Estrogen Replacement Therapy:
Is it Safe?
Are you experiencing hot flashes, decreased libido, or mood swings? This could mean that you are becoming menopausal. Are hormones the answer for you? Some 15 million women were comforted by multiple studies supporting all the benefits of Estrogen and many years of use by happy patients. In 2002, The Women’s Health Initiative (WHI), a collaborative study of 100,000 patients in multiple institutions, changed all of this. It is estimated that 8 million women discontinued their hormone therapy because of concerns about this study. The media blitz was widespread and overwhelming, causing patients and physicians alike to have serious concerns about the safety of estrogen replacement therapy. As a result, the Food and Drug Administration has mandated a “black box warning” on all proprietary hormone product. It states: “Estrogen therapy should be prescribed in the lowest dose and for the shortest period of time consistent with sound clinical judgment and only for the relief of vasomotor symptoms.” Nine years have passed since that announcement with many questions being raised as to the validity of the study. Many authorities have challenged this rigid statement. In order to shed some light on current thinking, I will present several questions that many women are asking, proceeding to answer them based on current research.
Does estrogen cause breast cancer? WHI had many flaws. The initial phase of the study was stopped at five years because of the finding that 8 in 10,000 women developed breast cancer with a combination of Premarin and medroxy progesterone. Estrogen-only users continued another two years. There was no increase in breast cancer in this group. Most breast cancers grow for at least two years before they can become detectable. This incidence of breast cancer is one in eight, whether you take estrogen or not. Some studies have actually shown a lower incidence in mortality in estrogen users.
How long can I safely take estrogen? As long as uncomfortable vasomotor symptoms persist. In order to gain the most benefit from estrogen therapy, it must begin at the onset of menopause and be continued for at least 10 years. Starting estrogen therapy well after the onset of menopause is not recommended because of increased cardiovascular risks. The relief of vasomotor symptoms is dramatic. The other benefits are more insidious. Estrogen helps prevent bone loss. It also prevents urogenital atrophy, or shrinkage and dryness of vaginal tissue. One of the most significant benefits is the potential to alter the progress of dementia or Alzheimer’s disease when started at the onset of menopause and taken for at least 10 years.
What form of estrogen is best and what about “Bio-identical” or “natural estrogen”? Premarin or conjugated estrogen was the gold standard for many years. It is taken in pill form, digested and processed in the liver into a usable form: Estradiol. Estradiol is the only natural and metabolically active form of estrogen. It is the same compound that is produced in the ovary. A newer delivery system called transdermal provides direct absorption of estradiol through the skin or vaginal wall into the bloodstream. It comes in the form of a skin patch, cream, spray, injection or pellets. Transdermal estradiol is thought to provide superior support for the cardiovascular system. It is important to note that the hormone progesterone actually inhibits the beneficial effects of estrogen in some respects. Progesterone, in addition to its use in the reproductive years, is necessary in order to protect the endometrium in postmenopausal women who still have a uterus. It can be given in a phasic manner in order to minimize its deleterious effects. Two other touted forms of estrogen, Estrace and Estriol, offer little benefit. Soy and other phytoestrogens as well as herbal drugs do little to relieve hot flashes or serve any other useful purpose.
The WHI study clearly showed that once the effects of aging take hold and vessels become atherosclerotic, the beneficial effect from estrogen decreases. The actual risk of developing breast cancer is uncertain. Early detection by virtue of annual mammograms and self-breast exam provide the best protection from advanced breast cancer. Estrogen offers many benefits with minimal risks: relief of vasomotor symptoms, alleviation of menopausal symptoms, improved quality of life, prevention of osteoporosis, delay onset of cardiovascular disease, delay onset of dementia and Alzheimer’s disease, reduction in degenerative eye disease, preservation of youthful appearing skin and prevention and treatment of urogenital atrophy.
Dr. Hutchinson is the senior partner at Three Rivers Ob/Gyn. He has over 30 years of experience in this field. Special interests include sexual dysfunction, hormone replacement therapy and aesthetic medicine, including laser assisted fat removal.
Dr. Manly Hutchinson, Jr.
The Hutchinson Center for Aesthetic Medicine
Estrogen Replacement Therapy: