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Hormone Replacement Therapy: Difficult choices

Now that doctors concede that hormone therapy is more menace than miracle, what's woman to do if she's to stay healthy and strong? asks LESLIE LAURENCE. Now that doctors concede that hormone therapy is more menace than miracle, what's a woman to do if she's to stay healthy and strong, asks LESLIE LAURENCE.

FOR decades, hormone replacement was touted as the modern way to maintain youthful good looks and prevent disease to boot. But an unrelenting stream of bad news for the past year has nearly indicted estrogen-progestin therapy as an evil of its own, raising the risk of heart disease, breast cancer, ovarian cancer and dementia, in some cases after as little as one year of use. These risks are so significant, say researchers, that they far outweigh any potential benefits, such as preventing osteoporosis and lowering the risk of colon cancer, diabetes and cataracts. "Hormone Replacement Therapy (HRT) has a more limited role than ever before," says JoAnn Manson, a principal investigator of the Women's Health Initiative (WHI), the largest randomised, controlled clinical trial of postmenopausal hormones ever conducted. "We now know it's only for a very small subgroup of women, well below 20 per cent, who have moderate to severe menopausal symptoms, such as hot flashes — and for as short a time as possible. It certainly has lost its lustre for the prevention of chronic disease."

Some researchers, such as Wulf H. Utian, M.D., executive director of the North American Menopause Society, still view the WHI findings with scepticism. For example, the study focused only on Prempro, one particular estrogen-progestin combination. And the majority of participants were between the ages of 60 and 79. "The study did not evaluate the disease risk among those 40 to 50, who are perimenopausal or in early menopause," says Dr. Utian. "That could be a different story."

Still, since the WHI published its first results in July 2002, women have abandoned all hormones in droves. Previously, 3.4 million women had been taking Prempro, says Natalie de Vane, a spokesperson for Wyeth, which makes the drug. By June 2003, only 1.2 million were. The number of women taking the estrogen-only pill, Premarin, declined from 6.4 million to 4.5 million in the same period, even though the results of the WHI estrogen-only study won't be available until 2005.

Another path to a healthy menopause

"In a really bizarre way, the bad news about HRT could be good news for women," says Debra Anderson, Ph.D., co-author of The Menopause Made Simple Programme. "It presents us with an opportunity to take a good new look at all the aspects of menopause rather than just the HRT issue. This doesn't have to be a time of gloom and doom."

A new look would reveal that even the 15 to 20 per cent of women who have a truly miserable menopause can target symptoms in other ways, either with lifestyle changes or different drugs. Indeed, a healthy lifestyle may be your best prescription for easing the symptoms and side effects of menopause — something women of every age should know. Ideally, you should start getting enough calcium and exercise in your youth, because by age 30 bones have reached their maximum density. But it's never too late to begin.

Food factors

You know that eating a healthy, well-balanced diet can help control your blood pressure, cholesterol levels and weight, three important factors in preventing heart disease. And the Harvard Nurses' Health Study found that as little as two alcoholic drinks a day can raise the risk of the disease by 20 to 25 per cent. The right foods may also help alleviate symptoms of menopause. For example, foods containing natural plant estrogens, such as tofu, soy milk, flaxseeds and beans, may help quell hot flashes.

Bone builders

With HRT less often in the picture for osteoporosis prevention, doctors are very concerned about what could become "a new epidemic of osteoporosis," says James A. Simon, M.D., clinical professor of obstetrics and gyneacology at George Washington University School of Medicine, in Washington, D.C. "The bone loss following the discontinuation of HRT is similar to that at menopause. When bone loss increases, there's a parallel rise in the risk of fractures, particularly of the spine and hip."

All postmenopausal women not on hormones should get 1,500 mg of calcium and 400 to 800 IUs of vitamin D a day, through diet, supplements or both. For better absorption, take supplements in several doses throughout the day. Exercise, too, has numerous benefits for bones.

The best exercise for bone health are lifting weights or those in which you support your own body weight, such as walking, running, climbing stairs, dancing, aerobics or tennis. The best prevention for osteoporosis is a lifetime of doing weight-bearing exercise and getting enough calcium.

If you've stopped taking HRT or lowered your dose and have never had a bone-density test, get one. Ethel Siris, M.D., director of the Toni Stabile Centre for the Prevention and Treatment of Osteoporosis at Columbia-Presbyterian Medical Center, in New York City, recommends a DEXA scan, which gives you a T score telling you how your bone density compares with that of a 30-year-old women. A score of 10 and above is normal; from -1 to -2.5 is low bone density. Anything lower indicates osteoporosis.

Lower-dose HRT

Hormones are still the most effective treatment for hot flashes. For women not comfortable taking the standard regimen, one option is a new lower-dose version of Prempro that contains only .45 mg of estrogen and 1.5 mg of progestin, compared with .625 mg and 2.5 mg, respectively, for regular Prempro. Studies found that the drug relieves hot flashes and vaginal dryness as well as the high-dose pill. Premarin prescription hormone cream can also relive vaginal dryness.

Body creams containing progesterone, when applied to the skin, appear to be helpful at relieving hot flashes. However, because they're unregulated, the dosage of such over-the-counter creams may vary.

Other remedies

Be wary of "natural" or herbal remedies making extravagant claims to treat symptoms of menopause. Most are unproven and may cause harmful side effects.

However, some studies have found the herb black cohosh and soy supplements containing isoflavones (plant-derived estorgents) moderately helpful for hot flashes. While further research is needed, some experts think black cohosh may work even better than soy.

A report in the Annals of Internal Medicine found no benefit for the Chinese herbs ginseng or dong quai. Red clover was found to be no more effective than a placebo.

Creams containing wild yam were not effective against hot flashes. Many over-the-counter lubricants are available for vaginal dryness.


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