Hormone Therapy After Menopause -- Susan Love, MD -- 03/18/03

Last Editorial Review: 10/23/2003

By Susan Love
WebMD Live Events Transcript

Whether you are undergoing hormone replacement or weighing the risks of starting, find out what the latest news means for you. Susan Love, MD, joined WebMD Live to discuss another chapter in the HRT debate.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Hello Dr. Love. Welcome to WebMD Live. Menopause and HRT -- when did menopause become a disease and how did we get into this mess?

Love: It really is a good question. And because of the past misunderstandings about how menopause works there are several areas.

First of all, we thought that the ovaries stopped working at menopause. They shriveled and dried up and became useless, sort of like what we thought happened to post-menopausal women. But, in fact, the ovaries keep making hormones at a lower level well into your 80s. It's just that we didn't have a test that was sensitive enough to measure it before, so we assumed that it wasn't happening. Which meant that we also assumed that women who had gone through surgical menopause were exactly the same as women who went through natural menopause. And we then used animals that had been castrated as a model to study menopause.

Now we know that there is a big difference between taking out your ovaries and going through a natural menopause. Indeed, we also thought that menopause was a disease -- estrogen deficiency disease. But if it's a disease, then all women have it! It seems a little crazy to term something that happens to all women as a disease. Menopause is programmed in. It's normal. It's supposed to happen. We need high levels of hormones to reproduce, and then we shift down to lower levels for the second part of life. But if you think of it as a disease, you end up thinking you need to treat it, or replace what's missing. And that led us to the hormone replacement (HRT) idea.

The other problem, once we started thinking this way, was that we did studies that were observational. What that means is that you looked at women who were taking hormones, for whatever reason, and compared them to women who were not taking hormones. And the women who took hormones, indeed, had less osteoporosis, less heart disease, less colon cancer, fewer strokes, less Alzheimer's, fewer car crashes, fewer bankruptcies, than the women who didn't take hormones.

It turned out that the women who took hormones were at higher socioeconomic levels, more educated, more likely to go to the doctor, more likely to exercise, more likely to eat a good diet, and to treat their high blood pressure than the women who weren't on hormones. So you never really knew whether hormones made you healthy, or whether healthy women took hormones, until you did a study that had the same number of couch potatoes in each group.

The Women's Health Initiative is that kind of study. It's actually very large. But one part of it looked at 16,000 women who are post-menopausal and randomized them so that half took estrogen and progestin, and half took a placebo. After five years they found, much to everyone's astonishment, that the women taking hormones had more heart attacks, more strokes, more blood clots, and more breast cancer than the women taking the sugar pill. They also had slightly fewer fractures and less colon cancer. But in no situation was the benefit higher than the risks.

The study that came out today looked at this same group of women to see whether the hormones at least improved the quality of their life, because many of the proponents of HRT have said, "Yes, but women feel so much better." Looking at 16,000 women they found no evidence of an improvement in the quality of their lives, including such things as having their brains work better, sleeping better, depression, sexual functioning, or just general feelings of well-being. So most women probably do not feel any better on HRT than not.

The one proviso is that most of the women in this study did not have severe symptoms, because women who really had severe symptoms would not agree to be randomized to a sugar pill. So you could argue that in those women with severe symptoms, HRT may still have a benefit. But the symptoms of menopause only last a few years. So they would only need to take hormones for a few years and should take the lowest dose possible.

Moderator: Would you prescribe HRT for one of your patients under any circumstances?

Love: Yes. Most women do not have severe symptoms. 30% of women have no symptoms of menopause, and another 30% have symptoms but they're not so bad that they feel like they have to do something about them. But there's another 30% who really are suffering. And for those women it is not crazy to take hormones for a short period of time if they have not had breast cancer. They should take the lowest dose available, which is usually lower than they think. We used to say that .625 milligrams of estrogen was the lowest dose. But now you can get .3 and even .15. So you want to get on the lowest dose that will work for you, and you only want to take it for three to five years.

The big question is how do you get off of it? What about women who have had hysterectomies and have been on it for years? Those women who have been on it for a long time really need to get off of it. The risk of hormones is higher the longer you've been on it. The trick to getting off is not to stop cold turkey. You want to taper off gradually over six to nine months or even longer, and then you won't have symptoms. People have thought that the symptoms would last forever, but that is not the case.

If you're on a pill, you can alternate one pill with half a pill, and do that for a couple of months. Then you go to half a pill a day, and do that for a couple of months. Then do a half pill every other day, and do that for a couple of months, and slowly get yourself off. If you're on the patch, it's even easier. You just cut a little wedge out of the patch. Then you wear it the same way that you have been except the wedge is cut out. After a month or two, cut a bigger wedge out. Gradually, you will only be wearing a little sliver of a patch. That's it.

Moderator: Let's take some questions.

Member: I am 42 years old and had a radical hysterectomy two weeks ago for endometrial cancer. I am concerned about going through menopause at such an early age and want to know if I should take HRT at least for a time. My oncologist says yes; my ob-gyn is anti-HRT and so I am torn.

