Hormone replacement therapy (HRT) used to be widely recommended for hot
flashes and other symptoms related to menopause. It was also believed to
help prevent and treat osteoporosis, and help prevent heart disease and
Alzheimer’s disease. In July 2002, the first of a series of articles
from the National Institutes of Health’s Women’s Health Initiative (WHI)
blew all of our previously held beliefs out of the water. This has left
patients and healthcare providers wondering where to go from here.
What are the findings?
Let’s try to untangle the information by first looking at what the
benefits of hormone replacement were thought to be. Many tissues have
estrogen receptors, meaning that they are influenced by the presence of
estrogen. Estrogen may somehow help the brain regulate body temperature
and decrease hot flashes. It increases vaginal blood flow, improving
lubrication and keeping vaginal tissue from thinning. Estrogen was also
thought to decrease heart disease by dilating blood vessels in the heart
and stabilizing plaques (fatty deposits) in the coronary arteries. Bones
benefited from estrogen's enhancing calcium absorption from the GI
tract. The brain had increased blood flow and improved connections
between brain cells, which was hoped to limit the frequency of
The WHI began in 1993 and studied over 100,000 women enrolled. These
women were between the ages of 50 and 79, from multiple ethnicities,
varied socioeconomic backgrounds, and from across the nation. They were
divided into three groups. One group took a daily estrogen and
progestin product, Prempro®, and a second took estrogen alone. This
second group enrolled women who had hysterectomies and therefore didn’t
need progestin. The third group received a placebo.
In 2002 the estrogen/progestin portion of the study was stopped early
because findings showed more heart attacks, strokes, and breast cancer
than expected. The exact number of cases was small: seven more women in
10,000 had cardiac events, eight more in 10,000 had strokes, eight more
in 10,000 had pulmonary emboli (blood clots in the lung), and eight more
in 10,000 developed invasive breast cancers.
One portion of the WHI study evaluated estrogen/progestin effect on
memory. The WHI Memory Study (WHIMS) involved 4,000 women over 65
who were placed on estrogen/progestin, estrogen alone, or placebo. Out
of these women, 61 developed dementia. Forty of these women were on HRT,
and 21 on placebo. This translates to 45 out of 10,000 women a year who
might be expected to be diagnosed with dementia. The good news from the
WHI is that HRT did decrease the frequency of osteoporosis and colon
The other good news is that there is life after hormone replacement
therapy. First of all, HRT is still acceptable for younger menopausal
women with significant hot flashes. After five years, the need for
treatment should be re-evaluated. But there are also alternatives
for women who are coming off HRT or women who prefer not to use HRT. Hot
flashes can be improved by using nonmedical options such as soy, eaten
in its natural form (not as a supplement), and paced breathing. Paced
breathing is done by using your abdominal muscles to take deep breaths.
This will lower your inner body temperature and help diminish hot
flashes. Smoking, alcohol, hot or spicy food, and stress can all trigger
flashes. Avoiding them as much as possible is beneficial. We’ve
found that some herbs that have been used in the past don’t actually
have much of an effect. These would include balm, chasteberry, dong
quai, evening primrose oil, licorice root, passion flower, sage, and
sarsaparilla. There is new data on black cohosh which shows it is
ineffective as well.
Nonhormonal medical therapies have met with some success. Clonidine®, an
antihypertensive, can be used as a low-dose weekly patch. Some
antidepressants, such as Paxil®, and medications that have been used for
seizures and chronic pain, like Neurontin®, can be very useful in some
None of these therapies addresses vaginal dryness, a common concern.
Using estrogen vaginally is different from taking it orally. Vaginal
estrogen comes in a variety of forms: cream, tablet, and a ring. It can
be used with or without a water-based lubricant. Some women have found
they are more comfortable when they use almond oil. Increasing foreplay
and having sex more frequently can also improve vaginal lubrication.
Estrogen and progestin therapy are no longer recommended to prevent
heart disease and Alzheimer’s. A healthy lifestyle is more beneficial.
Low-fat diets with high fiber, exercise, no cigarette smoking, and
cholesterol-lowering medications are the direction heart health is
Even though good results were achieved for osteoporosis and colon
cancer, hormones are not now recommended as the first choice for
preventing these problems. Again, healthy lifestyle and medications
specifically for bone health are the current emphasis of treatment. A
low-fat, high-fiber diet is important in decreasing the risk of colon
It is unclear if every estrogen or the way in which you take estrogen
(pill, patch, gel or spray) will have the same effects as found in the
WHI study. Taking hormonal therapy in a route that is not by mouth may
have a lower risk of DVT (blood clots). Many questions still need to be
answered. There are many factors to consider in deciding the optimal
therapy to treat menopausal symptoms. Each patient needs to be evaluated
and decisions made on an individual basis.
You should speak to your healthcare provider to determine what is safe
and most effective for you.
This article is part of the Menopause and You library,
a Web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own healthcare practitioner with your
specific concerns and questions.
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