As little as five years ago doctors still hailed hormone therapy (HT) as the saviour of post-menopausal women. A year ago the bubble burst when a huge study, known as the Women’s Health Initiative (WHI), was prematurely halted in the USA due to concern about the risks of long-term use of combined progestin and oestrogen.
Advertisement
The publicising of the findings has had a ripple effect. New studies in the USA and New Zealand have shown that more than half of women on HT stopped their therapy immediately. In general, menopausal and post-menopausal women are left with a sense of unease and confusion concerning HT.
Health24 investigated. After attending a lecture by Dr Alan Alperstein from the Department of Obstetrics and Gynaecology, University of Cape Town, and private practitioner at the Kingsbury Hospital in Cape Town, an interview with Dr Jacques Rosseau from the WHI and National Institutes of Health (NIH) in the USA, and scanning medical journals for the latest articles and reports on HT, we bring you the latest findings. Dr Alperstein reported back from the very recent North American Menopause Association’s (NAMA) congress.
Our primary objective is the best interest of all women, not the pharmaceutical companies, nor any other interest group. If a natural product is better, we will tell you. If you should worry about the risks of HT, we will tell you. If this whole upheaval has blown the findings out of proportion, then we will tell you. Now, read on.
The initial euphoria of a “fountain of youth”
Five, ten years ago doctors presented the option of HT almost as a “fountain of eternal youth” to their post-menopausal patients.
Many women face menopause and the post-menopausal time of their lives with dread. Not because menopause is a deadly disease – in fact, it is a natural phase in the ageing woman’s life. And that is just it: ageing is very natural, but not quite on everybody’s wish list. Neither are the symptoms of post-menopause. Does any woman in her right mind like to deal with hot flushes, mood swings and vaginal dryness when she still wants to feel attractive, sexy and wanted?
With oestrogen production dropping due to declining ovarian function (they are no longer needed for reproduction, translated to: sorry, you are now really too old for another baby), the protective effect of the woman’s own oestrogen against heart disease, osteoporosis and Alzheimer’s disease gradually disappears and the risk of these diseases and breast cancer will increase with age in the post-menopausal woman.
It made sense and sounded logical that replenishment of lost oestrogen will keep all the symptoms of menopause at bay, keep the risks for diseases of old age low, will keep the distraught, red-faced women happier and more even-keeled and their partners sane.
The logic went further: if a little bit of a good thing is good for a year or two, why not stick to hormones till you are 65 or maybe eighty? Why shrivel up, get Alzheimer’s and osteoporosis, and lose your protection against heart disease?
Who can blame women that they clung to HT as their elixir of youth and protector against diseases of old age? They believed their GPs and gynaes. Many post-menopausal women – especially after a hysterectomy (uterus surgically removed) or ovarectomy (ovaries surgically removed) - took hormones, either in pill form or as implants and later as patches. They took hormones, whether it was oestrogen alone or a combination of oestrogen and progestin. Most women did not bother to ask their gynaes whether it was one hormone or two, they took it.
The new studies
Between 2001 and 2002 the results from the WHI and other similar studies were published, showing an increased risk for breast cancer and cardiovascular disease for women on combination therapy. Women got scared and more than half stopped taking their hormones.
However, one out of four couldn’t tolerate their symptoms of hot flushes and mood swings and grabbed their hormones again.
Right now women are confused. Should one take hormones at all, and for how long? What about the risk for breast cancer? What about long-term use, what about plant hormones?
With female life expectancy on the increase and with the incidence of post-menopausal women, it is important to establish the status quo.
Explaining the findings
The first important aspect of the findings is that there is a difference between the risk due to the use of double HT (a combination of oestrogen and progestin) and the use of oestrogen alone.
Women should note that the findings are based on the use of oestrogen and progestin simultaneously. The preliminary findings of the trial in which women are receiving oestrogen alone (without progestin), have shown no increase in health risks. This arm of the trial is still continuing.
Breast cancer risk:
A 50-year-old woman (regardless of combination HT or not) has a 2.8% chance of developing breast cancer by age 60.
No increase in the risk for breast cancer was seen in the first four years of oestrogen and progestin treatment, according to the WHI study.
The WHI study reflected an absolute chance of breast cancer by age 50 after five years of HT of 3.5%. After five years on HT therapy, a woman’s chance will be 0.7 % higher to develop breast cancer by age 60. Dr Rossouw of the WHI described the increased risk as small.
If a 1000 women have two drinks daily, or have their first child at age 30 or older, or are obese, but are not taking any HT after age 50, 35 of them are likely to develop breast cancer at age 60.
Using another calculation called the “estimated cumulative incidence of breast cancer”, 45 out of 1000 women between 50 and 70 years and not using HT will develop breast cancer. After five years of HT use, 47 out of 1000 women will develop breast cancer (two extra per 1000). After 10 years of HT use, 51 out of 1000 women will develop breast cancer (six extra). After 15 years on HT, 57 out of 1000 women will develop breast cancer (12 extra).
