Finding a balance: Confusion over hormone replacement therapy leaves many women hot


What is menopausal hormone therapy?


Why is hormone therapy controversial?

It has been under intense scrutiny since 2002, when a large study called the Women’s Health Initiative reported that taking additional hormones — specifically the combination of estrogen and progestin — increased risk of blood clots, stroke, breast cancer, heart attacks and gall bladder disease for some women. For a woman with a uterus, estrogen treatment alone raises her odds of getting endometrial cancer. Researchers abruptly halted the study, concluding that risks outweighed benefits. Almost overnight, millions of women abandoned hormone therapy.

What have we learned over the last 10 years?

Hormone therapy still has an important role in treating women who have symptoms, but it shouldn’t be used to prevent disease. It’s best to take the lowest possible dose for the shortest amount of time.

For symptom relief, “if you’re healthy and in your 50s, and it has been less than 10 years since menopause, it’s pretty much a green light,” said Dr. Cynthia Stuenkel, a clinical professor of medicine at the University of California at San Diego. Hormone therapy is also beneficial for bone health and may decrease mortality and cardiovascular disease.

But it’s not right for everyone; the risk level depends on a woman’s age, health history and the number of years since her menopause began, says The Endocrine Society.

What is still up for debate?

Whether hormone therapy has a preventive role, Stuenkel said. There’s some evidence estrogen therapy can effectively reduce heart disease, but “it’s not universally agreed on,” she said. Estrogen has a positive effect on bones and can help with treating osteoporosis, but it’s not a first-line treatment, Isaacs added. Swiss researchers recently showed that boosting estrogen might enhance muscle strength in postmenopausal women.

Still, last year the U.S. Preventive Services Task Force recommended against using hormonal therapy to prevent chronic conditions. Until more is known, “use hormones if you have symptoms,” Stuenkel said. If you don’t, make some lifestyle changes to help prevent heart disease and other aging-related issues.

“Move more, try the Mediterranean diet, stop smoking. Eat, drink and be merry with a friend,” she suggested.


“Too many women don’t know this or are so confused about hormone therapy that they are not receiving any treatment at all,” Young said.

What about breast cancer?

It’s complicated. The increased risk, which is small, is primarily due to adding progesterone to estrogen therapy. Basically, after age 50 a woman has a 3 in 1,000 chance of developing breast cancer. If she uses combined hormone therapy for a year, the same therapy used in the Women’s Health Initiative study, her risk will be 4 in 1,000, Stuenkel said.

“That can be expressed as a 33 percent increased risk, which to most of us sounds much more ominous than an increase of 1 per 1,000,” she said.

For women who haven’t had a hysterectomy, progesterone can help prevent uterine cancer, Isaacs said. “But some of the heart disease issues have been tied to progesterone,” he said. A recent study in the Journal of the National Cancer Institute provided more evidence showing estrogen plus progestin in postmenopausal women is linked to an increased risk for breast cancer.

Breathing, relaxation techniques and clinical hypnosis show the most promise. Native Americans traditionally used the herb black cohosh to treat menstrual irregularity; research suggests it could have a role in menopause. But a systematic review of 16 studies found there’s not enough evidence to support the use of black cohosh. Phytoestrogens, which are found in soy, have run into the same problem.

How do I know if I need hormonal therapy?

Try an interactive tool called the “Menopause Map” at, which Stuenkel helped develop. The map guides women through the different options and weighs both hormonal and nonhormonal treatments.

What are bio-identical hormones?


“Oral estradiol, transdermal patches, estradiol sprays, gels and micronized progesterone are all chemically very close to identical to native hormones,” Stuenkel said. “Maybe a better term would be ‘biochemically identical,’” she said.

Compounded hormones are most commonly referred to as “bio-identical,” which contributes to consumer confusion. These hormones are prepared by compounding pharmacies, require a prescription and carry the same risks as conventional hormones.

Bio-identical hormones may contain two or three different types of estrogen rather than one. They often contain estriol, a form of estrogen that, while regarded as safe, has not been approved by the FDA.
