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Hormone Replacement Therapy Q&A

1. Should I stop taking hormone replacement therapy (HRT)? continued...

Is your risk for osteoporosis significantly greater than your risk for heart disease or breast cancer? What other treatments could preserve bone health as well as hormone replacement therapy without the risk? What lifestyle changes (such as diet and weight-bearing exercise) could preserve your bone health?

If you choose to stop hormone replacement therapy, taper off the hormones gradually. Some women suffer symptoms of withdrawal if they stop abruptly. For example, Laura Corio, MD, author of The Change Before the Change, recommends her patients taper off by taking the hormones every other day for two weeks, and then stopping completely.

If you choose to stay on hormone replacement therapy, ask your doctor to re-evaluate you once a year to look at risk vs. benefits. Remember, hormones are strong drugs. Staying on hormones longer than five years is no longer advisable, if you are not receiving a benefit.

2. Is any type of hormone therapy safer?

Unfortunately, no one knows for sure. About 20 million American women take some form of estrogen therapy -- in pills, patches, or creams -- but few of these treatments have been carefully studied for long-term risks.

The standard hormone replacement therapy that increased risks in the Women's Health Initiative is conjugated equine estrogen (made from horse urine) at 0.625 milligrams a day, combined with a synthetic progestin called medroxyprogesterone acetate at 2.5 milligrams a day. (Women who have their uteruses must take a progesterone with estrogen, because estrogen alone increases the risk of uterine cancer.) This combination is used by about 6 million American women and is sold under many brand names: Prempro, Premphase, Femhrt, Activella, and Ortho-Prefest.

Here's a summary of what's known -- and not known -- about other options:

Low-dose hormone replacement therapy: Some doctors believe that lower doses of hormone replacement therapy can offer the benefits without the risks. Studies do indicate that lower doses of estrogen and progestin (about half the dose as in Prempro) can relieve hot flashes and vaginal dryness. Theoretically, lower doses may pose less risk to breast tissue and heart health, but studies have not yet been done.

Estrogen Alone: Women who've had their uteruses removed through hysterectomy can take conjugated equine estrogen supplements without progestin. We've known for years that taking estrogen alone can increase the risk of uterine cancer, which is why women who have their uteruses also take progestin.

A study published in 2002 in The Journal of the American Medical Association showed that women who take estrogen also increase their risk of ovarian cancer. Researchers observed that the risk rose the longer the women were on estrogen. For example, women on estrogen for at least 20 years were more than three times as likely to develop ovarian cancer as women who did not take the pills. However, this was an observational study, which means researchers looked at the outcomes of women who chose estrogen, but they didn't divide the women into estrogen and placebo groups. 

Bio-Identical Estrogen Patches, Creams, or Vaginal Rings: These forms of estrogen are closer to the estrogen naturally produced by a woman's body and are effective against hot flashes and vaginal dryness. Also, they help build bone. They're sold under the brand names Estraderm, Climara, Vivelle, and Alora. Theoretically, estrogen delivered through the skin, thus bypassing the liver and digestive system, could pose less risk to breast tissue and cardiovascular health. However, studies have not yet been done to definitively answer the question.

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