Hormones- Should We Take Them or Not?

Hormone replacement therapy (HRT) for menopausal women has been back in the news. In medicine, we've swung from placing virtually every post-menopausal woman on estrogen to barely allowing even the most miserable, hot-flashing, night-sweating woman to have any (after the Women's Health Initiative- WHI). What's the answer? Is estrogen safe or not?

As always, the devil is in the details. The WHI never said that we shouldn't be using estrogen (and progesterone) for women who had menopausal symptoms (such as hot flashes and night sweats). In fact, this is an excellent use of estrogen, and physicians and patients need not fear the short term (around five years) use of hormones to reduce symptoms as a woman's body adjusts to menopause.

The larger questions are those involving taking hormones as prevention for other issues, such as thinning bones (osteoporosis), heart disease, or dementia. Although earlier studies suggested estrogen helped protect against Alzheimers, there is not enough evidence to support taking HRT for this reason. Estrogen is one of the strongest protective factors for thinning bones, however, so for women at high risk for osteoporosis and bone fracture, there is data to support starting hormones around menopause in this group. Heart disease, however, is another story. The old thinking was that it was estrogen in women that allowed women to have lower rates of heart attacks than men, and therefore HRT might continue that benefit for menopausal women. The WHI study raised the alarm that women on HRT had a higher incidence of cardiovascular events (heart attack and stroke), and therefore confirmed other studies that suggested HRT is not appropriate if given only for prevention of heart disease. This was not new information, but it was magnified in the media and popular interpretation was that HRT is BAD and causes heart disease.

What do we know today? We shouldn't be starting hormone therapy on women who have gone through menopause many years ago. Hormone therapy is best used at the beginning of menopause, and is fully indicated for those women who are complaining of hot flashes, insomnia, night sweats, etc., during this transition time. How long should we use it? About five years. If symptoms flare as the woman tries to go off HRT, go back on for awhile longer and try to taper next year. There are many subtleties that need to be addressed (such as adding progesterone if the woman still has a uterus) but the take home message should be that women need not suffer through menopausal symptoms.

BOTTOM LINE: Estrogen is still the best medication to address menopausal symptoms such as hot flashes, insomnia, and night sweats- talk to your doctor about HRT if you are suffering!

Can Hormone Therapy Prevent Dementia?

As our population ages and more members are developing dementia (primarily Alzheimer's), scientists are constantly on a quest to look for ways to prevent dementia. In the past, we felt the data supported that estrogen ("HRT"- hormone replacement therapy-given to women in menopause) might prevent Alzheimer's. Subsequently, the tide turned and evidence showed that not only did it not prevent, but it may worsen your risk. What do we think today?

A recently published study in the Annals of Neurology, Timing of hormone therapy and dementia: The critical window theory revisited, represents hope and a bit of a compromise. This study suggests that women who take HRT WHEN THEY BECOME MENOPAUSAL (but not later in life) have a significantly reduced risk of developing dementia!

The study was a good size- around 5500 women. Their pharmacy records were used to verify HRT use in their mid-life (average age around 49) and then evaluated again roughly 30 years later, when the women were in their late 70s and 80s. Over a quarter of these women developed dementia (27%) which may sound shocking, but is consistent with the growing incidence of dementia.

The analysis showed that women who TOOK HRT ONLY IN THEIR MIDLIFE had a 26% reduction in their risk of developing dementia compared with women who never took HRT, whereas those who took HRT only in their later life had a 48% INCREASED risk. Interesting, those women that took HRT BOTH midlife and later life had the same risk as those women who NEVER took it.

BOTTOM LINE: Current evidence-based medicine suggests that taking HRT at the time of menopause may DECREASE your risk of developing dementia, but starting HRT late in life can INCREASE your risk. Women, please factor this in when you have your discussion with your physician regarding pros and cons of HRT!