Millions of women who use hormone replacement
therapy (HRT) for the relief of menopausal symptoms have been left
confused and upset by the results from a new study. The study, published
in the Journal of the American Medical Association (JAMA) found
that the hormones increased the risk of heart disease by 29 percent,
stroke by 41 percent, and breast cancer by 26 percent.
The following is an article by Susan Okie
Washington Post Staff Writer
Tuesday, July 16, 2002; Page HE01
Last week's news about the stopping of the Women's Health Initiative
(WHI) study of post-menopausal women receiving hormone replacement
therapy with estrogen and progestin shocked many of the 6 million
American women who are taking the same or similar treatments. It also
raised many questions about what women should do to optimize their
health during and after menopause. We take on some of the questions here
-- with the caveat that all women should consult their physicians before
making any decisions about changing treatment. For more information on
the study, visit the Web site www.whi.org.
If I have been taking estrogen and progestin for several years,
what have I done to my risk profile for heart disease, stroke, blood
clots and breast cancer? If I stop now, will I remain at higher risk
than I would have been otherwise?
The findings showed that being on the hormones increased these
problems, but in the WHI study, each problem affected fewer than one in
1,000 women per year. So any increase in your individual risk resulting
from hormone use has probably been small. Researchers do not know
whether some risks of hormone treatment -- or the benefits, such as
reductions in hip fractures and colon cancer -- persist after a woman
goes off the drugs. They intend to continue the WHI study, now that
participants have stopped taking hormones, to answer that question.
In the case of breast cancer, there is some evidence to suggest that
the longer a woman's cumulative exposure to hormones, the greater her
risk. WHI experts recommended that current and former hormone users have
annual mammograms and clinical breast examinations.
If I'm taking a different type of estrogen and progestin than the
ones found in Prempro (the drug used in the study), should I still
worry?
Doctors don't know whether other products have exactly the same
effect on cardiovascular diseases, clots and breast cancer since they
haven't been as thoroughly studied. Prempro contains a mixture of
estrogens derived from horses, combined with a synthetic progestin (medroxyprogesterone
acetate). Premarin and Prempro were chosen for the WHI studies because
most of the earlier observational data suggesting possible benefits from
hormones came from studies of women who had taken them, and because they
were the most widely prescribed.
A number of other estrogen and progestin products are on the market
in pills, vaginal creams, a transdermal patch and even a nasal spray.
Scientists say additional research is needed on such alternatives, and
they caution against assuming they are safer. "We have to recognize
the possibility that the risk/benefit profile will be in the same
direction," said Marcia Stefanick of Stanford University, chair of
the WHI's steering committee.
If I am taking estrogen alone, should I stop?
Women who have had a hysterectomy are often prescribed estrogen
without progestin, since they don't run the risk of estrogen-related
uterine cancer that applies to women with an intact uterus. The WHI is
continuing its study of estrogen use in such women because so far, it's
not clear whether there's a net benefit or a net risk to such treatment.
Researchers have not seen the same increased risk of breast cancer with
estrogen-only treatment that they found in the study of combined hormone
therapy. They haven't provided any details about whether women given
estrogen alone are experiencing increased rates of heart attacks,
strokes and blood clots compared to those given a placebo.
If I go off hormones, will my hot flashes come back? What can I do
to minimize my chances of suffering bothersome symptoms?
Some women do experience hot flashes and night sweats when they stop
taking hormones, a response to the sudden drop in blood levels of
estrogen. This problem is more common in women under 55 and in those who
taken hormones for less than five years, said obstetrician-gynecologist
Susan L. Hendrix of Detroit's Wayne State University, a WHI researcher
and menopause expert. You can minimize your chances of hot flashes and
related estrogen-withdrawal symptoms if you taper the hormone dose,
although experts said that stopping "cold turkey" is not
dangerous. Hendrix suggests skipping one pill the first week, two pills
the second week and so on until you're off hormones.
You may notice temporary mood changes or problems with concentration.
You may also lose weight or experience other benefits from stopping,
since hormones tend to cause bloating, fluid retention and sometimes
hair loss. Hendrix said it takes about six weeks after stopping the
medication for the hormones to be completely gone from a woman's system,
so try to wait that long before assessing how you're going to feel
without them.
Women who stop hormones may experience vaginal bleeding or spotting.
It should occur within the first four weeks of stopping, and most often
lasts only a few days. If it occurs later or lasts longer, talk to your
doctor.
If I do get hot flashes or insomnia, what else can I do?
Dress in layers. Cut back on hot beverages and spicy foods. Quit
smoking. (Smoking triggers hot flashes.) Since stress and anxiety can
also exacerbate the problem, Hendrix recommends yoga or relaxation
techniques. There is no solid evidence that exercise, beta blocking
drugs, phytoestrogens (found in soy) or alternative therapies such as
dong quai, black cohosh or evening primrose oil are effective for hot
flashes.
If you're severely affected, consult your doctor. Antidepressants
such as paroxetine (Paxil) and venlafaxine (Effexor) have been shown to
reduce hot flashes. For most women, hot flashes are a temporary
nuisance, but a few women may find them so persistent and disabling that
they opt to take hormones to obtain relief.
Will stopping hormones hurt my sex life?
There's no evidence that estrogen and progestin increase desire, so
your libido will probably be unaffected. You may, however, be bothered
by vaginal dryness. Non-hormone-containing lubricants are helpful.
Hendrix also recommended Vagifem vaginal tablets and a vaginal ring (Estring).
Each contains estrogen that acts to reduce dryness but doesn't enter the
bloodstream in significant amounts.
© 2002
The Washington Post Company
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