June 20, 2003 -- Bone fractures, hot flashes, heart disease, dementia, breast cancer -- older women have big health concerns. But what should they do, with so many conflicting findings about hormone replacement therapy?
A panel of experts offered their advice today, based on research from the Women's Health Initiative (WHI). It's part of The Endocrine Society meeting being held in Philadelphia.
HRT does indeed improve an aging woman's bone health; In fact, the FDA has approved HRT for that specific purpose. But should a woman take HRT just for bone health? Only if hot flashes are getting the best of her, says Ethel Siris, MD, director of the Osteoporosis Center atColumbia-Presbyterian Medical Centerin New York.
"Women who are miserable, have poor quality of life because of hot flashes, in my opinion should get HRT for a short term. But if they are using it solely for bone health, there are other treatment options that should be used," Siris says.
The bone benefits of HRT are not linked to how long women take it, she says. "It's a case of 'what have you done for me lately.' Hormone replacement therapy works only as long as you take it, but if you stop you will have bone loss. It's critical that women who stop taking HRT not forget their bone health."
Most bone loss occurs in early menopausal years, she says. "That means women better find out where they stand in terms of bone health. Bone testing is very critical in women who quit HRT, to see if they need other treatment for bone health. If bone density is low, another therapy should be given, and given promptly."
Other treatments are highly effective and very safe, she says. "Each is somewhat different from the other, which means we can individualize treatment to fit the patient."
Among those options:
- Bisphosphonates are bone-specific drugs that prevent bone loss and reduce fracture risk.
- Selective estrogen receptor modulators (or SERMs) are drugs that are not hormones -- not estrogens -- but they can prevent bone loss and reduce breast cancer risk. However, women may get an increase in hot flashes and vaginal bleeding.
- Another new drug, called Forteo, for severe osteoporosis -- especially for people who have had fractures -- actually stimulates bone formation (other drugs block bone loss). It requires daily injections.
Heart disease is another big issue for aging women -- but "we're still getting reports from WHI that combined HRT is not effective in preventing heart disease," says Ellen W. Seely, MD, director of endocrinology, diabetes, and hypertension research at Brigham and Women's Hospital in Boston.
- Get treatment for high blood pressure. Only about 20% of women have been effectively treated for blood pressure problems, says Seely. Medication can help. So can lifestyle changes such as weight loss, eating more fruits and vegetables, and exercise.
- Get treatment for high cholesterol. Statin drugs have been shown to safely lower LDL "bad" cholesterol and reduce heart disease risk.
- Get diabetes treated, or prevent it altogether through lifestyle changes such as weight loss, aerobic activity, and a better diet. One three-year study showed that lifestyle changes can decrease frequency of diabetes by 60%.
- Lose weight. That's important for two reasons -- it decreases the risk of diabetes and heart disease.
- Quit smoking. Heart disease risk is two to four times higher in women who smoke.
- Get more exercise. Physical activity is shown in men and women to reduce heart disease risk by 30% to 50%.
Raloxifene (Evista) has been demonstrated to be effective against osteoporosis, says Seely. "The ongoing RUTH (Raloxifene Use for The Heart) trial will let us know whether it prevents heat disease but the answer will not be known for several more years," she adds.
Researchers have other questions about hormone replacement therapy, she says: Do some women, more than others, get greater heart disease benefit from HRT? Are there other forms of estrogen and progestin that could be heart disease-protective? Are there other progestins that could be more protective? Are lower doses of HRT beneficial for heart disease? Does the route of administration matter -- would an HRT patch work better and more safely? And what about for women that can take estrogen alone?
Quality of Life
Hot flashes, mood changes, lost sleep, decreased sexual interest, vaginal changes such as dryness -- "Quality of life is big issue for many women," says Charles Hammond, MD, chairman emeritus of obstetrics and gynecology at Duke University School of Medicine.
"For many women, symptoms often worsen in every category -- except for depression -- as she ages," he says. "This does not occur in all women by any means, but it does in many."
The vast majority of women, more than 60%, take hormone replacement therapy to relieve these symptoms, he says. In fact, some women will have these symptoms for up to a decade, possibly longer.
While short-term therapy would be a solution for the majority, what should the others do? There are plenty of unanswered questions about hormone replacement therapy, says Hammond.
Here's what works and what does not:
- Phytoestrogens and isoflavones in soy foods have been studied to a limited extent, and they do not seem effective in controlling hot flashes.
- Lifestyle changes, layered clothing, keeping the bedroom cooler -- those all help.
- Black cohosh has not been shown to help. Also, because such supplements are not FDA approved, there is a risk that the compound is not pure.
- Antidepressant drugs have shown some benefit in relieving hot flashes and improving sexual interest. But it's too early to suggest those drugs as a first line of treatment, says Hammond.
- New "estrogen rings" that are inserted in the vagina -- and topical cream -- will help with vaginal dryness.
Estrogen helps relieve symptoms, but would estrogen via a patch be safer as a long-term therapy? Research of the patch does not show as "robust" effectiveness as the pill, Hammond reports. Also, more research is needed of the progestin family of drugs. "We probably know less about progestin than estrogen."
"Each patient has to balance risks and benefits of hormone replacement therapy," he says. "Short-term use does not increase the relative risk of breast cancer.""
The verdict: "I see women every week whose quality of life is so poor, that I think there is still a place for estrogen until something better comes along," says Hammond.
"No protective effect against dementia" -- that was the WHI finding.
But further study has pointed to a different scenario for younger women, reports Hadine Joffe, MD, psychiatry instructor at Harvard Medical School.
"Women in WHI were over age 65; also, they had not taken HRT before," she points out. Indeed, hormone replacement therapy may help the brain function of younger women during the transition years between ages 50 and 55, Joffe tells WebMD.
"We're finding a window of opportunity in which estrogen can aid brain function," says Joffe. "There is some evidence that waiting longer before starting hormones may present a different scenario ... that when we replace estrogen in younger women, it can bring some immediate benefit. There's an indication that in the right context, women could see some benefit."
Younger women are a "very, very different population than older women," she says. A younger woman's brain has seen fluctuations of estrogen. "The 65-year-old woman hasn't seen estrogen for a number of years, so it may not respond the same."
These days, researchers can watch brains "in action" thanks to brain scans called functional magnetic resonance imaging (fMRI). While women perform various memory tests, they can see a "clear suggestion that various brain regions that affect working memory [and thinking] are enhanced [when women take HRT]. It supports the possibility that estrogen has direct effects on brain function."
Her advice: "The truth is, for the average woman who is younger, with hot flashes, mood problems, memory problems, we could see some improvement. I've heard women say it when they go on hormone replacement therapy, 'I'm back.' Hopefully it's validating for women who feel they're having memory problems, that it's not dementia, that it's just short term."