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.
At the moment, doctors are following the recommendations of the Food and Drug Administration: Prescribe the smallest dose that relieves a woman's symptoms, and do it for the shortest time. While in the 1990s doctors typically prescribed a 0.625-milligram dose of estrogen and sometimes as much as 5 mg for five to 10 years or more, they now generally start with just 0.3 to 0.5 mg and give it for months or up to a few years. Kirchoff is using a patch that delivers just 0.015 mg of daily estrogen, the lowest dose on the market. Doses of progesterone haven't changed much.
The question of how long a woman can safely be on hormones is a thorny one. There's just no "risk-free interval," says Adriane Fugh-Berman, a professor of family medicine at Georgetown University School of Medicine, who serves as a paid expert witness in trials involving the over-marketing of hormone therapy. She says women should be especially wary of hormones if their mothers or sisters had premenopausal breast cancer or if they or close relatives have heart disease or blood clots.
The increased risk of breast cancer associated with hormone use in the WHI study appears to kick in after five years for those taking estrogen and progesterone and after seven years for those taking estrogen alone. A slightly increased risk of ovarian cancer, however, may occur within four years, regardless of the regimen, according to a study released in July. For every 8,300 women on hormone therapy, one extra case of ovarian cancer would result, a risk that drops back to normal within two years of stopping the treatments.
A good rule of thumb to follow: Stay on hormone therapy for no longer than five years, says Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital. Taper off earlier if you can. "Some women take it for six months, feel wonderful, and stop," he says. About half of hormone users, though, find they need to taper off gradually to avoid a return of their symptoms. Some can switch to a lower dose, while others may need to alternate between their usual dose and lower-dose pills for three to six months. Those already on very superlow doses can try skipping days between pills or wearing a patch every other week.
Whether to use a pill, cream, gel, spray, or skin patch depends largely on personal preference and the severity of symptoms. Women with more severe hot flashes may want to opt for a pill if lower-dose patches or creams don't work. Vaginal dryness may be alleviated with a low-dose product delivered through a vaginal ring, cream, or tablet inserted into the vagina to deliver hormones directly to the tissues. [Other Ways to Relieve Vaginal Dryness] Breast cancer patients who simply can't take hormones may find their hot flashes can be relieved by antidepressants or a pain-reliever called gabapentin.
Kirchoff's daily cocktail of estrogen has not been a panacea for all that ails her. "It's definitely not a stress-reducer. I still need to exercise and do all my other healthy living things to combat that," she says emphatically. But she's finally sweating less.