Andrey Nailor, M.D.·Published 27 April 2011·10 min read
Key points
Every year, millions of women worldwide enter menopause, a universal female experience.
Although these symptoms can be quite troubling in the short term, the good news is that most symptoms will eventually subside over time as the hormonal tempest calms and one's body adjusts to its new steady state of lower estrogen levels.
In the meantime, however, women are faced with one of the most complex healthcare decisions that many have ever had to make: to take or not to take hormone therapy.
There is little debate that hormone therapy offers highly effective relief from hot flashes and some (though not all) of the other menopause symptoms mentioned-it clearly does!
Every year, millions of women worldwide enter menopause, a universal female experience. Although some women sail through the transition with few problems, three of every four experience symptoms due to the wide fluctuations of the female hormones estrogen and progesterone during this time, and one in four experiences major symptoms. The most common symptoms include bothersome hot flashes, drenching night sweats, disturbed sleep, mood swings, vaginal dryness, concerns about sexuality, and worries about memory slippage-all of which may affect a woman's most important relationships and her ability to function effectively at home and/or at work.
Although these symptoms can be quite troubling in the short term, the good news is that most symptoms will eventually subside over time as the hormonal tempest calms and one's body adjusts to its new steady state of lower estrogen levels.
In the meantime, however, women are faced with one of the most complex healthcare decisions that many have ever had to make: to take or not to take hormone therapy. Many women (and their doctors) feel that they are in great need of guideposts in making informed and rational choices about this treatment.
There is little debate that hormone therapy offers highly effective relief from hot flashes and some (though not all) of the other menopause symptoms mentioned-it clearly does! Where the complexity arises is with regard to hormone therapy's safety and whether benefits will outweigh risks. Only a short time ago, hormone therapy was considered fairly safe for most women. But a seismic shift in attitudes toward hormone therapy has occurred in recent years because of apparent discrepancies among results of different types of studies. Dozens of observational studies, which examine large numbers of people over long periods of time and record their health-related characteristics and behavior in relation to their health outcomes, have suggested major health benefits of hormone therapy, including reductions in heart disease, hip fractures, and colon cancer, as well as major risks, such as breast cancer, stroke, and blood clots in the legs or lungs. More recent findings from randomized clinical trials, which use a figurative flip of the coin to assign either an active treatment or an inactive placebo to participants, have not only appeared to refute the idea that hormone therapy protects the heart but also suggest it may actually increase the risk of heart disease.
The largest of these clinical trials, which my colleagues and I carried out as part of a huge study called the Women's Health Initiative, assigned more than 27,000 women to a five- to seven-year course of hormone therapy or placebo to determine the impact of such treatment on a myriad of health outcomes. The heart disease findings became major news and convinced many women and their healthcare providers that the potential risks of hormone therapy outweighed the potential benefits. Women began to abandon hormone therapy in droves, feeling betrayed by the earlier assurances of its benefits.
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Andrey Nailor, M.D.
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While the pendulum has swung from the view that hormone therapy is good for all women to the view that it's harmful for all women, both positions are oversimplifications that have confused and alarmed women, not to mention their doctors.
In my opinion, the answer is much more subtle and individual. A "one-size-fits-all" approach is inappropriate, yet very few physicians can provide women with truly satisfactory answers to their questions about hormone therapy-that is, answers tailored to a patient's particular situation and health profile. (Along with doctors, nurse practitioners and other health professionals are on the front line of giving advice and providing care to women as they navigate the menopausal transition. Although for brevity's sake I tend to use the words doctor or physician throughout this book, in most instances what I am saying also applies to other healthcare providers.)
After initially giving up hormone therapy, many women are now finding that their untreated menopausal symptoms are eroding their quality of life. In 2004, the American College of Obstetricians and Gynecologists stated that 25 percent of U.S. women who had stopped taking hormone therapy had restarted it-a mere two years after the Women's Health Initiative trial reported that such therapy increased the risk of cardiovascular disease. They apparently found the symptoms simply unbearable.
But how did it happen that decades of research suggested heart protection from hormone therapy only to have clinical trials, when finally undertaken, seem to show the opposite? What are the reasons for such discrepancies between earlier and later research? And why am I now saying that the new conclusion that hormone therapy is "bad" for all women is an inaccurate oversimplification?
