Menopausal Hormone Therapy

History of Menopausal Hormone Therapy Prescribing

Menopause hormone therapy has gone through a rollercoaster in relation to prescribing. With 2002 marking the year where up to 80% of women stopped MHT, both women and doctors became afraid of the treatment that had been helping the women feel better. The fear was specifically focused on the perceived increased risk of breast cancer, and that fear can still come up in conversations about MHT today. Why was this? To understand more about what happened, read on.

Development of Estrogen Therapy

Estrogen was first synthesized in the 1920s, when a researcher in Toronto was able to synthesize a product from pregnant mares’ urine called Premarin, which contained various forms of estrogen, including horse estrogen. This product was advertised to enhance women’s sexuality, prolong their lives, and provide a “fountain of youth”.

Discovery of Combined Hormone Therapy

The popularity of estrogen grew, but by the 1970s, it was discovered that taking estrogen alone increased the risk of uterine cancer in women with a uterus. Researchers then found that adding progesterone could prevent this increased risk, and combined hormonal therapy became standard HRT (hormone replacement therapy).

The Women’s Health Initiative

The National Institute of Health decided to address this and to design a study to address this. They wanted to research if HRT could provide benefits beyond symptom control and if it could prevent or delay the diseases of aging. The gold standard to answer this question is a prospective large-scale randomized control trial, and that is what was set up: The Women’s Health Initiative.

Age-Specific Risk Analysis

The study was stopped early in 2002 due to concerns when the risk of cardiovascular disease and breast cancer exceeded a predetermined threshold. The premature release of these findings, which emphasized the risks without providing context, led to widespread panic and a sharp decline in hormone therapy use. However, the WHI results did not accurately represent the majority of women for whom hormone therapy is suitable, particularly those aged 50 to 59.

Benefits of Menopausal Hormone Therapy

Reduction in Hot Flashes and Night Sweats

MHT is considered the most effective treatment for vasomotor symptoms, such as hot flashes and night sweats. It reduces hot flashes in over 90% of women, even in low doses. Relief can be felt soon after starting treatment, but it can take up to 12 weeks for the full effect.

Improved Sleep Quality

By reducing night sweats and hot flashes, MHT can significantly enhance sleep quality, leading to increased energy and improved mood. MHT is considered the gold standard treatment for hot flashes. Other treatments, though in general less effective, are available for those who can’t or choose not to take MHT.

Stronger Bones

Estrogen and progesterone are important for bone health. MHT reduces bone loss and hence reduces fracture risk, particularly in women at increased risk of osteoporosis.

Relief from Genitourinary Syndrome of Menopause (GSM)

MHT effectively addresses GSM – both in relation to sexual and urinary function problems. Local estrogen therapy can be very helpful in improving GSM and can be used without systemic MHT in women who do not need, prefer not to take, or have a contraindication to MHT.

Cardiovascular Benefits

Studies indicate potential heart-protective effects of estrogen therapy when started within 10 years of menopause and before the age of 60.

Improved Mood and Sense of Wellbeing

Many women find that as the night sweats and hot flashes subside, their mood improves. They have a reduction in anxiety, depression, panic attacks, and irritability. As they sleep better and have more energy, they are better able to exercise and eat well.

Cognitive Function

Early initiation of MHT is thought to possibly offer protection against cognitive decline and potentially reduce the risk of Alzheimer’s disease. This benefit is not yet confirmed by studies, so the prevention or treatment of cognitive decline is not currently a reason to start MHT.

Reduced Joint Pain

MHT is found by some women to alleviate symptoms of joint pains related to menopause. Joint pain alone is not an indication to take MHT currently.

Important Considerations When Starting Menopausal Hormone Therapy

Timing is Important for Menopausal Hormone Therapy

The benefits of MHT are most likely to outweigh the risks for women who start before age 60 and within 10 years of menopause onset.

Individualized Approach

MHT is not one-size-fits-all. The type, dose, and route of administration should be tailored to each woman’s unique needs and risk factors. Factors considered include the presence or absence of a uterus, personal and family medical history, and individual preferences.

Ongoing Evaluation

The decision to continue MHT should be reviewed at least annually with a healthcare provider. There are no mandatory limits on the duration of MHT, but long-term use warrants careful consideration.

Lifestyle Modifications

A healthy lifestyle, including regular physical activity, a balanced diet, avoiding smoking, and limiting alcohol intake, can play a crucial role in managing menopause symptoms and mitigating risks associated with MHT and aging in general.

Risks of Menopausal Hormone Therapy

Starting any medication involves an evaluation of the potential benefits and risks for the individual woman…

Risks in Women Aged 50-59 Years Taking Estrogen-Only Therapy

• Coronary heart disease: 5.5 fewer cases
• Breast cancer: 2.5 fewer cases
• Stroke: 0.5 fewer cases
• Venous thromboembolism: no additional cases with transdermal estrogen

Risks in Women Aged 50-59 Years Taking Combined Estrogen-Progestin Therapy

• Coronary heart disease: 2.5 additional cases
• Breast cancer: 3 additional cases
• Stroke: 2.5 additional cases

Breast Cancer Concerns and Menopausal Hormone Therapy

The relationship between MHT and breast cancer has been the subject of extensive research and discussion…

Combined Estrogen and Progestogen Therapy

Long-term use of combined estrogen and progestogen therapy…

Estrogen Therapy

Estrogen therapy alone (ET), typically used by women without a uterus, appears to have little or no impact on breast cancer risk…

Side Effects of Menopausal Hormone Therapy

• Bloating
• Breast tenderness
• Drowsiness (specifically with micronized progesterone)

Resources

Articles on Menopausal Hormone Therapy

• The Canadian Menopause Society patient information booklet on Menopause Hormone Therapy