Do I have to stop my estrogen?

Has your long time physician, who seemed more like a friend than a doctor, retired and you’ve had to find a new one? And had your old doctor encouraged you to take hormones, but now your new doctor, younger but no doubt very smart, is telling you that you need to quit them? Are you wondering if you really need to?

This has been a dilemma for a lot of women over the last 15 years because the guidelines for taking hormone replacement (HRT) change.  Up until 2002, doctors generally encouraged women to take hormones when they went through menopause because they not only helped hot flashes, but many reputable studies showed that taking estrogen prevented osteoporosis, heart attacks, and even Alzheimer’s disease.  The studies did find a small increase in cases of breast cancer and blood clots, but overall the benefits outweighed the risks.  So many women entering menopause from around 1970 to 2002 went on HRT and for the most part felt great – not only did estrogen cure their hot flashes, but it improved their sleep, mood, and sex lives.  And they saw significant health benefits such as good cholesterol readings and stable bone densities.

Then a major study, the WHI (Women’s Health Initiative), was published which concluded that, instead of preventing heart attacks and strokes, hormone replacement increased them. This led to a major change in the guidelines – recommending that women take only the lowest dose of HRT for the shortest period of time.  Millions of women stopped their hormones and millions of women were discouraged from starting them.

HOWEVER, there has been much controversy about this study for two main reasons.

1. The women in the WHI were much older than the typical woman starting hormones (the average age was 64 in the study instead of an average age of 50, which is when women normally go through menopause).
2. The study used only one combination of hormones – Premarin and the synthetic progestogen, Provera.

I will talk more in later posts about the significance of these big issues and the WHI. But bottom line, applying the current guidelines to all women may not be appropriate.

If you are just now entering menopause and having hot flashes, most doctors should feel comfortable prescribing hormones for as long as you need them to control your symptoms.  Taking them for up to 5 years has been shown to carry very little risk.  Taking them up to 10 years also likely carries more benefits than risks for most women.  In fact, studies are showing that starting estrogen at the time of menopause actually decreases a woman’s risk of a heart attack, a broken bone, diabetes, and other health conditions.

So the issue remains – what to do after age 60 if you want to continue HRT.  A substantial number of women, with the blessing of their physicians, have remained on estrogen beyond the time their hot flashes have died down because they feel really good on them.  They see less aging effects in their skin, they have less tummy fat, and they’re happy with the beneficial effects estrogen has had on their bladder and vaginal tissue. They also like the idea of not taking other drugs for their bones.  On top of this, they’re reading articles in health newsletters about some of the other benefits from estrogen, such as preventing diabetes.

Coming back to the original question – do these women need to stop HRT?  This is where it gets murky.  The current guidelines have been based heavily on the results of the WHI study, which concluded that hormone therapy appears to carry more risks than benefits.  But, it should be clarified that the majority of women in the WHI began hormones roughly 10 years after menopause.  This is quite different from the situation where a woman starts taking hormones at the time of menopause and wants to continue them for a long duration.  Under these circumstances, evidence shows the benefits can be greater than the risks.

So, doctors are left somewhat up in the air as how to advise patients.   Fortunately there is some guidance.  The North American Menopause Society, which represents thousands of experts in menopause have come out with their latest position statement in 2017.  In it, the panel of experts writes that the decision to continue hormone treatment “in women aged older than 60 years should be made on an individual basis for quality of life, persistent vasomotor symptoms, or prevention of bone loss and fractures, after appropriate evaluation of medical risks and counseling about potential benefits and risks of hormone treatment and with ongoing surveillance.” (From the NAMS Position Statement, Menopause Magazine, July 2017).

So that is the best answer to this question and something you should be able to sit down and talk about with your doctor.  In future posts I will be giving you more information to consider when deciding whether hormone therapy is right for you and how long you should take HRT.