Hormone Replacement Therapy: Should Women Take It?

Many Experts Say It Helps Bones and Heart; Brain May Benefit, Too

By Elizabeth Tracey, MS
WebMD Medical News

Reviewed by Dr. Pamela R. Yoder

Oct 12, 2000 - When Barbara Finn, 48, started experiencing hot flashes late last year, she sought the advice of her gynecologist. "He started me on Prempro, and I took it for about three weeks," says Finn, an assistant bank manager from Baltimore County, Md. "But I had a lot of trouble with bleeding, and I was so hungry I felt like if I stayed on it I would end up gaining a hundred pounds." Finn stopped taking the drug without telling her doctor, but says the hot flashes seem to be better now.

Like many women across the country who are entering a period of life that health professionals call "perimenopause" -- which means literally "around the menopause" -- Finn was prescribed a type of hormone replacement therapy (HRT) to help ease her symptoms related to hormone loss. And like many women, she had doubts about it.

"My doctor told me Prempro would help with the hot flashes," Finn says. What she wasn't told was that some physicians are recommending that women begin HRT during perimenopause and continue on it for the rest of their lives. One such physician is Sue Zieman, MD, a specialist in geriatrics and heart disease at Johns Hopkins Medical Institutions in Baltimore.

"I use HRT for prevention of both heart disease and osteoporosis, the dangerous thinning of a woman's bones that may increase her risk of fractures as she gets older," Zieman tells WebMD. "While some studies have shown that initially, when a woman starts on HRT, there may be a slight risk of lung or gallbladder problems, I am convinced that the long-term benefits outweigh the risks."

Just what are the benefits, and the risks, of hormone replacement therapy? "That's a very controversial question," says Zieman. "Many, many studies have been done and are under way addressing this issue, but briefly, we are convinced that HRT has a beneficial effect on bone, which we think translates into a decreased risk of fractures as a woman ages. Fractures are associated with disability and death in older people, so reducing them is critical to maintaining health in an older person."

Felicia Cosman, MD, clinical director of the National Osteoporosis Foundation, agrees with Zieman. "There is a lot of good clinical evidence that HRT reduces the amount of turnover we see in bone after menopause, and that it actually helps increase bone mass," she tells WebMD. "What we don't know is if that actually results in fewer fractures.

"Studies have looked at fractures in two places that cause older women problems: the hip and the spine. It appears that spinal fractures are reduced by using HRT, but not [fractures] in the hip. Studies looking at the hip, however, may not have shown an effect because of characteristics of women who participated in the trial. I remain convinced that HRT does help protect bone, and I recommend it to my patients."

Many doctors also prescribe hormone replacement therapy to reduce a woman's risk of heart disease. "HRT originally was prescribed because we observed that a woman's risk of heart disease and osteoporosis increased dramatically after menopause," Cosman says. "It seemed obvious that estrogens, [one of the major] hormones women make that stop being made after menopause, must play a major role. Thus we began replacing estrogens on the assumption that that would have an impact on these two diseases."

Does HRT reduce heart disease? Unfortunately, many studies have failed to show a benefit of HRT in women who already have heart disease. "It's quite possible," Zieman says, "that HRT's most beneficial effect will be in prevention."

"I think the timing of HRT is critical," says Cosman. "It's been viewed as a rather old-fashioned concept that women should start HRT at the time of menopause, because studies have shown a beneficial effect even when HRT is started when women are in their 60s or beyond. And the thought was, why expose women to such prolonged therapy if the benefits could be reaped even when it was started later?

"I think we're now coming to believe that early introduction of HRT will have the biggest impact on outcome, but this is a study that clearly needs to be done."

Why did doctors think delaying hormone replacement therapy might be a good idea? Some studies have shown an increase in breast cancer in women taking the therapy. "I think the fear of breast cancer is much greater than the [actual] evidence suggesting that it may occur more frequently in women taking HRT," Zeiman says. "If one of my patients has a strong family history of breast cancer, I won't usually put them on HRT, but I still might recommend it if they do have a strong family history of osteoporosis or heart disease, or both."

