For Some Women, the Benefits of Hormone Therapy Outweigh the Risks

Results released in 2006 from the Women’s Health Initiative (WHI)—a large, randomized trial that studied the effects of hormone therapy (HT) in postmenopausal women—showed that taking estrogen and progestin increased the risk of breast cancer, blood clots and stroke, but also improved bone health and lowered colon cancer risks. In all, the balance showed no net benefit to using HT for preventive health, but also little net risk for women choosing to use HT to treat bothersome menopausal symptoms.

Fast forward 15 years, and additional analyses from the ongoing WHI study suggested that heart benefits might occur in women starting HT in the immediate perimenopausal years. However, the breast cancer risks, though small, remain.

If severe menopausal symptoms (hot flashes, night sweats, disturbed sleep, decreased sex drive, vaginal dryness, discomfort or pain with intercourse) are disrupting your life and HT may be the only treatment that provides effective symptom relief, how do you decide if it’s worth the risk?

Breast Cancer Risk: A Major Factor for Many Women

“When determining whether or not the potential risks of taking HT outweigh the potential benefits, the most important factor is the patient’s own concerns,” says Margaret Polaneczky, MD, FACOG, associate professor of obstetrics and gynecology at Weill Cornell. “Women with problematic menopausal symptoms who choose to use HT can be reassured that the risks overall are small. However, I find most of my patients do not want even a very small increased risk of breast cancer, and many avoid even vaginal estrogen. I respect their choices and work with them to find non-hormonal solutions for their symptoms.”

Determining Risk

Researchers have found that when you begin HT and how long you are on it contributes to determining your risk of breast cancer. Among study participants, duration of HT use was between seven and 10 years, and mean age was 50 years at menopause and 50 years at starting HT. Every type of HT except use of vaginal estrogen was associated with higher breast cancer risks, which increased steadily as duration of use increased and were greater for estrogen-progestin than estrogen-only preparations.

“This research suggests that breast cancer risk when using HT is slightly higher than the risk found in the WHI. I used to say, ‘If you use HT for 20 years, your risks for breast cancer will be 1 percent higher.’ Now, I say the risk will be 1 to 2 percent higher,” explains Dr. Polaneczky.

“The study also supports the idea that estrogen alone rather than a combination of estrogen and progestin and intermittent rather than continuous progestin use carries less risk, so I discuss that with my patients when we are deciding which HT regimen to use.”

Consider the Pros and Cons

HT use dropped dramatically in response to the initial results of the WHI study, but the position taken by the North American Menopause Society and the Endocrine Society is that HT is an acceptable treatment for menopausal symptoms. However, several factors must be taken into account when HT use is being considered, including the patient’s current health, medical history, age, and the number of years since her menopause began.

Dr. Polaneczky stresses that each woman needs to have a thorough discussion with her doctor if she is considering HT. “Depending on your age and other individual factors, the consequences of taking HT can vary, and the benefits may outweigh the risks if you experience severe hot flashes or other intolerable menopausal symptoms that do not respond to nonhormonal treatments.”

If a woman does opt for HT, she is advised to take the lowest effective dose for the shortest amount of time to minimize the increase in breast cancer, blood clot, and stroke risks. Dr Polaneczky also recommends that women use transdermal estrogens that are absorbed through the skin rather than oral estrogens when possible, as these may carry a lower risk for blood clot formation.

Dr. Polaneczky explains that it’s unlikely that she would recommend HT if a patient has had breast cancer or coronary artery disease or is at risk for deep vein thrombosis (a blood clot in the leg), pulmonary embolism (a blood clot in the lungs), or stroke.

Managing HT Effectively and Safely

“Women who choose to use HT for symptom relief can be reassured that the breast cancer risks, while present, are less than one in 1,000 per year of use. If women choose to use HT long term, they must accept an increased risk on the order of 1 to 2 percent over their baseline, but, in truth, most women stop using HT once their symptoms diminish,” Dr. Polaneczky says. If you do choose HT, Dr Polaneczky says that using an effective dose is key for success.

“In my opinion, the worst outcome is women choosing to use HT but not getting relief from their symptoms because they take a smaller dose than prescribed— or they decide not to take the progestin I prescribe, and taking estriadol without progestin increases the risk of endometrial cancer,” she explains.

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