The Women’s Health Initiative (WHI) study from 2013 seems like a long time ago but it’s impact is still reverberating throughout the health community as well as with women’s feelings about hormone replacement therapy (HRT). The take-away message at that time was: ‘hormones are bad; they cause heart disease, blood clots and breast cancer and even dementia. Go off of them because the consequences and risks are way worse than any benefits they may have’. Well…things have changed since then.
Where do I begin?
First, we need to remember that the average age of women in the study was 63 years. Most women start HRT in their 50’s. The number of women who developed breast cancer was statistically insignificant compared to those that were not on HRT. Second, there was a difference in those women starting hormones that were within 10 years of menopause onset which showed less adverse effects than those who started later. Third, the majority of women whom developed dementia were over the age of 85. Research shows that 1 out of 2 people over the age of 85 develops dementia.
This study was a large NIH-funded placebo-controlled randomized trial and evaluated only those women on oral estrogen (Premarin) or estrogen-progestin (Prempro) pills. That is to say that HRT comes in many shapes and sizes… topical, vaginal, creams, gels, sublingual trouches and patches. These forms were not tested and studies have shown that these forms of hormones are safer and better tolerated than oral.
Investigators of the WHI reported a 13-year cumulative follow-up of mortality in the 27,347 women who participated in the study. They found that prior use of oral hormones when initiated by women aged <60 or within 10 years of starting menopause did not affect risk for overall, cardiovascular, or cancer mortality. These findings support guidance from the North American Menopause Society and the Endocrine Society which endorse HRT for symptomatic management in recently postmenopausal women without contraindications.
In my practice I reassure my recently menopausal women that initiating HRT can not only help with bothersome symptoms (hot flushes, insomnia, cognitive impairment, low libido, vaginal dryness), but can delay or prevent degenerative diseases such as osteoporosis. I use only bio-identical hormones and prefer to use topical options for women. The important thing is to individualize treatment for each woman.
Reference: Kaunitz, A. Extended Follow-up of Mortality in WHI Participants: Continuing Reassurance About Hormone Therapy. Journal Watch: Women’s Health October 2017; p. 80.