The Truth About Cancer: A Global Quest - Episode 2
5 Hidden Facts About Hormone Therapy
Considering doctors now know hot flashes aren't just a fleeting inconvenience but can last up to 14 years, finding a way to thrive—and not just muddle through them—is key.
So why are fewer than 5% of women taking a widely available and effective treatment for those hot flashes? We're talking about hormone therapy, of course. Yes, there's more scary info than convincing arguments out there, but now experts both in and out of gynecology say HT can be beneficial. "There are definitely doctors who believe estrogen is dangerous and won't prescribe it," says Lauren Streicher, medical director at Northwestern Medicine's Center for Sexual Medicine in Chicago. "That is not the approach of menopause experts, and it is not supported by science." Even stronger fighting words come from Diana Bitner, medical director of midlife and menopause health services at Spectrum Health Medical Group in Grand Rapids, MI: "Among those who know the data, most of us are going to take it until we die." (!)
Here's what you need to know about the new stance on hormone therapy.
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1. It doesn't always come in pill form.
Think of estrogen as fertilizer and progesterone as weed killer, Bitner says. Throughout the menstrual cycle, estrogen builds up the lining of the uterus, and if you don't get pregnant, progesterone kicks in: "The lawn gets mowed, and you have your period."
After menopause, if you're taking estrogen, you'll need progesterone, too. "If I give you fertilizer, I have to give you weed killer," Bitner says, or you face an increased risk of uterine cancer. (A woman who has had her uterus removed has no chance of uterine cancer, so progesterone isn't needed.) The problem is that a synthetic progesterone called progestin typically used in HT pills or patches seems to increase breast cancer risk in older women. "A lot of us are moving toward the IUD with progestin," Bitner says, "to put the weed killer right into the lawn and less into your system."
While the plan has not been approved by the FDA—yet—many menopause experts couple that progestin IUD with a transdermal estrogen, like a patch, Streicher says, to avoid the risk of clotting. Oral estrogen is processed through the liver, which can make the blood "stickier," Bitner says. That, in turn, increases a woman's risk of blood clots and stroke, perhaps the most well-known hazards of HT. Estrogen from a patch, gel, or spray bypasses the liver, going straight through the skin into the blood.
Women who don't have hot flashes might need only local estrogen, applied to the vagina as a cream or tablet. Local estrogen doesn't help allover symptoms, but it can alleviate dryness and discomfort. "Vaginal estrogen does not enter the bloodstream, so it does not affect the breasts or uterus," says Jennifer Ashton, cohost ofThe Doctorsand a practicing ob-gyn in New Jersey. "Women with a history of breast, endometrial, or uterine cancer, for whom systemic estrogen is generally off the table, should check with their oncologist about whether local estrogen is an option for them."
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2. The early-2000s freak-out was based on misinterpretation.
The recent perception that hormone therapy is bad news comes largely from a Women's Health Initiative study released in 2002, which suggested HT could increase the risk of heart attack, stroke, and breast cancer. Today experts know that the results were overblown. For starters, nearly 70% of the women in the study were over 60. "A woman going through menopause with severe symptoms is not going to be 66, she's going to be 50 or 51, and that's a very different risk profile," Ashton says. In other words, women over 60 have disparate health concerns from 50-year-olds—namely, higher risk of heart disease, stroke, and breast cancer, the same risks HT was shown to worsen.
3. You have to time it right.
The longer you wait to start HT, the more likely it is you'll be facing age-related health problems like clogged arteries or belly fat that increase your risk of complications. For this reason, if it's been 10 years or more since your last period, HT is probably not a great idea. But if you're healthy and it's been 5 years or less since you menstruated, you might be a good candidate for HT. (If you're somewhere in between, your doctor should evaluate your health before writing a prescription, Bitner says.)
Why the 5-years-from-menopause rule? When you look at only 50- to 60-year-old women from the WHI study, HT actually decreased the risks of heart disease and fractures and made no difference in breast cancer risk until participants had been taking it for more than 5 years.
4. Often, the pros outweigh the cons.
Some women are willing to trade an increased heart disease or breast cancer risk for severely needed hot flash relief. This is a risk-benefit calculation each individual woman, along with her doctor, has to make. That might include reevaluating changing risk factors, like gaining weight or developing heart disease. Check in with your doctor yearly about how your personal pros and cons are evolving.
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5. "MD" doesn't stand for "Menopause Doctor."
Calculating that equation can take the expertise of a menopause pro. It's no surprise that women who see an ob-gyn are more likely to use HT than those who just see a primary care physician, as anObstetrics & Gynecologystudy found. Sometimes even a seasoned gyno might not be up to date on the latest HT research. If yours flat-out tells you HT is dangerous without acknowledging differing opinions, search for a specialist, Streicher says.
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