A recent widely publicized editorial is raising more questions about the true benefits of hormone replacement therapy (HRT). HRT is synthetic estrogen and/or progesterone (called progestin) designed to "replace" a woman’s depleting hormone levels at menopause. An estimated 20 million American women take some form of HRT to relieve menopausal symptoms or prevent bone loss associated with osteoporosis. Over the years, it has also been suggested that HRT can prevent heart disease, help with Alzheimer’s disease and diabetes, and potentially provide a host of other benefits.
However, recent studies have raised doubt that HRT can prevent heart disease and some suggest that HRT can actually increase heart attack and stroke risk during the first few years of treatment. Now, to add to the confusion surrounding HRT, a newly published editorial by University of California researchers questions whether HRT can really reduce the risk of bone fractures in older women with low bone density.
The Latest Argument: HRT and Bone Loss
Hormone replacement therapy (HRT) is approved by the U.S. Food and Drug Administration (FDA) to help prevent osteoporosis, a degenerative bone disease that is a threat to 28 million American women. Past studies have shown that HRT can reduce the risk of bone fractures in post-menopausal women. In fact, a study published in the June 13, 2001 issue of the Journal of the American Medical Association found that HRT significantly reduced the risk of bone fractures in women under age 60, though HRT was less effective in women over 60.
However, an accompanying editorial also published in the Journal of the American Medical Association find flaws in this study and with several other studies on HRT and osteoporosis. According to the authors of the editorial, evidence that HRT can really prevent bone fractures is weak. This may be because most of the studies that have examined HRT and bone loss have been "observational" and therefore prone to bias. Because women who choose to use HRT tend to be in better physical health than women who do not use HRT, Deborah Grady, MD and her colleague argue that the studies of HRT may have overestimated the treatment’s ability to prevent bone fractures.
In conclusion, the authors suggest that women who are considering HRT for the sole purpose of preventing osteoporosis may wish to consider other non-hormonal treatments first. Other FDA approved drugs such as Fosamax (generic name, alendronate) and Actonel (generic name, risedronate sodium) may be better options for these women. Of course, further research is necessary to fully understand the effects of HRT on bone loss. A long-term study conducted by the Women’s Health Initiative is currently underway. The results of the study, which are expected in late 2005 or early 2006, will likely answer many of the looming questions about HRT.
Accepted Facts About HRT: Menopausal Symptoms, Endometrial Cancer
One aspect of hormone replacement therapy (HRT) that virtually every researcher and physician agrees upon is that HRT effectively relieves bothersome menopausal symptoms including hot flashes, vaginal dryness, and sleep disturbances. In fact, recent research shows that low-dose formulas of HRT are equally effective at treating menopausal symptoms as the standard doses of HRT. Low-dose formulas also reduce side effects such as vaginal bleeding and breast tenderness, which are main reasons why many women stop taking HRT.
It is also accepted that women who take estrogen alone (without progestin) are at a higher risk of developing cancer of the uterine lining (endometrial cancer). However, this risk is eliminated if combination HRT (estrogen and progestin) is used.
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Debating Points About HRT: Breast and Ovarian Cancer, Heart Disease
Aside from the new editorial that questions the effects of hormone replacement therapy (HRT) on preventing bone fractures, there have also been other points of contention regarding HRT. One of the most publicized points in question is whether or not HRT increases the risk of breast cancer. Several studies on this subject have produced conflicting results and most all experts agree that more research is needed. However, the general consensus is that HRT does not significantly increase the risk of breast cancer, at least for women who take estrogen less than five years or who take less than 0.625 milligrams per day. The effects of long-term use of HRT (more than five years) on breast cancer risk are less clear, and therefore, women should carefully weigh the benefits and risks of HRT with their physicians when deciding whether the treatment is right for them.
Recent research has also linked long-term use of HRT (10 years or more) with a slight increase in the risk of ovarian cancer. However, in the study of over 200,000 women conducted by the American Cancer Society (ACS), the women were taking estrogen alone, not combination HRT (estrogen plus progestin). While the ACS researchers are not certain why long-term estrogen use increases the risk of ovarian cancer, they do know that estrogen causes ovarian cells to produce at faster than normal rates. The more times a cell divides, the higher the chances that it will replicate an abnormal copy, which could result in cancer if the abnormal copy controls cell growth. Again, further research is necessary to better understand the effects of HRT on the ovaries.
Finally, recent research has questioned whether or not HRT protects against heart disease—a benefit that has long been associated with estrogen therapy. Logically, HRT would help prevent heart disease in post-menopausal women because the loss of estrogen at menopause is associated with a higher risk of heart disease. Thus, adding estrogen therapy would decrease heart disease risk. However, recent studies have actually shown an increase in heart attack and stroke risk in women who use HRT for the first few years, although the risk is minimized with prolonged use. Again, it is difficult to say whether this risk is real or that the women who experienced heart problems in HRT studies were at greater risk of heart disease anyway. Currently, HRT is not FDA approved to prevent heart disease. Experts say that cholesterol-lowering drugs and other therapies are much better options for lowering heart disease risk than HRT.
Summary
The following bullet points help sum up the latest news on HRT. Right now, individual physicians may disagree on the benefits of HRT. Further research will help clarify the debate. Because every woman’s medical situation is different, it is important for all women considering HRT to discuss the advantages and disadvantages of HRT with their physicians. Some women will find that the benefits of taking HRT for a certain amount of time outweigh the risks while others may wish to consider other options.
- HRT helps relieve menopausal symptoms, including hot flashes.
- HRT may or may not significantly reduce bone fractures in post-menopausal women.
- Long term use of HRT may slightly increase the risk of breast and ovarian cancers.
- HRT may or may not help protect against heart disease.
- Low dose HRT appears to be as good as the standard dose for relieving menopausal symptoms and may be associated with fewer side effects, such as vaginal bleeding.
Additional Resources and References
- The editorial by Deborah Grady, MD and Steven Cummings, MD, "Post-Menopausal Hormone Therapy for Prevention of Fractures: How Good is the Evidence?," is published in the June 13, 2001 issue of the Journal of the American Medical Association, http://jama.ama-assn.org/
- The study, "Hormone Replacement Therapy and Prevention of Nonvertebral Fractures," is published in the June 13, 2001 issue of the Journal of the American Medical Association, http://jama.ama-assn.org/
- The report by Rita Rubin, "Hormone Therapy: Doubts Grow," is published in the June 12, 2001 issue of USA Today, http://www.usatoday.com/
- To learn more about hormone replacement therapy, please visit http://www.imaginis.com/breasthealth/hrt.asp
- To learn about other treatments for osteoporosis, please visit http://www.imaginis.com/osteoporosis/
