A UVA Heart & Vascular Center Initiative

A New Take on Hormone Therapy

Posted April 03, 2018

Hormone therapy has gotten a bad rap in recent decades, leaving many women hesitant or even fearful to give it a try. But are those fears still warranted? UVA Midlife Health Center Director JoAnn V. Pinkerton, MD, NCMP, thinks not.

“It’s time to change the conversation about hormone therapy,” she says. As Executive Director of the North American Menopausal Society (NAMS), Pinkerton set out to do just that, leading an effort to release a revised Hormone Therapy Position Statement in mid-2017 clarifying the risks and benefits of HT.

Why the Worry?

The new NAMS guidelines are a long-overdo rebuttal to research findings released in 2002 by the Women’s Health Initiative, an effort of the National Institutes of Health to look at health issues of postmenopausal women, which linked the hormone combination estrogen-plus-progestin with an increased risk for heart disease, stroke, blood clots and breast cancer.

The impact of this study was swift and long lasting. Fear and confusion set in among both patients and providers, leaving women with few options to relieve their menopause-related symptoms for more than a decade. Follow-up studies began chipping away at the WHI research findings as early as 2004, but it was a report published just last year in the Journal of the American Medical Association that may have finally shed a positive light on HT.

In this 18-year follow-up of the more than 27,000 patients involved in the 2002 study, researchers found that women taking HT did not have a higher risk of death or chronic illness compared to women receiving a placebo. In short, HT was shown to be safe and effective.

What’s the Catch?

More recent studies have found that, while HT is safe and effective overall, there are many variables to consider. “It’s important for women to keep in mind that there is no one size fits all approach when it comes to hormone therapy,” says Pinkerton.

The risks and benefits vary depending on the type of therapy, the dose used, the duration of use, type of administration — whether it’s a pill or a patch, for example – and especially when therapy is initiated or how old the woman is and how long it’s been since the onset of menopause.

To give women some clarity, the NAMS panel of 23 experts offers the following guidelines:

  • The best candidates for hormone therapy are symptomatic women younger than age 60 or within 10 years of menopause.
  • Older women who begin therapy more than 10 years from the start of menopause have a higher risk of heart disease, stroke, blood clots and dementia.
  • Women at an increased risk for blood clots or metabolic syndrome should not take oral HT but may be candidates for low dose transdermal (non oral) HT.
  • There is no evidence that would suggest women over age 65 already using hormone therapy to alleviate menopausal symptoms should necessarily discontinue hormone therapy. But these women should consult with and be evaluated by a physician as their health risks increase as they age and benefit/risk ratio may change.

“The overarching goal of hormone therapy remains the same,” says Pinkerton. “We want to get the most benefit with the least risk.”

What’s New?

Achieving that goal is now easier than ever thanks to the growing number of options available to treat the symptoms of menopause. “There are now different types of administration and dosages, so we’re no longer limited,” says Pinkerton.

For example, for women with vaginal or bladder symptoms, there are targeted low-dose hormone therapies available that minimize systemic exposure to hormones, lowering the risk of side effects. There are also bioidentical hormones approved by the Food and Drug Administration available for women who are not good candidates for or who prefer not to take synthetic HT.

Created to resemble those hormones produced by your own body, bioidenticals are derived from soy and yams, but these plants must be chemically altered before they can be used by the body, according to the NAMS. There are many FDA-approved bioidentical products that are safe – and often recommended as the best choice for women. The problem is that there are also many custom-made bioidentical products being formulated by compounding pharmacies, which means they are not government-approved or monitored and therefore, are not always safe or effective. (Read more about bioidenticals in this article by Dr. Pinkerton.)

The takeaway: do your research and talk to your doctor about whether you are a good candidate for HT and about the many HT options now available. “The decision to use hormone therapy and which is the best choice of hormone therapy has to be determined by a woman and her provider,” says Pinkerton.

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