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Menopause And HRT (Hormone Replacement Therapy)- Is It For You?

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  • Menopause And HRT (Hormone Replacement Therapy)- Is It For You?

    Estrogen Replacement Therapy—Is It for You?

    IF YOU are a woman who is confused and worried about taking estrogen after menopause, you have company. ERT (estrogen replacement therapy) confuses many people today, even doctors. On the one hand, you may have learned that estrogen helps prevent heart attacks and protects against bone loss that may lead to terrible fractures. On the other hand, you may have heard that estrogen is linked to cancer of the womb and possibly even to breast cancer.

    You may have been told that the cancer risk is eliminated by taking a second female hormone produced by the ovaries, progesterone, or its synthetic counterpart, progestin. But you may also have heard that progesterone causes menstrual bleeding every month and may cancel the benefits of estrogen to the heart.

    Adding to the confusion, many doctors take strong positions for or against ERT. Writes one doctor in the American Journal of Obstetrics and Gynecology: "We now generally consider that the benefits of estrogen replacement therapy far outweigh its risks. To avoid the problems of estrogen deficiency, [nearly all] women should begin a lifelong course of estrogen replacement therapy during the perimenopausal period."

    Expressing the opposite view, a doctor in Britain with 50 years of experience in cancer research said: "If you mess about with hormones, there is a very real possibility of serious damage. Oestrogen stimulates the tissues to grow and growing tissue is far more sensitive to carcinogenic substances. It is almost impossible to handle hormones safely, so it is better to forget it."

    Menopause and ERT

    When girls reach puberty, at about 11 years of age, their ovaries begin to produce estrogen, a hormone that plays a major role in the development of female characteristics and in the control of the menstrual cycle. About 40 years later, on the average, by the time menopause occurs, estrogen production will have declined to the point that it no longer sustains ovulation and menstrual periods. Eventually the ovaries stop producing estrogen altogether. This may usher in a time of reduced responsibilities, opening the door to new ventures and opportunities and the time to learn and do new things.

    But it is also a time when lack of estrogen may cause both short-term and long-term problems. To counteract these problems, doctors began prescribing synthetic estrogen in the 1940's. By 1975 six million women were taking it. Then came the news that estrogen users were five times more likely to develop endometrial cancer than nonusers. There was also talk of an estrogen link to breast cancer. Enthusiasm for ERT quickly fizzled out. But researchers labored to minimize the risks, and by the early 1980's, the addition of progestins seemed to cancel the cancer risk. ERT then made a comeback worldwide.

    What accounts for its popularity? Elimination of hot flashes, preservation of an active sex life, and a reduced risk of developing osteoporosis and heart disease.

    Hot Flashes, Other Problems

    The hot flash (or, flush), hallmark of the menopause, is a direct result of estrogen loss. A typical hot flash begins with a sudden reddening of the skin over the head, neck, and chest. Accompanying this is a feeling of intense body heat, followed by sometimes profuse perspiration. A majority of menopausal women experience them. For some they are but a mild sensation. For others they are severe and disabling, producing sweat-drenched clothes and sheets and causing socially embarrassing situations and sleepless nights.

    Another result of declining estrogen production is the drying and thinning of the walls of the vagina. In time sexual intercourse becomes uncomfortable, painful, or even impossible. Some women accept these changes as an inescapable consequence of advancing years and assume that their sex life is over. However, vaginal change can usually be prevented or rapidly corrected by ERT.

    One of the most common health problems affecting older women is osteoporosis, a condition wherein the bones become more porous, thinner, and weaker because of the loss of calcium and protein. This leads to broken bones and fractured hips. When osteoporosis becomes severe, a woman might break an arm by merely lifting a casserole out of an oven. She might even break a rib with a sneeze! Everybody experiences bone loss as he or she grows old, but in postmenopausal women the process speeds up because of the lack of estrogen. Women who smoke tobacco and who regularly drink alcoholic beverages are more prone to this problem than those who do not.

    Osteoporosis often develops without warning signs, and people don't know they're in trouble until they fracture a bone. By then it is usually too late to remedy the situation. What about taking large doses of calcium? Without estrogen it does little to curtail the loss of bone. Calcium is important; that is why doctors recommend that women take it along with estrogen. Estrogen helps the body absorb calcium.

    Heart Disease

    In Europe and the United States, the major cause of death in postmenopausal women is heart disease. Does ERT reduce its likelihood? There is strong evidence that it does. It seems that estrogen increases the level of so-called good cholesterol, HDL, in the bloodstream and decreases the level of so-called bad cholesterol, LDL. The Nurses' Health Study followed the health records of 121,700 women from 1976 to 1982. The data showed a 70 percent reduction in the risk of heart disease in current users of estrogen as compared with nonusers.

    Such findings argue powerfully in favor of ERT, but so far we have considered only the positive side. Before you rush to your doctor to ask for a prescription, consider the risks.

    Cancer and Progesterone

    Estrogen, taken by itself, promotes the buildup of cells on the lining of the womb. In time cancer may develop. On the average, 1 in every 1,000 postmenopausal women develops endometrial (womb) cancer each year. For those who take estrogen, the number developing endometrial cancer shoots up to from 4 to 8 in every 1,000. For long-term users of high doses of estrogen, the figure is 10 per 1,000 each year. Some doctors suspect that estrogen is also linked to other gynecologic problems.

    To counteract these risks, doctors prescribe, in addition to estrogen, progestin. Because it inhibits cell buildup in the womb, progestin reduces both the cancerous and the noncancerous problems associated with taking estrogen by itself. Dr. Lila Nachtigall and Joan Heilman, in their book on estrogen, caution: "If you have a uterus, you must never stop taking progesterone unless you stop taking estrogen too. Progesterone is what makes ERT so safe today."

    But adding a progestin carries its own problems. A major complaint is that the estrogen-progestin combination causes the return of menstrual periods. A much more serious problem with progestin is that it may negate the beneficial effects of estrogen on the heart. Another factor in the risk/benefit equation is the effect, if any, of ERT on the likelihood of acquiring breast cancer.

    Since 1974, researchers have conducted at least 30 studies to see if there is any link between ERT and breast cancer. The studies showed no association between short-term ERT and breast cancer. Long-term use was different. Studies in the United States showed a possible increased risk of 50 percent after 15 or more years of ERT. European studies suggested an even higher risk with long-term ERT. Other rigorous studies, however, showed no connection between long-term estrogen use and breast cancer.

    Is ERT for You?

    "It's not yet possible to write up a set of simple rules for estrogen replacement," says Dr. Isaac Schiff of Harvard Medical School. "The decision should be an individualized one, based on thorough, thoughtful, and frank discussion between the physician and patient."

    As an alternative to ERT, some prefer nonprescription or natural remedies. Some women, for example, find that vitamin E and evening primrose oil pills works wonders in easing the severity and frequency of their hot flashes. And whether you take ERT or not, good nutrition and regular exercise are proved allies against both heart disease and osteoporosis.

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