The Hormone Dilemma
The latest flip-flop on hormone therapy gives new hope to younger women
The studies changed medical practice for older women. Doctors stopped prescribing hormones for heart protection. But the pendulum may have swung too far the other way. "The response of the medical community was to say, 'No women should ever be on hormones,'which probably wasn't the most appropriate response," says Marcie Richardson, codirector of the Harvard Vanguard Menopause Consultation Service in Boston.
After the studies, doctors turned to shorter-term, lower doses of hormones, often administered by patch, not pills, for menopause symptoms. But the trials didn't look at hormones taken like this. And they didn't explain one very glaring contradiction: Why did some observational studies, including the renowned Nurses' Health Study of more than 120,000 women, show that hormones could reduce the risk of heart disease?
In February, WHI leaders put forth a possible answer in the Archives of Internal Medicine: Hormones may work differently depending on your age and how close you are to menopause. When the WHI authors looked at participants in the estrogen-alone trial by age, they found that women ages 50 to 59 saw a 34 percent reduction of heart attacks, heart bypass surgery, or angioplasty compared with the placebo group. But women 60 or older on estrogen alone didn't experience a heart benefit. As for women on estrogen plus progestin, although the researchers did not have enough data to issue a definitive analysis based on age, "we did see a suggestion of a similar trend with time since menopause, with increasing risk among women starting hormone therapy more than 10 years past menopause," says Manson.
Similarly, an article in the Journal of Women's Health in January took a closer look at the Nurses' Health Study findings. The study had suggested that hormone therapy could prevent heart disease and seemed to conflict with the WHI study--until researchers looked at the age and time since menopause. Those in the WHI trials were, on average, age 63, and many years past menopause, while the nurses were in their early 50s, the typical start of menopause in the United States. When researchers looked at the nurses who started estrogen within four years of menopause, they found these women were 34 percent less likely to suffer from heart disease; those who started estrogen plus progestin were 28 percent less likely. Women who started hormone therapy more than a decade after menopause did not have any heart benefit. "The takeaway is that if you start hormones around the time of menopause, if you take it when you start having hot flashes, it's probably good for your heart also," says Hugh Taylor, associate professor of reproductive endocrinology at Yale University and director of Yale's menopause program.
So what does all this mean for women nearing menopause? There's no cut-and-dried conclusion. But for women suffering serious symptoms of menopause, the risks and benefits of hormone therapy are well worth a closer look. "I see women suffering every day and afraid to take hormone therapy," says Taylor. "We've blown the risks out of proportion and forgotten a lot of the reason women started taking hormones."
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