman's hormone levels can be as unique to her as her fingerprints. What is right for one woman is not necessarily right for another. In addition, every woman's metabolism is different. While these dosages might be just perfect for one person, they could be too high for another, and even too low for another. In fact, hormone replacement therapy should be as individual as the woman who is taking it. 

A few enlightened doctors have been working to change the face of hormone management by incorporating hormone level testing and variable dosing designed to meet the individual needs of patients. Monitoring medication levels is not a new concept, just one that has not been routinely applied to hormones. Hormone replacement has long been considered somewhat of a benign process. It is not. Hormones are prescription medications that affect hormone levels. Replacement hormones are most effective when they mimic what the body does naturally. There are many examples in medicine of treatments that are routinely monitored - thyroid, blood pressure, and heart medications just to name a few. It's now time to include HRT in the same category. 

Individualized Risk Assessment

Every woman must weigh the risks and benefits of HRT as they pertain to her own life. Most women consider replacement hormones because they are experiencing symptoms of menopause that are interfering with their quality of life. Unrelenting hot flashes, sleep disturbances, night sweats, dramatic mood swings, and forgetfulness, as well as loss of libido, vaginitis, or painful intercourse due to vaginal dryness can all be very disturbing and can add unnecessary stress to a woman's life. Yet, for most women, all of these symptoms can be relieved quickly and effectively with the right individualized hormone replacement program. 

If you have no history of heart disease in your family, and none of the other risk factors, your chances of experiencing a cardiovascular event may seem minor when compared to the daily discomforts of severe menopausal symptoms. HRT may give you relief during your symptomatic years and greatly improve the quality of your every day life. On the other hand, if you do have a family history of CVD, or suffer from obesity, poor lipid profile, diabetes, or hypertension you may not be a good candidate for long term HRT. You may want to choose more lifestyle-oriented options to help manage your symptoms. Improved diet, regular exercise and stress management are all proactive measures that can help you protect your heart. 

Osteoporosis is a disease characterized by low bone mass and deterioration of bone tissue. It has reached nearly epidemic proportions in the US population aged 50 and older. Osteoporosis can lead to increased bone fragility and risk of fracture, particularly of the hip, spine and wrist. Often referred to as "the silent killer" it can occur without symptoms and can have enormous consequences for its victims - disfigurement, lowered self-esteem, reduction or loss of mobility, and decreased independence to name a few. As of 2002, an estimated 44 million people in the US alone are at risk for osteoporosis. More studies than not have revealed that balanced optimum levels of both estrogens and androgens are necessary for strong healthy bones. If you have a family history of osteoporosis but not of heart disease you may benefit greatly from the bone protection benefits of HRT. 

The Dual Energy X-ray Absorptiometry (DEXA) scan is the gold standard for measuring bone density. The Pyrilinks-D test measures deoxypyridinoline (Dpd), a product of bone breakdown found in urine. It can help you determine your rate of bone loss. And, because Dpd decreases with intervention, Pyrilinks-D can help monitor the effectiveness of HRT and other preventative lifestyle modifications.

Making a Decision about HRT

Our hormones somehow impact almost every aspect of our health. Because of that hormone replacement is a critically important area of scientific investigation. We must look more and more to the individual way in which the body metabolizes and utilizes them. Clearly more studies need to be done, including more on the impact of dosage levels and delivery systems, as well as the differences between natural bio-identical hormones and other forms. Rather than force all hormone replacement therapy to bear the consequences of a single study result we should begin a process of suitable testing for each protocol available. 

The decision to take hormones is a highly individual one, and one that is best made between a woman and an informed healthcare practitioner. When you are questioning whether or not hormone replacement is right for you keep in mind that the information we obtain from scientific study is designed to help us build a base of knowledge that is comprehensive. No one study is the final word. 

As Part of Your Decision Making Process: