Menopause: Study lists the benefits of hormone replacement therapy

A research review published today in the Canadian Medical Association Journal recommends hormone replacement therapy (HRT) as a first-line treatment for menopausal women who don't have risk factors.

Symptoms of menopause can begin 10 years before the onset of menopause and can last more than 10 years. The symptoms can reduce the quality of life for many women.

"Although many treatments exist for menopausal symptoms, fears around the risks of menopausal hormone therapy and lack of knowledge regarding treatment options often impede patients from receiving treatment," the authors wrote.

"Despite early concerns of an increased risk of cardiovascular events with menopausal hormone therapy after the Women's Health Initiative trial, increasing evidence shows a possible reduction in coronary artery disease with menopausal hormone therapy among younger menopausal patients, specifically those who start menopausal hormone therapy before age 60 years or within ten years of menopause," the authors added.

Dr. Samantha Dunham, the co-director of the Center for Midlife Health & Menopause in the Department of Obstetrics & Gynecology at NYU Langone Health in New York, points out there has been a change in terminology.

"For the sake of clarity, the term ‘hormone replacement therapy’ (HRT) is now known as ‘menopausal hormone therapy"‘ when hormone therapy is given to patients in menopause," she told Medical News Today. "We still use the term ‘hormone replacement therapy’ for patients who have premature ovarian insufficiency, which is when the ovaries stop making estrogen before age 40, or for patients that have early menopause due to surgery, radiation or chemotherapy and take hormones for menopausal symptoms."

In the 1960s, HRT became popular and was approved by the Food and Drug Administration (FDA) for the treatment of menopause.

It was initially used for hot flashes, but in 1988 the prevention of osteoporosis was added as an approved condition.

Some in the medical community said HRT could help reduce the incidence rate of cardiovascular disease. However, the FDA would not approve it without further testing. A clinical trial found that coronary events increased, but then decreased in subsequent years.

A study published in 2002 found that women with a uterus had an increased rate of coronary heart disease and breast cancer. It was thought that the risks outweighed the benefits. A further study was stopped because of a small risk of ischemic stroke.

The use of HRT greatly declined.

The study in the Canadian Medical Association Journal says that HRT doesn't cause other health problems and is safe when used as directed.

Dr. G. Thomas Ruiz, the OB/GYN Lead at MemorialCare Orange Coast Medical Center in California, says the new study helps clear things up.

"I believe the benefits far outweigh the risks," he told Medical News Today. "Previous recommendations were based on a flawed study. Today, there are patches and creams that are bioidentical to a woman's estrogen. If a woman has a uterus, she needs progesterone and estrogen. If she no longer has a uterus, she doesn't need the progesterone."

Hormone therapy steadies the levels of estrogen and progesterone in the body, according to the National Institutes of Health. The institutes says it is an effective treatment for hot flashes in women who can use it and can also help with vaginal dryness, sleep, and maintaining bone density.

"I am glad this information is coming out," Ruiz said. "Especially for older women who are sexually active. Using HRT can make sex more comfortable. Estrogen creams work locally, so when they are used in the vaginal area, they work there and don't cause problems elsewhere in the body."

"For women who are perimenopausal, I let them know this is a good time to start researching to decide if HRT is right for them," he added.

Experts say hormone therapy can improve the quality of life for women.

"I do recommend hormone replacement therapy (HRT) for patients after a detailed review of their symptoms and a discussion about the risks and expectations from therapy," Dr. Adi Katz, the director of gynecology at Lenox Hill Hospital in New York, told Medical News Today. "HRT helps improve the quality of life of many patients and is reasonably low risk if started early during the menopause/perimenopause years."

Before starting hormone therapy, a thorough physical and discussion about medical history and symptoms are required.

"Hormone replacement therapy recommendations are based on the symptoms and medical history of an individual patient, their family history, and overall health," said Dr. Monte Swarup, FACOG, an OB/GYN in Chandler, Arizona, and founder of HPD Rx.

"The decision to use HRT depends on understanding the potential risks and the benefits," he told Medical News Today.

Some of the benefits include:

"The benefits of HRT generally outweigh the risks when a woman is prescribed and cared for by a menopause healthcare practitioner," Dr. Sherry Ross, an OB/GYN and women's health expert at Providence Saint John's Health Center in California, told Medical News Today.

Dunham agrees.

"I often do recommend HRT to treat the symptoms of menopause because the benefits of HRT are well known, and for most women, the benefits outweigh any risks," she said. "It is the most effective treatment for many symptoms of menopause, as the symptoms are often related to a loss of estrogen production from the ovaries. In addition to treating symptoms, we know that HRT reduces the risk of fracture later in life, and HRT also treats the genitourinary syndrome of menopause."

Previously, studies showed an increased risk of breast cancer in women taking HRT. It is now thought that the risk is lower in women in their 50s and those who start the therapy in the first 10 years of menopause.

The authors of the new report also note that some studies show an increased risk of ischemic stroke in women older than 60 who start HRT 10 years after the start of menopause. For women younger than 60, the risk is low.

"There is a small increased risk for coronary artery disease for older women using hormone replacement therapy," Swarup said. "The risks and recommendations are based on the patient's age when they start HRT and existing medical conditions."

Because there is a potential for increasing the risk of coronary artery disease, experts say this must be taken into consideration.

"Increasing evidence does shows a possible reduction in coronary artery disease when HRT is started close to menopause. It seems like timing is key," Dunham said. "Most women around 50 years old do not have an elevated risk of coronary artery disease (CAD)."

"For patients with an elevated risk, we calculate that risk using a digital risk estimator, and we have a discussion, she added. "The risk of cardiovascular disease is based on factors like age and race, their blood pressure, and their cholesterol values, as well as if they have diabetes, if they smoke, and if they take medicine for high blood pressure. Patients with active CAD or a history of CAD are not candidates for estrogen therapy."

Based on medical conditions, experts say some women should not take hormone replacement therapy.

"Those who should not take HRT include those with a personal history of breast, ovarian or endometrial cancer, a strong family history of breast cancer, a history of blood clots, stroke, heart disease, liver disease or untreated high blood pressure," Ross said.

"Ideally, it is best to use HRT for the shortest amount of time at the lowest dose, especially if a woman is under 60 years old or within ten years of being diagnosed with menopause," she added.

There are nonhormonal therapies for women who do not want to take HRT.

Harvard Health lists the following options:

"Acupuncture and relaxation techniques, including mindfulness, biofeedback, hypnosis, cognitive behavior therapy, yoga, and Tai Chi, may be helpful in controlling mood swings, depression, anxiety, hot flashes, and other mild symptoms of menopause," Ross said. "Certain researched herbs may combat menopausal symptoms and improve quality of life. These herbs include passionflower extract, chasteberry, ashwagandha, Ginkgo biloba leaf extract, and maca root. Use these herbs cautiously and, under the care of an Eastern medicine specialist, who can safely navigate these treatment options."

Medical professionals say they understand that there are many factors that can contribute to menopause. Stress, insomnia, life events, diet, weight, and a sedentary lifestyle all work to negatively affect overall health.

"All patients should try modifying their lifestyle and identifying triggers of hot-flashes (caffeine, wine, diet)," Katz said. "Regular exercise also helps regulate hormones and menopause symptoms. There are non-hormonal medications that work on the brain that can help decrease the frequency and intensity of menopause symptoms. They are less effective than hormonal therapy but work well."