Dr. Stephanie Coulter

Hormone replacement therapy (HRT) has been used to treat menopausal symptoms and protect long-term health until large clinical trials showed greater health risks than benefits from HRT, particularly when given to older postmenopausal women. 

Although HRT is no longer recommended for disease prevention, such as heart disease or memory loss, further review of clinical trials and new evidence shows that it may be a good choice for certain women, depending on their risk factors. 

How does HRT therapy work? 

HRT works by replacing hormones the body no longer makes with medication that mimics the hormone. These medications are called “replacement therapy” because they actually contain the female hormones estrogen and progesterone.

Types of HRT 

Estrogen (only) Based Therapy: This type of HRT is for women who have had a hysterectomy (have had their uterus removed). Estrogen comes in different forms. 

• 1. Systemic estrogen (pill, skin patch, gel, cream, or spray). This form is the most effective treatment for relief of menopausal night sweats and hot flashes. Estrogen also decreases vaginal symptoms of menopause, such as dryness, discomfort during intercourse, and itching.

• 2. Low-dose vaginal preparations of estrogen (cream, tablet, or ring form). This preparation is used to treat vaginal symptoms and some urinary symptoms, while minimizing absorption of estrogen into the body. Low-dose vaginal estrogens do not treat hot flashes or night sweats or protect against osteoporosis.

Estrogen/Progesterone/Progestin Hormone (Combination) Therapy 

This type of HRT is a combination of estrogen and progestin (a synthetic form of progesterone) for women who still have their uterus. In this case, estrogen is prescribed along with progestin to prevent growth of the lining of the uterus to decrease the risk of uterine cancer, which is increased by taking estrogen alone.

Why is there so much debate about HRT?

The biggest debate about HRT is whether its risks outweigh its benefits. In recent years, several studies showed that women taking HRT have a higher risk of breast cancer, heart disease, stroke, and blood clots. 

Women’s Health Initiative Study

More than a decade ago, the Women’s Health Initiative performed the largest clinical trial of hormone therapy—involving 27,347 postmenopausal women (average age, 64 years). This study found that women who took the combination therapy (estrogen/progesterone/progestin) had an increased risk of coronary heart disease, stroke, venous thromboembolic disease (“blood clot formation”), and breast cancer, whereas women taking estrogen alone had an increased risk of only stroke. In this study, the overall risks of long-term use outweighed the benefits.

ELITE Trial

In this well designed, placebo controlled trial; over 600 postmenopausal women with no prior cardiovascular disease were studied. Some of these women still had their uterus and some did not (no prior hysterectomy/hysterectomy). The women were divided into two main groups based on the length of time since they entered menopause:

GROUP 1:  <6 years “early” group (average age, 55 years) 

GROUP 2: >10 years “late” group (average age, 65 years)

All of the women were treated with HRT for about 5 years but women with a uterus were treated with oral estrogen pills plus vaginal progesterone gel and women without a uterus were treated with oral estrogen pills alone.

To measure the response of the two different treatments, the researchers used atherosclerotic plaque growth by measuring the change in the thickness of the inner layer of the women’s carotid artery that runs along the neck. This test was measured by ultrasound every six months.  

The results showed that plaque growth was slower in estrogen-treated women if women started taking HRT within 6 years after menopause, but not if they waited until 10 years after menopause. 

This trial suggested that the beneficial effects of estrogen on slowing plaque growth that can lead to hardening and narrowing of the arteries (atherosclerosis) depends on the timing of estrogen therapy. 

Thus, the benefit is really only limited to women who start therapy within a few years of menopause. So for those of you who are 10 years out from the big “M” it is just too late according to this trial.

Who should consider HRT?

Despite the health risks, estrogen is still the most effective treatment for menopausal symptoms. 

In a joint statement, the North American Menopause Society, the American Society for Reproductive Medicine, and The Endocrine Society have said, “Therapy is an acceptable option for the relatively young (up to age 59 or within 10 years of menopause) and healthy women who are bothered by moderate to severe menopausal symptoms. Individualization is key in the decision to use hormone therapy. Consideration should be given to the woman's quality of life priorities as well as her personal risk factors such as age, time since menopause, and her risk of blood clots, heart disease, stroke, and breast cancer.”

The benefits of HRT in relieving symptoms of menopause may outweigh the risks if you are younger than 59 and at least one the following applies to you:

• Suffering from moderate to severe hot flashes or other known menopausal symptoms.
• Stopped having periods before 40 (“early menopause” or “premature menopause”).
• Your ovaries have been removed. 
• Diagnosed with “early or premature menopause” and did not take estrogen therapy until at least age 45. When menopause happens before age 40, it is considered early. This type of menopause typically lowers the risk of types of breast cancer. If you reached menopause prematurely, the protective benefits of HRT usually outweigh the risks.
• Have lost bone mass or cannot tolerate other treatments for osteoporosis.

Who should avoid HRT?

• Women with current or previous stroke, heart disease, blood clots, breast cancer, endometrial cancer, or ovarian cancer. 
• Current smokers.
• Women who started menopause after 45 with mild or no menopause symptoms. Ideally, ask your doctor about strategies to reduce the risk of heart disease, osteoporosis, and cancer. 

Conclusion 

There is no question that HRT therapy plays an important role in managing symptoms for healthy women during the menopause transition and in early menopause.

Although new data suggests that estrogen when taken early in the postmenopausal years, can decrease the progression of plaque build up (atherosclerosis), use of systemic HRT for prevention of symptoms in women 10 years past onset of menopause is no longer routinely recommended. 

Until next time! 

Stephanie Coulter, MD 

Special thanks to Dr. Karla Campos for her assistance in writing Straight Talk.

Further Reading: A Change of Heart at Menopause   

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