What Are The Risks And Benefits Of Hormone Therapy
When deciding on using hormone therapy, there are often a lot of questions that come up for women. Is using hormone therapy (HT) safe? How long can I take hormones? Does treatment just delay the inevitable? What type of hormones should I take? The answers to these questions are not the same for each person – which is why individualizing treatment is so important. Each woman has a unique past medical history, a diverse range of symptoms, prior risk factors and personal goals of treatment, which have to be taken into consideration to provide optimal care.
Over the past 20 years there has been much research as well as controversy, around the risks and benefits of HT. Fortunately for women in 2020, we have a lot more information and choice of treatment options than our mothers and grandmothers did.
Here is what we know today:
- Relief of menopausal symptoms – Hormone therapy is the most effective treatment of menopausal symptoms. These include hot flashes, night sweats, as well as menopause related sleep disturbances, mood changes, palpitations, dry skin, hair and decreased libido. Exercise, diet, managing stress and taking certain supplements can all help with menopausal symptoms, but women who have more severe symptoms, often need the addition of HT for optimal management.
- Relief of painful intercourse that results from vaginal dryness – With lower estrogen, many women experience thinning of the vaginal tissues resulting in decreased elasticity, and increased pain and tearing with intercourse. This can be treated effectively with vaginal estrogens.
- Decreased urinary symptoms – During menopause, hormonal changes in the vagina and pelvic floor during menopause can result in increased urinary frequency, urinary tract infections and incontinence. Many women experience improvement in symptoms with vaginal estrogen.
- Decreased risk of fracture and development of osteoporosis – HT protects against the rapid bone loss that occurs when hormone levels decline in menopause. Thus, bone mass is sustained for a longer duration while on hormone therapy and can lower the chance of fractures.
- Decreased tooth loss – HT helps keep bones strong that hold teeth in place.
- Improved mood and vitality – In some women, changing or declining hormone levels can often have dramatic effects on mood, energy and stress tolerance. Studies have shown an overall sense of wellbeing and quality of life in women using HT.
- Decreased risk of colon cancer – Studies show that HT is strongly associated with a significant decreased risk in colon cancer. Estrogen receptors are present in the colon and it is thought that estrogen helps in the inhibition of cancer progression.
- Decreased risk of diabetes – Estrogen improves insulin sensitivity and thus, lowers the risk of the development of diabetes and central weight gain.
- Improvement in joint pain –Joints contain estrogen receptors, so the presence of hormones, protects the structure, function and lubrication of the joint. Without lubrication the cartilage degrades and the joint becomes inflamed.
- Overall decreased death rate and decreased risk of heart disease – For women who initiate therapy between 50-59 and are on long-term therapy, studies have shown that HT can mitigate the risks of heart disease and can provide protective measures for good heart health.
Breast Cancer – This is the most talked about and most feared risk factor when discussing HT. However, research has shown that the first 5 years of using HT are very safe with regards to breast cancer, with only an additional 2 cancers per 1000 women. With 10 years of use, the risk increases to an additional 6 cancers per 1000 women. What is not commonly known, however, is that lifestyle plays a much more significant role in breast cancer risk. Looking at the table below, we can see that 2 glasses of alcohol increase breast cancer risk by an additional 27 cancers per 1000 women, and that lack of regular exercise also carries a similar risk! In comparison, the risk of using HT for 15 years still carries a much lower risk of breast cancer than several other lifestyle risk factors.
Risk Factors for Breast Cancer
*Baseline or basic risk applies to all women and is due to factors that cannot be controlled (e.g., aging, gender)
Heart Disease – Information on HT and heart disease has evolved over the last 2 decades. There seems to be a “critical window” of time to start HT to optimize cardiovascular health benefits and minimize risk. Women who start HT in their 50’s, or within the first 5-10 years of menopause appear to have a lower risk of heart disease than women not using HT. In contrast, there is an increased risk in women who start HT after 10 years of menopause, although this risk declines over time.
Overall, we do know that estrogen has many positive physiologic effects on the cardiovascular system and can be protective.
Stroke: HT is associated with an increase risk in stroke in older women. Studies show that there is no increase stroke risk when using HT within the first 5 years of menopause. In addition, this risk of stroke appears to lessen when using transdermal estrogen (i.e. through the skin)
Gallstones: HT has been seen to slightly increase the risk of gallstones or gallbladder problems. This is uncommon and is found less with transdermal estrogens.
Choosing the Type and Length of Treatment:
Bio-identical hormones are hormones that replicate the same molecular structure as our own hormones. In our body, they fit like a lock and key, thereby creating the same physiologic effects as our own hormones. Luckily we have many bio-identical hormones options that are pharmaceutical grade and are readily available. Sometimes, depending on symptoms, the dose required and patient preference, bio-identical hormones have to be customized and created by a compounding pharmacist to tailor to the patients needs. A wide array of gels, patches, creams and oral tablets, are available to customize treatment for each woman.
When choosing to treat menopausal symptoms with HT, it is important to reflect on a few questions:
- How is my quality of life affected by my menopausal symptoms?
- Am I looking to treat my symptoms alone, or to optimize my aging and disease prevention?
- What is my osteoporosis risk and cardiovascular risk versus my breast cancer risk?
- Are there things I can change in my lifestyle to reduce my risk?
- What are my goals of treatment?
The decision to use HT therapy, and how long to continue, has to take into account these types of questions and more. For example, a woman who has severe menopausal symptoms, a strong family history of osteoporosis, and a low risk of breast cancer may choose to stay on HT for 10 years or more for her quality of life and bone protection. In contrast, a woman who has high risk factors for breast cancer may choose to use HT for only the first 2-5 years of menopause to help her with the most troublesome symptoms of the menopause transition. Another woman may not have severe hot flashes, but may choose to continue HT for the improvement in her mood and libido that have been significantly affected by changes in menopause.
Most importantly, women make better decisions when they are empowered with knowledge, understand the goals of treatment and are involved in the decision-making process. Having an in-depth risk assessment and a conversation with a knowledgeable health practitioner allows a woman to be well informed and confident about her choices.
By Dr. Nishi Dhawan, MD
Westcoast Womens Clinic