Reviewed by Dr. Amber Hayden, DO
If you’ve been keeping up with the news, you’re probably aware of the recent questions about risks and benefits of hormone replacement therapy (HRT). These reports, along with new scientific evidence, are leading some women and their healthcare practitioners to reconsider the 2002 mandate to stay off of HRT. We hear this question again and again: “What’s changed since the negative results of the Women’s Health Initiative?”
We’re happy to say that researchers have been busy over the past few years, and their findings give the medical world new perspective on the use of HRT for menopause symptoms. The answers we now have are similar to what Women’s Health Network has been telling women all along — the decision to go on hormone replacement therapy is individual, and the risks, benefits, and side effects differ depending on the individual.
In the end, you can take comfort in the fact that there are several options for menopause symptoms — and we’re here to help you understand them.
Want to get off HRT safely?
Consider our Program for getting off HRT. It’s uniquely tailored for women to minimize side effects and symptoms during their transition off of hormone replacement therapy.
Learn more.
The Women’s Health Initiative results — then and now
Time has given researchers more perspective on the results that came out in 2002, when women were warned that hormone replacement therapy leads to higher risks for breast cancer, cardiovascular events, blood clots, cognitive decline, and more. An extensive collection of data has been scrutinized and published, showing us that timing and individual circumstance are key.
New studies suggest that women under 60 years old and within ten years of menopause can benefit from HRT with much less risk (even with potential benefit) than older women who are more than ten years away from menopause. The majority of the women enrolled in the WHI study were older and much past menopause.
The most recent evidence on the use of hormones for menopause
Here’s an overview of how HRT may affect certain health issues:
Coronary heart disease. If HRT is initiated within ten years of menopause or in women under 60, it may help reduce the incidence of coronary heart disease. It appears that estrogen therapy alone delivers better results than combined estrogen and progestin (any hormone that causes progesterone-like effects.) But women with a uterus need a form of progesterone to “oppose” potential risks of estrogen alone.
Cognitive health. The 2004 Women’s Health Initiative Memory Study showed that initiating estrogen therapy or estrogen/synthetic progesterone therapy in women over 65 had a negative effect on cognition — particularly if they had already experienced some cognitive decline. But another study looking at women between the ages of 50 and 63, showed that those on hormone therapy had a lower risk of Alzheimer’s disease than those that weren’t.
Cholesterol and triglycerides. In 1997, the Postmenopausal Estrogen Progestin Intervention trial showed that women aged 45–60 on Premarin alone or Premarin and natural progesterone had significant increases in “good” cholesterol, compared to those receiving Premarin with a synthetic progestogen (Prempro). Now, we also have evidence that bioidentical estradiol delivered across the skin reduces triglycerides, rather than increasing triglycerides as pill forms (synthetic and bioidentical) do.
Blood clots. Estrogen has long been known to increase blood clotting. A recent study showed that the lowest risk comes with using natural progesterone and the highest comes with synthetic progestogens. Estrogen, on the other hand, if given transdermally (across the skin), comes with no increased risk of blood clots.
Breast health. The relationship between HRT and breast cancer risk continues to be the subject of intense debate. Close scrutiny of data on women in the WHI who were ages 50–59 who had undergone hysterectomy reveals that estrogen therapy alone did not increase their risk of breast cancer. However, women of that same age group who had not undergone hysterectomy and who took estrogen with a synthetic progesterone did.
A recent large study in France following over 80,000 women observed a much lower risk of breast cancer when they used estrogen combined with bioidentical (natural) progesterone than nonbioidentical progesterone — as long as they used it for less than about six years. But for users of estrogen alone, compared to “never-users” of HRT, the researchers noted a significantly increased risk of breast cancer.
In the end, making generalizations about HRT and breast cancer risk is not a good idea; the number of variables keeps increasing and the field is changing daily!
Although the new research is promising, one limitation is that much of it still looks only at synthetic progesterones and equine estrogens (estrogens derived from a pregnant horse). These hormone forms are molecularly different from the hormones we make in our bodies, so drug companies can patent them.
Bioidentical hormones, on the other hand — those that have the same molecular structure as those made in our bodies — are becoming more popular. We’ve always supported the use of bioidentical hormones because we feel they are gentler on the system than synthetics, and a significant and growing body of research is now bearing this out.