According to Charles Hammond, MD, professor and chair of obstetrics and gynecology at Duke University, this evidence about HRT and breast cancer is conflicting. "Much of the data on breast cancer risk and HRT was gathered at a time when HRT was quite different than it is today," he tells WebMD. "I tell my patients who are concerned about it to make sure they have regular mammograms and do self-examinations, but the idea that they are at increased risk for breast cancer should not prevent them from taking HRT for its other benefits."

According to Hammond, some of the evidence that breast cancer risk was increased in women taking hormone replacement therapy came from an era when only estrogen was prescribed. Prempro, the type of HRT Barbara Finn was taking, is a combination medication containing another type of hormone called progesterone. Today, most hormone replacement therapy involves both estrogen and progesterone, which can be given in various combinations and forms. Women without a uterus are often given only estrogen. But women with an intact uterus need to take both estrogen and progesterone, as progesterone helps avoid buildup of the lining of the uterus, as well as uterine cancer.

Still other research suggests that HRT may reduce a woman's risk of developing Alzheimer's disease. "I find this research very thought-provoking and interesting," says Zeiman. "We're still too early to be able to say with any certainty that HRT helps maintain the brain, but I'm sure those studies will be done."

But what about those women, like Finn, who choose to stop taking hormone replacement therapy, or don't want to take it in the first place?

"Women who elect to stop taking HRT do so for a number of reasons," says Zieman. "Breast tenderness, a feeling of bloating, and weight gain are often reported. Sometimes women complain of bleeding. I usually prescribe therapy that continues throughout the month, without the five days or so off that is usually when most bleeding occurs. Other people advocate for the days off, saying it helps keep the lining of the uterus from building up, but some women who are postmenopausal find the bleeding so troublesome they stop therapy."

Finn, who stopped HRT because of side effects she found intolerable, has investigated an alternative: herbals. "My chiropractor gave me a compound containing the herb black cohosh," Finn says. "She says it's a natural supplement that will help me deal with my symptoms of menopause without taking estrogens. I haven't started taking it yet, but I like the idea that it's natural."

Black cohosh, dong quai, and ginseng are among the herbs that some believe can ease the symptoms of menopause. "Before using an herbal, I remind my patients that such products are entirely unregulated by the U.S. Food and Drug Administration, and, as such, may vary quite a bit from product to product or even from batch to batch," says Zieman. "I would never advocate the use of these products instead of those for which we do have safety and efficacy data.

"I think it's just a matter of time before studies are done on supplements, and that will require their standardization, but until then, I'm not comfortable that they will provide the benefits we're looking for."

Another alternative is soy, which research has shown has effects similar to estrogen. Although supplements are available, most experts suggest that it be taken in the form of food, including tofu.

In the meantime, there are other drug alternatives to hormone replacement therapy that women might consider to help ward off osteoporosis. Medications such as Evista (also known as raloxifene) and a class of drugs called bisphosphonates have shown great promise in helping keep bones healthy.

Says Cosman: "They have been shown to actually help rebuild bone, but we don't have any data looking at how they affect the skeleton if women have been on them for 15 years or more. In my view, HRT and possibly raloxifene should be used for prevention when women are perimenopausal or in their 50s, and the bisphosphonates during the period when we know fractures become more of a risk -- that is, in the 60s and older."

For now, it appears that the decision whether to take hormone replacement therapy or other medications or herbs, or to simply let Mother Nature take her course, must still be individualized -- and a matter of discussion between a woman and her physician.

"I'm always happy to discuss the pros and cons of any therapy with my patients," Zieman says. "I'm convinced that for most perimenopausal women, HRT is safe and effective, but any woman considering such therapy needs to feel comfortable with that, too."