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Hormone Replacement Therapy: What Now?

A Very Personal Decision continued...

If a woman's primary goal is to relieve menopausal symptoms, for instance, researchers say she shouldn't feel concerned about taking the combo for a few years. "I feel very comfortable saying that fear of breast cancer should not discourage women from using drugs in the short term if they have severe menopausal symptoms," said Catherine Schairer, PhD, an epidemiologist at the National Cancer Institute and lead author of the study. "Any increase in risk would be slight."

Long-term use, though, is more problematic. If a woman's main concern is to stave off heart disease or osteoporosis, she may be able to get most of the benefits while minimizing risk by delaying the start of HRT until close to age 60, when the likelihood of those ailments climbs more steeply, says Laura Esserman, MD, director of the University of California, San Francisco/Mount Zion Breast Care Center.

Medical factors alone, though, often aren't enough to clinch a woman's decision. It's frequently emotional issues that will determine whether she takes hormone therapy, and in what form.

"A woman has to decide what she's most scared of and how she feels," said John Robbins, MD, of the University of California, Davis, and a principal investigator of the Women's Health Initiative, a 15-year study of women's health.

That's a process that Joanne Watson, 58, understands only too well. Watson, a counselor in San Francisco, has been taking estrogen ever since she had a hysterectomy at the age of 35. One of her biggest fears is developing Alzheimer's, particularly since her mother, grandmother, and aunt died from the disease. The evidence that estrogen can protect against Alzheimer's is still inconclusive, but because of her personal experience with the debilitating illness, Watson continues to take estrogen. "I'd stay on Premarin (estrogen) until I drop dead if it can keep me from getting Alzheimer's," she said.

Modifying the Dose

Physicians recognize that a woman's decision to take or forgo HRT is extremely personal. What is needed, they say, are more studies on how to make hormones safer for women who choose to take them.

One likely outcome of last week's study, experts say, is that it will spur researchers to examine whether prescribing lower doses of progestin can whittle down the likelihood of breast cancer. Already, some physicians are experimenting with giving the hormone only every few months, hoping that the dosage will preserve benefits while reducing risk. Others, including Malcolm Pike, MD, chair of preventive medicine at the University of Southern California School of Medicine, suggest that since the aim of including progestin is to protect the uterus, placing a dose in the vagina might eventually be shown to be more effective, while generating fewer side effects, than taking a pill.

The results from this latest study provide evidence that is "plenty strong enough for us to make changes," said Laura Esserman, MD, director of the University of California, San Francisco/Mount Zion Breast Care Center. "The trend is so strong; it keeps coming up in study after study, so we have to take this seriously."

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