Above all, hormone therapy, synthetic or bioidentical, is not the right choice for every woman — because we all have our own unique set of circumstances. Each HRT case should be evaluated individually so women can make informed decisions about starting or continuing bio-HRT on her own terms. We generally recommend women stay on hormones for fewer than five to seven years.
Risks and benefits of HRT — individuality is central
Do the benefits outweigh the risks for you?
Consider these questions while making your decision about HRT:
- Are you less than 60 years old?
- Are you close to menopause and still having symptoms?
- Does your personal or family medical history include breast cancer, endometrial cancer, ovarian cancer, or liver disease?
- Is your quality of life being seriously compromised by your symptoms?
Researchers tell us that the risk profile for hormone replacement therapy goes down in women under 60, women less than ten years from menopause, and women who don’t have a history of breast cancer, endometrial cancer, or liver disease.
Taking a look at whether or not your hormones are still fluctuating is also an important consideration. It is safer to introduce HRT when hormones haven’t tapered off yet. This way, your estrogen and progesterone receptors are still active.
Each woman has a different set of circumstances that determine her personal risk, but based on the new evidence, the safety of HRT is enhanced if the following guidelines are met:
- It is given to younger women (under 60), who are close to menopause and whose hormones are still fluctuating.
- The woman does not have a history of breast, ovarian or endometrial cancer, or liver disease.
- The woman uses bioidentical hormones as opposed to synthetic HRT.
- The woman uses transdermal, transvaginal, sublingual, or “melt” forms of HRT instead of pills that need to be swallowed.
- Hormone replacement therapy doesn’t go on for more than five to seven years.
For a broader discussion of risks, read our perspective on the risks of HRT.
Phytotherapy: a safe and effective alternative
Many of the women who were on hormone therapy in the past were instructed by their practitioners to get off of it. Now, as their bodies have gone for some time without replacement hormones, it’s not a great time for these women to start up again — even though their symptoms are still bothering them. A safe and effective option for these women, and for those who just don’t feel comfortable with HRT, is phytotherapy.
Phytotherapy is the use of plants for healing purposes. Herbs like Black Cohosh, Red Clover, Passionflower, and many others are wonderful alternatives for menopause treatment because they work with your endocrine system to ease symptoms instead of the “sledgehammer effect” pharmaceutical drugs often provide.
Herbs offer a gentler approach to menopause symptoms, which means there’s less risk to you than taking a hormone. Though using herbs for menopause may not provide enough relief for some, we’ve found that 85% of women can find relief from a plant-based product like our Herbal Equilibrium.
Your options for menopause symptom relief
The media can often make it seem like we have limited options when it comes to our health, but if we’re willing to adopt a more holistic approach, the options are endless. Here are just some of the treatment options available.
Diet and lifestyle changes. Diet and lifestyle play a large role in exacerbating menopause symptoms. For some women, adding more protein, high-quality fats, and fresh fruits and vegetables, while limiting refined carbohydrates, sugar, gluten, and highly processed foods can make a world of difference. You may also want to consider supplementing with a quality multivitamin like the one we offer in our Health Programs.
Phytotherapy. Soy, Black Cohosh, Red Clover, Ashwagandha, Wild Yam, and other botanicals can offer satisfying relief from menopause symptoms. You can explore our Herbal Equilibrium, which provides a safe and effective combination of herbs for gentle endocrine support and menopause symptom relief.
Bioidentical HRT (bHRT). Bioidentical HRT consists of hormones made in a lab, primarily from Wild Yam and soy, that are identical to the hormones your own body produces. Bioidentical hormones are available through compounding pharmacies by prescription. For more on how to choose the right bioidentical hormones for you, see our guide to bioHRT options.
Synthetic HRT. Hormone replacement therapy drugs like Premarin and Prempro are the drugs studied in the original Women’s Health Initiative. Premarin is made from the urine of a pregnant horse, while Prempro combines Premarin and a synthetic progestogen. There are also synthetic forms of testosterone. We feel most comfortable with bioidentical HRT, but understand that there are cases where synthetic hormones are a viable choice.
Your body, your choice
Only you can decide what is best for your body. Menopause can be a confusing time, a time when it’s difficult to make decisions (especially if you haven’t slept well in weeks!). But know that there is an option out there for you — and it’s okay to take your time in deciding. We have some customers who don’t mind enduring the symptoms as long as they know there will be an end to them in good time. Others simply can’t perform their day-to-day activities without some relief from their symptoms. Look inside to make your decision, and don’t ever be afraid to ask questions!
