Should I take Hormone replacement therapy (HRT) after menopause?
The answer has shifted from “Yes” 20 years ago, to “if you have to” as information from studies continues to roll in. The Yes answer was in response to the problem of osteoporosis, and heart disease, as well as the perceived improvement in postmenopausal symptoms. The “if you have to” answer evolved as incidence of strokes and heart attacks increased, along with breast and uterus cancer rates. There was minimal improvement in sleep disturbance scores, quality of life and functional scores, and osteoporosis.
An initial trial called the Postmenopausal estrogen/progesterone initiative (PEPI) showed a marked increase of endometrial hyperplasia in women with an intact uterus who were given estrogen alone. The Women’s Health Initiative (WHI) trial then restricted Estrogen alone, to women who had had a hysterectomy. The WHI enrolled more than 16,000 women between 1993 and 1998, and randomized them to HRT vs. Placebo. HRT Estrogen + Progesterone arm was stopped in 2002, and the Estrogen only arm was stopped in 2004, due to the adverse effect of strokes, blood clots, heart attacks and breast cancer, but participants were followed through 2009, and it continues to generate data, and confusion.
The most common reason why women choose to use HRT is sleep disturbances. This is slightly alleviated with the combination therapy, but comes at a risk of strokes. Other quality of life scores did not improve. Side effects included breast pain and bleeding in the combination arm.
The Estrogen-only group did not show any statistical benefit in QOL, sleep disturbance and functioning scores, or improvement in osteoporosis related complications.
Interestingly, there was a strong placebo effect, with 25 % of women in the placebo arm reporting improvement in QOL and sleep disturbance scores.
Who should not take HRT? Anyone with an increased risk of breast cancer based on family history, or their own personal history of breast disease, or history of blood clots.
Who may take HRT? Women, who are not at risk for strokes or blood clots, or breast cancer, and who are experiencing severe menopausal symptoms. Keep it low dose and no more that 5 years.
What else can you do to keep your bones healthy? Weight bearing exercise, Calcium and Vitamin D.
There will continue to be regular updates on the studies that were closed in 2004, but there have been no major changes to the recommendations.