By Ken Cohen, MD, FACP, Chief Medical Officer
Until the 1990s, it was thought that hormone replacement therapy (HRT) provided many health benefits to postmenopausal women including prevention of heart disease and osteoporosis. In order to confirm the benefits of using HRT the National Institutes of Health launched the Women's Health Initiative (WHI) study in 1993. Researchers expecting to find that hormones prevented chronic diseases related to aging in women were stunned to discover a small but significant increase in cardiac events as well as increased incidence in breast cancer and stroke. Publication of the WHI results in 2002 raised significant concerns at the time and left women and their physicians wary of using HRT. This resulted in an 80% decrease in the use of HRT among postmenopausal women. Many women experiencing postmenopausal hot flashes and/or vaginal dryness were left with few options other than waiting for the symptoms to settle down on their own.
Fortunately, further evaluation of the WHI results revealed that the risks of HRT differed with age and other patient characteristics. It was determined that in healthy women less than 60 years of age the risk of cardiac events or breast cancer was the same as women not taking HRT. A very small risk of developing blood clots persists in this age group but can be further minimized or even eliminated by how the
HRT is taken. Currently, recommendations from all major women's health organizations support the use of HRT for women with moderate to severe postmenopausal symptoms who are less than 60 years of age without other medical reasons for not taking HRT.
There are two general ways to take HRT; systemically and locally.
Systemic products circulate throughout the bloodstream and to all parts of the body. This can be accomplished as an oral tablet or by injection. Alternatively, topical products such as a patch, gel, emulsion, or spray allows systemic absorption through the skin. All systemic products are considered equally effective for hot flashes and vaginal dryness. Systemic estrogen must be taken with a progestogen in women who have not had a hysterectomy to protect the lining of the uterus. Women without a uterus should use estrogen only products.
Local products when used in low doses affect only a specific area of the body and result in little or no absorption into the bloodstream. They are available as a vaginal cream, ring, or tablet and are primarily used to relieve vaginal symptoms. Local products usually do not relieve hot flashes or other postmenopausal symptoms. Topical systemic and local (nonsystemic) products are believed to cause little or no increased risk of blood clots. This is seen only with oral estrogen products.
Ultimately the decision whether to start HRT for postmenopausal symptoms rests with each woman in consultation with her health care provider. The HRT treatment plan should be individualized to each woman. There is no "one size fits all" approach to HRT therapy. If the decision is to begin HRT, special consideration should be given to specific symptoms experienced, preferred method of taking HRT, duration of treatment, and cost of HRT product. In general, HRT should be taken at the lowest dose that treats the symptoms and for the shortest amount of time.