1 Hodis, H. 2008. Assessing benefits and risks of hormone therapy in 2008: New evidence, especially with regard to the heart. Cleve. Clin. J. Med., 75 (Suppl. 4), S3–S12. URL: https://www.ccjm.org/content/75/Suppl_4/S3.long (accessed 02.11.2009).
2 Encyclopedia — DukeHealth.org. URL: https://dukehealthsystem.adam.com/content/?productId=10&pid=10&gid=000091 (accessed 02.11.2009).
3 Hofling, M., et al. 2007. Testosterone inhibits estrogen/progestogen-induced breast cell proliferation in postmenopausal women. Menopause, 14 (2), 183–190. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/17108847 (accessed 02.11.2009).
See also:
Ness, R., et al. 2009. Influence of estrogen plus testosterone supplementation on breast cancer. Arch. Intern. Med., 169 (1), 41–46. URL: https://www.ncbi.nlm.nih.gov/pubmed/19139322 (accessed 02.27.2009).
4 Crandall, C., et al. 2008. Increases in serum estrone sulfate level are associated with increased mammographic density during menopausal hormone therapy. Cancer Epidemiol. Biomarkers Prev., 17 (7), 1674–1681. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/18628419 (accessed 02.11.2009).
5 Ursin, G., et al. 2004. Post-treatment change in serum estrone predicts mammographic percent density changes in women who received combination estrogen and progestin in the Postmenopausal Estrogen/Progestin Interventions (PEPI) trial. J. Clin. Oncol., 22 (14), 2842-2848. URL (abstract); https://www.ncbi.nlm.nih.gov/pubmed/15254051 (accessed 02.11.2009).
6 Espeland, M., et al. 2004. Conjugated equine estrogens and global cognitive function in postmenopausal women: Women’s Health Initiative Memory Study. JAMA, 291 (24), 2959–2968. URL: https://jama.ama-assn.org/cgi/content/full/291/24/2959 (accessed 02.11.2009).
Shumaker, S., et al. 2004. Conjugated equine estrogens and the incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women’s Health Initiative Memory Study. JAMA, 291 (24), 2947–2958. URL: https://jama.ama-assn.org/cgi/content/full/291/24/2947 (accessed 02.11.2009).
Shumaker, S., et al. 2003. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: The Women’s Health Initiative Memory Study: A randomized controlled trial. JAMA, 289 (20), 2651–2662. URL: https://jama.ama-assn.org/cgi/reprint/289/20/2651 (accessed 02.11.2009).
7 Henderson, V., et al. 2005. Postmenopausal hormone therapy and Alzheimer’s disease risk: Interaction with age. J. Neurol. Neurosurg. Psychiatry, 76 (1), 103–105. URL: https://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1739309&blobtype=pdf (accessed 02.11.2009).
8 Smith, N., et al. 2008. Effect of progestogen and progestogen type on hemostasis measures in postmenopausal women: The Postmenopausal Estrogen/Progestin Intervention (PEPI) Study. Menopause, 15 (6), 1145–1150. URL (no abstract available): https://www.ncbi.nlm.nih.gov/pubmed/19186375 (accessed 02.11.2009).
Barrett–Connnor, E., et al. 1997. The Postmenopausal Estrogen/Progestin Interventions (PEPI) study: Primary outcomes in adherent women. Maturitas, 27 (3), 261–274. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/9288699 (accessed 02.11.2009).
9 Godsland, I. 2001. Effects of postmenopausal hormone replacement therapy on lipid, lipoprotein, and apolipoprotein (a) concentrations: Analysis of studies published from 1974–2000. Fertil. Steril., 75 (5), 898-915. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/11334901 (accessed 02.11.2009).
10 Canonico, M., et al. 2007. Hormone therapy and venous thromboembolism among postmenopausal women: Impact of the route of estrogen administration and progestogens: The ESTHER study. Circulation, 115 (7), 840–845. URL: https://circ.ahajournals.org/cgi/reprint/115/7/840 (accessed 02.11.2009).
