Estrogen Therapy

“One of the most complex and difficult health care decisions that women face is whether to use postmenopausal hormone-replacement therapy”, says an article in the New England Journal of Medicine (NEJM).

Couple of weeks ago we discussed hormone-replacement therapy (testosterone) for aging men. Benefits and risks of testosterone therapy in men are still being debated. And there aren’t millions of men on testosterone yet.

But hormone replacement therapy (HRT) – estrogen – for women has been prescribed for many years. On an average, women live 30 years after menopause. Currently, approximately 38 percent of postmenopausal women use HRT although there is dearth of conclusive evidence regarding the benefits and risks of this therapy.

What are the definite benefits of postmenopausal HRT in women?

About 50 to 80 percent of women suffer from menopausal related symptoms like: hot flashes, night sweats, vaginal dryness, insomnia, mood swings, and depression. There is strong evidence that estrogen therapy is highly effective. For genital and urinary symptoms, vaginal estrogen is as effective as oral or skin patch estrogen.

HRT reduces age-related bone loss (osteoporosis) and reduces the fracture of the spine by 50 percent and the risk of hip fracture by 30 percent. Increased physical activity and adequate intake of calcium and vitamin D may also help reduce the risk of osteoporosis-related fractures.

What are the definite risks of HRT?

Cancer of the uterus (endometrial cancer) and blood clot in the legs and lungs (venous thromboembolism) are definite risks related to HRT.

Besides these there are two probable areas where there is increased risk of HRT. These are breast cancer and gall bladder disease. There is no appreciable increase in the risk of breast cancer if the postmenopausal estrogen therapy is given for less than five years. In contrast, the risk of breast cancer was increased by 35 percent in women who used estrogen for five years or more. Combination therapy – estrogen and progesterone – is worse than estrogen therapy alone when it comes to breast cancer risk, says the NEJM article.

What are the areas of uncertainty?

Coronary artery disease
Colon and rectal cancer
Alzheimer’s disease
Ovarian cancer
Diabetes

What is the best approach to starting HRT for a postmenopausal woman?

Two most valid reasons for starting HRT are menopausal symptoms and prevention and treatment of osteoporosis. Patients with intact uterus should be warned that they might get vaginal bleeding if on estrogens therapy alone. They should be on combination therapy (estrogen-progesterone).

Short-term use (less than five years) is appropriate for relieving menopausal symptoms. But longer-term use (five years or more) of HRT is problematic due to increase risk of breast cancer. Some women with osteoporosis will require long-term therapy.

Your family physician or gynaecologist will carefully weigh the risks and benefits before prescribing HRT.

The central principle is that menopause does not always need to be treated with medication, says the NEJM article. Life style changes, such as quitting smoking, increasing physical activity, and maintaining a healthy diet, may be useful in controlling symptoms and preventing chronic disease.

Further research on this subject continues. Results of one large-scale study are expected to come out in 2005 and another one in 2012. Until then, postmenopausal women and their clinicians will have to make the best possible judgement regarding the use of HRT.

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