By Dr. Herzl Melmed
There are few areas in medicine where there is as much confusion as regards the taking of hormones after the cessation of menstruation (menopause). This decision is of great importance because in our society a woman at the age of 50 (around the time of menopause plus or minus 5 years) still is only about half way through her adult life with about another 35 years to live. Taking or not taking estrogen can have a profound effect on her quality of life & health.
Hundreds of studies have shown the benefit of estrogen on the heart, brain, bones, vagina & sexual interest & response. Clearly any woman suffering from hot flushes, night sweats, moodiness & irritability, anxiety, insomnia, loss of libido, vaginal dryness should seek help from her doctor. In most cases hormone replacement therapy (HRT) will take care of all these symptoms with or without testosterone added.
There is general agreement that taking HRT for 10 years or till the age of 60 the benefits outweigh any possible negatives. After that it becomes a personal decision for the woman together with her Dr. to decide how long to continue. If a woman has been on HRT since her menopause there are many gynecologists who never take them off, if it is felt that they feel well & their quality of life is positively affected. Certainly yearly breast exams & mammograms are important. No study has ever been done to follow women for life to try & show if the benefits outweigh the risks. Women on estrogen who still have a uterus (never had a hysterectomy) should also take progesterone to prevent excessive thickening of the uterine lining.
There may be a very small risk of breast cancer remembering that breast cancer is the most common cancer in women. The biggest study, the Womens Health Initiative, found that 3 women/1,000 who DID NOT TAKE HORMONES got breast cancer each year & about 4 women/year who took HRT got breast cancer. I extra case /1,000 women is regarded as a small risk. It has been observed by some experts that breast cancer is a very treatable disease. The largest group of cancer survivors in the USA are breast cancer survivors. Other diseases that may be positively affected by estrogen such as heart disease, dementia & osteoporosis are not that easy to treat. A realistic assessment of risks & benefits is therefore very important.
The story becomes more complicated for women who have had breast cancer. The standard recommendation is to stop estrogen & the menopausal symptoms are added to the distress of the other cancer treatments. I am aware of patients who have started estrogen after their cancer has been successfully treated. This is a very important discussion to have with the treating oncologist.
What about “bio-identical” hormones? Most of the products used today & in particular the transdemal patches & gels are bio-identical to what the body produces. It is not an issue in most cases. As for especially compounded formulations it is generally recommended to use the commercial products which are very carefully monitored by the FDA if possible.
In the final analysis the decision to take hormones after the menopause, & for how long, should be individualized. Certainly the fear in some circles about the risks of hormones is greatly exaggerated & many women, their partners, children, co-workers, friends & family suffer unnecessarily by an unwarranted fear of taking them.
Herzl Melmed MD
Fellow of the American College of Obstetrice & Gynecology
Fellow of the Royal College of Obstetrics & Gynecology (London)
e.mail hmelmed@comcast.net