11 Stefanick, M., et al. 2006. Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. JAMA, 295 (14), 1647–1657. URL: https://jama.ama-assn.org/cgi/reprint/295/14/1647 (accessed 03.30.2009).
12 Chlebowski, R., et al. 2003. Influence of estrogen plus progestin on breast cancer mammography in healthy postmenopausal women: The Women’s Health Initiative randomized trial. JAMA, 289 (24), 3243-3253. URL: https://jama.ama-assn.org/cgi/reprint/289/24/3243 (accessed 03.30.2009).
13 Brinton, L., et al. 2008. Menopausal hormone therapy and breast cancer risk in the NIH-AARP Diet and Health Study Cohort. Cancer Epidemiol. Biomarkers Prev., 17 (11), 3150–3156. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/18990757 (accessed 04.20.2009).
Lee, S., et al. 2006. Postmenopausal hormone therapy and breast cancer risk: The multiethnic cohort. Int. J. Cancer, 118 (5), 1285–1291. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/16170777 (accessed 04.20.2009).
Ewertz, M., et al. 2005. Hormone use for menopausal symptoms and risk of breast cancer. A Danish cohort study. Br. J. Cancer, 92 (7), 1293–1297. URL: https://www.nature.com/bjc/journal/v92/n7/abs/6602472a.html (accessed 04.20.2009).
Bakken, K., et al. 2004. Hormone replacement therapy and incidence of hormone-dependent cancers in the Norwegian Women and Cancer study. Int. J. Cancer, 112 (1), 130–134. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/15305384 (accessed 04.20.2009).
Stahlberg, C., et al. 2004. Increased risk of breast cancer following different regimens of hormone replacement therapy frequently used in Europe. Int. J. Cancer, 109 (5), 721–727. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/14999781 (accessed 04.20.2009).
Beral, V. 2003. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet, 362 (9382), 419–427. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/12927427 (accessed 04.20.2009).
Newcomb, P., et al. 2002. Postmenopausal estrogen and progestin use in relation to breast cancer risk. Cancer Epidemiol. Biomarkers Prev., 11 (7), 593–600. URL (abstract): https://cebp.aacrjournals.org/cgi/content/full/11/7/593 (accessed 04.20.2009).
Magnusson, C., et al. 1999. Breast-cancer risk following long-term oestrogen- and oestrogen-progestin-replacement therapy. Int. J. Cancer, 81, 339–344. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/10209946 (accessed 04.20.2009).
Collaborative Group on Hormonal Factors in Breast Cancer. 1997. Breast cancer and hormone replacement therapy: Collaborative reanalysis of data from 51 epidemic logical studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet, 350 (9084), 1047–1059. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/10213546 (accessed 03.30.2009).
14 Fournier, A., et al. 2008. Unequal risks for breast cancer associated with different hormone replacement therapies: Results from the E3N cohort study. Breast Cancer Res. Treat., 107 (1), 103–111. URL (PDF): https://www.springerlink.com/content/x2uu758471t00635/fulltext.pdf (accessed 03.26.2009).
15 Mørch, L., et al. 2009. Hormone therapy and ovarian cancer. JAMA, 203 (3), 298–305. URL (abstract): https://jama.ama-assn.org/cgi/content/abstract/302/3/298 (accessed 07.20.2009).
16 Heiss G, et al., WHI Investigators. 2008. Health risks and benefits 3 years after stopping randomized treatment with estrogen and progestin. JAMA, 299 (9), 1036-1045. URL: https://www.ncbi.nlm.nih.gov/pubmed/18319414 (accessed 06.29.2009).
Stein, R. 2008. Study finds risk of cancer persists after therapy ends. Washington Post. URL: https://www.ajc.com/services/content/printedition/2008/03/05/hormones0305.html (accessed 06.18.2009).
Tanner, L. 2008. Follow-up of landmark hormone study finds new cancers arise. URL: https://www.ajc.com/services/content/health/stories/2008/03/05/hormone_0305.html?cxntlid=inform_artr (accessed 06.29.2009).
17 Koomen, E., et al. 2009. Estrogens, oral contraceptives and hormonal replacement therapy increase the incidence of cutaneous melanoma: a population-based case-control study. Ann. Oncol., 20 (2), 358–364. URL (abstract): https://www.ncbi.nlm.nih.gov/pubmed/19593232 (accessed 08.11.2009).