Love: Most women who have had a hysterectomy at a young age probably should take estrogen until they reach the age of a normal menopause. Your situation is a little different because of the endometrial cancer. And there is still some controversy as to whether someone who has had a

cancer that is caused by estrogen should take estrogen. There are ongoing studies looking at this. But it is controversial as to how safe it is. This is probably why you're getting mixed messages from your doctors. You're going to have to decide for yourself which answer feels more comfortable to you, as we don't have a definitive answer at this time.

Member: I am having a lot of hot flashes, and I am up six to seven times a night; would short-term HRT be good for me?

Love: If you haven't had breast cancer you might want to consider it. It really does work to get rid of hot flashes.

Moderator: Are there alternatives you could recommend for dealing with hot flashes?

Love: Yes. There are alternatives. One is called Remifein, which is a form of black cohosh. It's not estrogenic and has been studied and shown to reduce a lot of the symptoms of menopause. The problem is that it can take up to six weeks for the effects to kick in. So if you need a quick answer, HRT is a better choice.

If you're going to start HRT for the hot flashes have your doctor start you on the lowest level, and then only increase it if a low level doesn't work. This is sort of the opposite of the way we used to do it, where everyone got the same dose no matter what, and only if they had problems with that dose then it would change. But we think lower doses may be safer. We haven't proven it, but that's what we're hoping.

Member: Hi Dr. Love. What do you think of the progesterone creams?

Love: Progesterone creams are a problem, because they're certainly not as safe as Dr. Lee would have you think. In the Women's Health Initiative women who were on both progesterone and estrogen had much more breast cancer than women who just take estrogen alone. So the notion that taking progesterone to balance out your estrogen will prevent breast cancer is not correct. It also has not been shown to prevent osteoporosis, in the one randomized study that has been done.

Having said that, it does help with hot flashes. So short-term use, for a year or two, for hot flashes may be OK. But as with all hormones, long-term use probably is not a good idea.

Moderator: What other remedies can you suggest for symptoms such as vaginal dryness, urinary incontinence, and low libido?

Love: First of all, let's talk about vaginal dryness. This is not uniform. Only about 10% of women get vaginal dryness. But if you have it, it can be a real problem. It turns out that HRT is not the best solution for this. You'll do better with a local cream or application of estrogen directly to the vagina. And there are now two forms available: One is called Estring, which is a vaginal ring that is inserted into the vagina and will last three months. It works very well. It releases only a small amount of estrogen, so it's safe, even in women with breast cancer. The other is Vagitab. It is a tablet. The vaginal creams are not very good because the estrogen is very well absorbed, and you get high systemic levels.

If the vaginal dryness is not too bad, there are alternative products, like Replens, which can help increase the water level in the lining of the vagina, and make it more lubricated. There are also lubricants, like Astroglide, which just makes things more slippery. I think it's worth having Astroglide on your bedside table, just because it looks like you're having a good time, even if you don't need it.

As to urinary incontinence, or losing urine, recent studies have shown that HRT makes it worse. You are better off with biofeedback or kegel exercises, where you strengthen your vaginal floor in order to better be able to hold on to your urine.

Finally, there is libido, which is a real problem. HRT does not help it, because it doesn't seem to be related to estrogen. There are some formulations of testosterone that have been used for this with mixed effects. And it's important to recognize that we don't know whether testosterone is safe. This is an area that really needs some more research. But there are no magical answers.

Moderator: So does HRT help with anything besides hot flashes?

Love: HRT will help hot flashes and night sweats and so far that seems to be about it. We don't even have good data to suggest that it will make you look younger. In fact, if you read the package insert (if you are old enough to take it, you cannot read the package insert, so get out a magnifying glass :)) it says, "will not make you look younger, will not help your skin," all of these myths that we have been told have been shown not to be true. When something sounds too good to be true, it usually is.

Moderator: And there are alternative remedies for hot flashes and night sweats for most women, it seems as if HRT really has little place in women's healthcare.

Love: Most women probably don't need HRT. But there are some women whose symptoms are so bad that the alternatives won't work for them. And I don't believe women should suffer. Short-term use in the lowest dose that they can get away with for those women is fine.

Member: Are all these suggestions in your book, Hormone & Menopause?

Love: Yes. The new revised edition has just come out and has all the new information and all of the suggestions in it as well.

Moderator: Dr. Love, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Love: Although the media is very prone to point out how confused we are by all of this new information, I think that we really should be cheering. We finally are doing studies to tell us what is safe and what isn't safe; what works and what doesn't. So we actually are getting data on which to base our decisions. This is terrific. But be forewarned that these studies we've talked about today may not be the last word. Medicine is a work in progress. And as we do more research we figure it out better. At any one time, we are only giving you our best guess at the moment and that may change.

There are a lot of ongoing studies looking at issues of menopause and menopause in older women. We will be back talking about this over and over again in the next few years. Thank God we'll have new data, and we'll have actual facts to use to figure this out.

Moderator: Our thanks to Dr. Love for joining us today. For more information, please read Dr. Susan Love's Menopause & Hormone Book and visit her on the web at www.SusanLoveMD.com.

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