A generation ago, Hormone Replacement Therapy (HRT), which is a combination of estrogen and progestin, was regularly prescribed as a preventative measure for cardiovascular disease, breast cancer, colorectal cancer and osteoporosis—all diseases that were common in post-menopausal women.
In 1991, the National Heart, Lung and Blood Institute, part of the National Institute of Health, launched the Women’s Health Initiative (WHI). It was one of the largest study of post-menopausal women to date involving 160,000 women ages 50-70. The results, released in 2002, rocked the medical world and changed the way HRT was used for future generations.
It found that women taking the combination of estrogen and progestin hormone therapy had an increased risk for breast cancer, stroke, blood clots, and urinary incontinence. Women still had a lower risk for fractures and colorectal cancers, but it was determined the benefits did not outweigh the risks. Women immediately stopped using HRT and were left with few options for their menopausal symptoms.
Menopausal Hormone Therapy
Since the original WHI study, more research and treatment adaptations to HRT, now called Menopausal Hormone Therapy (MHT), have occurred. MHT is now the primary treatment for women experiencing severe hot flashes that may affect sleep and quality of life. Additional benefits may include improved depression, mood swings, and prevention of osteoporosis. For women with an intact uterus, MHT includes a form of estrogen and must be combined with a progestin, a type of progesterone, to prevent excessive tissue growth in the uterus. For women post hysterectomy, progestin is not needed. Before the WHI, all women received the same dose of HRT. Now women start with the lowest dose of MHT that relieves their symptoms.
Treatment is for as short a period as possible. If women are under the age of 60, treatment recommendations are usually from 3-5 years, although may be longer if hot flashes continue to persist. Treatment can be administered with skin patches, creams or sprays, or through oral medication. Complaints of vulvavaginal dryness/atrophy without hot flashes is treated locally at the tissue level through creams and vaginal rings. Absorption through the rest of the body is considered minimal.
Taking MHT, just like any medication, should be discussed extensively with your primary healthcare provider. For younger, healthy post-menopausal women experiencing severe hot flashes it is a viable and safe short-term treatment. Women should avoid systemic MHT if they do not have severe hot flashes, are older than 60, and have a history of blood clots, stroke, heart attack, bleeding disorders, liver disease, or cancer. MHT is no longer recommended for prevention of heart disease or cognitive decline.
Bio-identical Hormone Therapy
An alternative to MHT is bio-identical hormone therapy (BHT). While the hormones in MHT are made synthetically, BHT are plant based and their molecular structure is identical to what is made in the human body. These hormones are widely promoted and can be medically prescribed or sold without a prescription. Although promoted as being safer than MHT, there is no evidence to support this claim. In fact, there is emerging evidence that BHT are less safe than MHT in breast cancer risk. BHT may be sold with FDA approval or can be made at compounding pharmacies. Through analysis of serum or saliva tests, compounding pharmacies produce a hormone that is purported to be made specific to the individual’s needs. There is no FDA efficacy or safety of the bio-identical hormones produced by compounding pharmacies. The American College of Obstetrics and Gynecology (ACOG) and other medical societies do not support the use of BHT secondary to lack of Federal Drug Administration (FDA) approval on compounding BHT. There is potential for compounded BHT to have higher doses of estrogen than needed, inadequate progesterone to protect against uterine wall proliferation and the unvalidated serum or salivary hormone testing to determine dosage. There are physicians that disagree with the recommendations of ACOG and prescribe BHT. Many women perceive that BHT manages their symptoms adequately, is safer than medical MHT, and is tailored to their individual body’s needs.
The decision to choose MHT or BHT for menopausal symptoms is an individual one. Discuss your concerns, fears, and menopausal symptoms with your healthcare provider. A management strategy may include MHT or BHT but also needs to incorporate healthy lifestyle behaviors for best results.
Special thanks to Laura Covill, D.P.T., OCS, COMT, who also contributed to this article.
Our exceptional providers at the Des Moines University Clinic are here to help you thrive before, during, and after menopause. For more information or to make an appointment, visit DMU Clinic website or call 515-271-1717.