Bottomline: There is an increased risk for breast cancer, especially after four years of HT use. Despite the increase in breast cancer incidence, the mortality is unchanged. It seems that breast cancer is detected earlier in women on double HT because of increased awareness and annual mammography.
Risk for heart disease, stroke and deep vein thrombosis:
About 37 out of 10 000 women older than 50 and who are taking HT are likely to develop heart disease, instead of 30 out of 10 000. Therefore, for every 10 000 women on HT, seven more are likely to develop heart disease.
About 29 out of 10 000 women older than 50 and taking HT are likely to suffer from a stroke instead of 21 out of 10000. This is an increase of eight per 10 000 women.
About 34 out of 10 000 women older than 50 and taking HT are likely to suffer from deep vein thrombosis instead of 16 per 10 000. This signifies an increase of 18 per 10 000.
The risk for stroke and pulmonary embolism appeared to increase within the first two years of use in the WHI study. This increase may be followed by a decreased risk. According to Dr Alperstein the decreased risk after two years does not sound enticing enough for women to put their health and life on the line in the first two years.
Bottom line: This so-called protective benefit against heart disease and stroke is now recognised as an increased risk. There should be no combined therapy for women with a family or personal history of heart disease, stroke, hypertension, elevated cholesterol or lipid levels. No combined therapy with the objective to reduce the risk for heart disease. Delete this idea. The American College of Obstetricians and Gynaecologists (ACOG) states: Combined oestrogen and progestin is not recommended for the prevention of heart disease in post-menopausal women.
Risk for colorectal cancer, hip fractures and Alzheimer’s:
The use of HT decreases the risk for cancer of the colon and endometrium.
The risk for colorectal cancer may drop from 16 per 10 000 women to 10 per 10 0000 women using HT.
The risk for hip fractures, an indicator of osteoporosis, may decrease from 15 per 10 000 to 10 per 10 000. HT can be regarded as a bone protector.
HT can be regarded as a protector against Alheimer’s disease.
Bottom line: Protection against cancer of the colon and endometrium, and against bone loss (osteoporosis) is real.
What about alternatives?
According to Dr Alan Alperstein women are desperately looking for alternatives to HT because of the “scare” stories, and because of some side effects of HT (including headache, nausea, breast tenderness and weight gain).
In the USA, the trend towards natural remedies is so huge that the public’s expenditure on alternative therapies is approximately four times its contribution towards all pharmaceuticals.
More and more women are trying phyto-oestrogens derived from plants. Studies on phyto-oestrogen from the Black Cohosh specie Cimicifuga racemosa has shown relief of menopause symptoms, according to naturopath Dr Chase Webber. Phyto-oestrogens do not act in the same way as HT. It may relieve some of the menopause symptoms, with no additional health benefits.
Studies have also shown that high amounts of soya in the diet is effective to treat some menopause symptoms, but that phyto-oestrogen extracts from soya supplements are not. Other herbals that may be effective in providing some relief from menopause symtoms are Dong Quai (Aelica sinensis), licorice root (glycyrrhiza glabra) and chaste berry (vitex agnus castus).
The bottom line: Some natural remedies do relieve some symptoms. They do not act like HT and are not as effective in relieving symptoms of menopause as HT.
The ultimate bottom line for all post menopausal women
Menopause is not an illness, but a discomfort.
The following applies to the use of combined oestrogen and progestin therapy (not to the oestrogen therapy alone – that seems to be fine and without the health risks involved in combined HT.)
HT (oestrogen plus progestin or oestogen alone) should be prescribed primarily for the treatment of menopause symptoms such as hot flushes, mood swings and vaginal dryness, and not primarily to protect against heart disease as was previously the case. Rather treat women with heart disease with statins.
Combined oestrogen and progestin treatment can be prescribed with relative safety for four to five years to women without a personal or family history of breast cancer and heart disease. If prescribed for longer than five years, re-assessment of the benefits and risks is recommended, because the risk of breast cancer seems to increase after four years.
The short-term use (up to five years) of combined oestrogen and progestin to manage menopause symptoms is regarded as appropriate treatment. Added benefits will include protection against osteoporosis, Alzheimer’s disease and colorectal and uterine cancer.
If a woman still suffers from menopause symptoms after five years, and she needs the protection against bone loss, Alzheimer’s or colorectal cancer, the doctor should discuss the benefits and risks again before continuing with the long term use of HT. She may need annual mammography.
A woman with a family history of breast cancer or a personal history of breast lumps should not be considered for combined oestrogen and progestin therapy.
A woman with a family or personal history of or increased risk for heart disease, stroke or deep vein thrombosis, or who has hypertension, should not be considered for oestrogen plus progestin therapy. These women should be treated with statins. Studies show that women are under-treated in this regard.
It is important to use the most effective dose of the purest hormones for the shortest duration. In older women using HT for more than five years, it may be best to change to low dose oral or transdermal preparations (skin patches).
The oestrogen alone trial should bring even more insights.
Bookmark with:
What are social bookmarks?