While hormone replacement therapy (HRT) can benefit women experiencing menopause, a major clinical study recently indicated that it should not be used solely to reduce a woman’s risk of developing heart disease. Last year’s report from the National Heart, Lung and Blood Institute’s Women’s Health Initiative (WHI) study determined that HRT actually increased the risk of developing cardiac problems for some women. This contradicted previous studies that initially indicated HRT could reduce a woman’s risk for heart disease by as much as 50 percent.

“Last summer’s findings were a bit of a surprise. Many of my patients were on HRT and were naturally worried about the implications,” says Rolf Andersen, M.D., of The Heart Group. “From a cardiologist’s point of view, there was no longer any reason for a woman to be on HRT for heart health because it does not reduce risks associated with cardiovascular disease. There are other medical choices and lifestyle decisions that can significantly lower a woman’s risk of developing heart disease.”

 

In general terms, hormone replacement therapy involves the combined use of estrogen and progestin to replace the hormones that a woman’s body ceases to produce after menopause. Menopause occurs when a woman permanently stops having menstrual periods, thus resulting in a change in hormone production. Hormonal changes can produce multiple associated side effects and can also elevate a woman’s risk of developing osteoporosis and heart disease, in particular.

Many women took HRT to reduce their risks of developing health problems—like heart disease—and to provide relief from symptoms of menopause, including hot flashes, sweating, sleep disturbances, increased urinary tract infections and other gynecological conditions.

As Tatjana Sljapic, M.D., of Heart Specialists of Lancaster, explains, “In addition to discontinuing HRT, if a patient in menopause has risk factors for cardiovascular disease that are well-defined (like family history of heart disease, smoking, high blood pressure, high cholesterol), then overall risk modification such as smoking cessation, high blood pressure and cholesterol-lowering medications, if needed, are paramount.”

For some women on HRT, the WHI study raised significant questions. Sunil Patel, M.D., of Cardiac Consultants, says that women asked questions like “I am taking HRT for menopausal symptoms, should I stop taking it? I am taking HRT for osteoporosis, should I take it? I have taken HRT for four years or more, should I continue?” Dr. Patel’s advice is simple, “HRT should not be initiated for the sole purpose of primary or secondary prevention of cardiovascular events.”

Dr. Sljapic adds, “At this point, many physicians believe that the only acceptable use of HRT is for the short-term relief of several menopausal symptoms.”

One benefit of HRT is in the prevention of postmenopausal osteoporosis. HRT can reduce the risk of spine and hip fractures by 34 percent, says Richard W. Reese, M.D., Lancaster Rheumatology Associates. The Food & Drug Administration recommends that women needing relief from menopausal symptoms should use HRT in low doses for short amounts of time. “When considering HRT for prevention of osteoporosis, it’s important to consider all available medications prior to making a decision,” he says.

Dr. Andersen says that while many of his cardiology patients stopped HRT, others felt that the benefits were worth continuing. “Some women feel absolutely horrible off it and would rather take the risks associated with HRT,” he says.

The American Heart Association addressed the issue on their Website stating that for some women “using estrogen plus progestin for short-term relief of menopausal symptoms may be worth the small absolute increase in risk for heart disease…”

John Eichenlaub, M.D., OB-GYN of Lancaster, serves as Department Chairman and Acting Medical Director of Obstetrics and Gynecology (OB/GYN) at Lancaster General Hospital (LGH). Dr. Eichenlaub recommends that patients “consider all factors, including family history of heart disease and breast cancer, personal symptoms of menopause, bone health and personal fears. For women without risk factors, HRT could be appropriate to prevent osteoporosis or relieve menopausal side effects.”

Some women who stopped HRT reported that the side effects of menopause were minimal and that they did not need alternative forms of relief. Other women have opted to take different medications or try natural alternatives to minimize their risks of developing heart problems and to diminish uncomfortable side effects associated with menopause.

While HRT did receive some negative press as a result of the WHI study, the therapy has definite and multiple benefits that continue to merit further investigation. Dr. Patel says that newer generations of HRT that are being studied have had positive initial reports, although the studies are still preliminary. Dr. Sljapic also says it is important to have sufficient clinical trial data before assuming the safety level of any type of treatment.

“Menopause management is not a one-size-fits-all proposition,” explains Christine Stabler, M.D., LGH Family & Community Medicine. “A woman should meet with her physician and outline her health risks, symptoms and lifestyle. Hormones are not the only solution, but may play a valuable role in symptom management, especially for women who experience menopause at a younger age.” Dr. Stabler adds a reminder that the only part of the WHI study that was terminated was the estrogen plus progesterone group. “Women receiving estrogen alone (women with a hysterectomy) are still being studied,” she notes.

Women with additional questions about what to expect when they reach menopause can meet with a certified menopause educator at the Lancaster General Women & Babies Hospital. Individual and group counseling programs are available. A Menopause Discussion Group offers an opportunity for women to share information, concerns and learn about specific aspects of midlife changes. For information on both of these programs, please call 290-3779.

For more information about HRT, please consult with your family doctor, OB/GYN or cardiologist or visit our on-line Health Library.