Risks and Benefits of Hormone Replacement Therapy

There is considerable debate on whether or not to treat women in menopause with hormone replacement therapy (HRT). The Women's Health Initiative has given us new insights on the pros and cons of HRT. What we do know from this study is that estrogen with unnatural progesterone called Provera or medroxyprogesterone does not help prevent Alzheimer's disease, heart disease or stroke. It does slightly increase the risk of breast cancer. It also significantly decreases the risk of osteoporosis and the risk of colon cancer. Estrogen without the combination of Provera in the form of Premarin (oral estrogen) in the six year study has shown no increased risk of breast cancer. It is too early to tell whether or not it has benefits for preventing Alzheimer' s disease or heart disease. Long-term studies have shown that estrogens prevent heart disease after five to six years of treatment, short-term HRT increases a woman's blood clotting ability and thus increases her risk of heart attack and stroke in high-risk patients. For that reason, we screen all women for heart disease before they begin HRT. It is prudent for most women to start taking 81 mg of aspirin seven days before they take their hormones for the first time. We know that estrogen protects women from osteoporosis, colon cancer, premature atrophy of the genitourinary system including the breasts, and the skin in general. It certainly reduces menopause symptoms such as hot flashes and mood swings.

Previous studies have shown that medroxyprogesterone has negative health consequences in women, and certainly the Women's Health Initiative has given us confirmation. It certainly seems logical to use natural progesterone in the treatment of menopause. "Natural" progesterone is the same chemical structure that is produced by the woman's ovaries and adrenal glands. During pregnancy, a woman's progesterone level can rise to 300-400. We usually keep progesterone levels around 6 in women on HRT. Research has not shown that progesterone has caused any of the complications seen with medroxyprogesterone. Long-term research is lacking. Pharmaceutical companies cannot obtain a patent on natural progesterone, therefore, it is unlikely that a large amount of money will be spent on this compound. The three most common ways that women take natural progesterone are Prometrium which is made by a pharmaceutical company. Insurance companies usually pay for it. It is micronized to help the absorption. They may also obtain natural progesterone from an apothecary such as Nora Apothecary or Meridian North. This must be compounded by the pharmacist and is usually used in women who absorb too much of the micronized progesterone in Prometrium. Unfortunately many insurance companies do not pay for medications from an apothecary. Women may also use progesterone cream. They apply the cream to the soft skin of the upper inner arms and thighs once daily. Whether or not a women wants to take HRT is her personal decision. Logic tells me that if a woman is taking hormones and she has side effects such as breast tenderness, increase in breast density, a decreased sense of well-being, she should not be taking the hormones. However, if women have no increase in breast density or tenderness, no change in a mammogram and they have improved sense of well-being, I would consider the benefits of HRT over the theoretical risk.