What dose? Pill, patch, gel, or suppository? How to taper off?
For three years, Susan Kirchoff tried all the usual remedies to manage her menopausal hot flashes—exercise, soy foods, herbal supplements. But she still woke up with her nightgown sopping night after night. "My husband thought he was going through it, because I was making him sweat," says the 53-year-old health center director from Portland, Ore. Exhausted and desperate, she talked to her doctor about hormone therapy and her own personal risks: a family history of breast cancer and an elevated platelet blood count, which put her at increased risk of blood clots and stroke. In October, when blood tests revealed a normal platelet count, she decided, "I needed relief." Sure enough, within a few weeks of affixing a dime-size estrogen patch onto her abdomen, Kirchoff's hot flashes ceased. She plans to stay on the estrogen for a few years.
Women like Kirchoff have been frightened away from hormone therapy ever since a large clinical trial called the Women's Health Initiative found seven years ago that the treatments raised the risk of breast cancer, heart disease, and strokes. Prescriptions for estrogen and progesterone—the typical combination regimen that protects against uterine cancer, which can result from taking estrogen alone—quickly dropped (breast cancer rates did too, partly because of this). Today, doctors no longer prescribe hormones as they once did to prevent osteoporosis, clogged arteries, and dementia. Many experts, however, contend that the pendulum has swung too far, leaving women without any effective remedy for severe menopausal symptoms. The WHI study, designed to test whether long-term use of hormone therapy could prevent age-related illnesses, "was never meant to test the effectiveness of hormones for symptoms," says Nanette Santoro, director of Montefiore Medical Center's Institute for Reproductive Medicine and Health. The average age of the participants was 63, more than a decade beyond the average age of menopause (and well past the worst of its annoyances).
So now, after trying unhappily to go without, many of the 40 percent of menopausal women who suffer from severe hot flashes and night sweats are turning to a new way of using hormones—an ultralow dose for as short a time as possible. "The initial drop in hormone prescriptions . . .is now tapering off," says Anne Nedrow, medical director of women's primary care at Oregon Health and Sciences University in Portland, who treated Kirchoff. "We are really filtering out the women that require it for quality-of-life symptom control."
In women just entering menopause, it appears, heart disease risks may be elevated only slightly. One re-evaluation of WHI data found 28 additional cases of heart disease and 28 additional cases of strokes per 10,000 women in their 50s who took the hormone combination for an average of 5½ years; for those in their 70s, the numbers were an extra 134 cases of heart disease and 62 strokes. What's more, a study published in the Journal of the American Medical Association in March 2008 indicates that the small increase in the likelihood of having a heart attack, stroke, or dangerous blood clots associated with taking estrogen and progesterone disappears soon after women go off the hormones—though the increased risk of breast cancer persists for more than two years.
There are, however, a number of issues women need to consider along with their personal health risks: What formulations of estrogen and progesterone to take, and at what dose? How to get the hormones—pill, patch, gel, or suppository—and how long to take them? How to taper off? For Kirchoff, who had had a hysterectomy, Nedrow recommended just a low dose of estrogen in the form of a skin patch, which she replaces weekly at a cost of $30 per month.
For now, research is lacking to guide women and their doctors to the best of the plethora of hormone choices. Scientists still don't know whether one form of estrogen made from horse urine, called conjugated equine estrogen, poses any greater health risks than estradiol, which comes from plants and is identical in structure to the estrogen made by the body. [More details on bioidentical hormones.] And while some studies suggest that women who use a transdermal delivery method, which bypasses the liver, have lower risks of blood clots and gallstones than those who take pills, no one knows for certain.
The ongoing Kronos Early Estrogen Prevention Study, which is randomly assigning patches, pills, and placebos to 720 women ages 42 to 58, is trying to determine if one option is safer and whether estrogen in either form actually protects against coronary artery disease—as well as cognitive decline—if started within three years of menopause. (A handful of previous studies suggest that it might.) "More testing is critical," admits principal investigator JoAnn Manson, a professor of medicine at Harvard Medical School who is one of the study's principal investigators.
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