Only in the past year have we come to a "unifying theory" that can explain the apparent discrepancies in the research and that can help women and their doctors make appropriate use of hormone therapy. I have had the privilege of being a lead investigator on two of the largest and most comprehensive research studies on the health of U.S. women undertaken to date-the Nurses' Health Study, which has observationally followed more than 121,000 female nurses for three decades and is still going strong, and the Women's Health Initiative, mentioned previously. My colleagues and I developed the unifying theory based on detailed analyses of data from these and other observational studies and randomized clinical trials. Some of the results have been recently published, and others will appear in the medical literature in the coming months. I have also had the opportunity to become involved with a new randomized clinical trial testing low-dose hormone therapy in recently menopausal women. This trial, the Kronos Early Estrogen Prevention Study (KEEPS), is assessing the effects of oral versus patch estrogen on the development of atherosclerosis as well as on quality of life and memory and thinking ability.
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The key concept of the unifying theory is that hormone therapy tends to be beneficial when started early after menopause (as was done in the observational studies that seemed to show favorable results) and harmful when started late after menopause when women already have less-than-healthy blood vessels (as was the case with most women in the randomized clinical trials, which showed the negative results). In other words, a woman who starts taking hormone therapy when she already has advanced atherosclerosis is particularly susceptible to having a heart attack or stroke while on treatment, while a woman just entering menopause who has healthy blood vessels may even receive heart protection. A similar pattern may apply to the effect of hormone therapy on memory and cognition: hormone use may help preserve thinking ability when initiated in newly menopausal women but hasten the progression of preexisting memory problems when started later in life.
There are several biological reasons for these differences in outcomes, which I'll explain in detail in these pages. But let me clarify-although the evidence is mounting, it is not yet conclusive, and no woman should begin taking hormones for the express purpose of preventing cardiovascular disease or cognitive decline. However, the findings to date can be reassuring to women who have recently entered menopause and are considering hormone therapy for treatment of moderate-to-severe menopausal symptoms. (At the very least, such women generally have an extremely low underlying risk of heart attack, stroke, and other complications.) This book is the first to present the unified theory in a way that I hope will be accessible to any woman who is struggling with the decision of whether or not to take hormones.
And I know that there are many of you out there. Besides having had the extraordinary opportunity to investigate the relation between hormone therapy and women's health in not just one but two landmark research studies, I've also been fortunate enough to have had nearly 20 years' experience as an internist and endocrinologist in a clinical practice largely devoted to women's health. In that role, I've been called upon by innumerable patients for advice on how to best navigate the menopausal transition. Some of my patients requested a prescription for hormone therapy for relief of their symptoms with nary a thought about the potential health consequences, while others wouldn't hear of taking hormones under any circumstances, even though their hot flashes and night sweats were making them miserable. Yet by far the most common situation I've encountered is that of the perplexed patient who sought a clear explanation of the benefits and risks of menopause hormones so that, with my input, she could ultimately make the choice with which she was most at ease. When I began practicing medicine, providing satisfactory answers to these women was hard to do, because I was acutely aware of how little information about the health outcomes of women on hormone therapy was actually out there. But now that such data have begun to accumulate, it's possible to give evidence-based answers to those questions. So that's why I wrote this book.
I'm often asked if there was a particular event that inspired my interest in women's health and my commitment to helping women get the health information they need. When I started medical school, I was curious about endocrinology and the effects of hormones on health, but I didn't know that medical research would become my mission. But early in my medical training, my mother died of ovarian cancer at a relatively young age, an event that raised my awareness-in a profoundly painful and personal way-of the relative inattention paid by the medical establishment to women's health issues in comparison to men's. Once I realized how little research had actually been done on health issues unique to women, including the effects of hormones on health, I decided to pursue my interest in endocrinology and plan a dual career in both research and patient care. But let's return to the present.
Several health concerns should figure prominently when you weigh the potential benefits against the risks of hormone therapy, and heart disease is only one of many that should be factored into your choice. This book provides a step-by-step personalized framework for making the most informed hormone-therapy decision for your own symptoms and health profile. The following issues are addressed:
• Which women are now considered good candidates for hormone therapy and who should avoid hormone therapy at all costs? • How can you calculate your personal risk for common conditions likely to be affected by hormone therapy-namely heart disease, stroke, blood clots in the legs and lungs, breast cancer, and hip fracture? How should these calculations guide your decision making about hormone therapy? • For women who are good candidates, what is the best formulation and dose of estrogen to take, the preferred progestogen, and the optimal duration of treatment? • For women who can't-or prefer not to-take hormone therapy, what are the best options for symptom relief and general health? • What is the appropriate role for soy, black cohosh, and other alternative remedies in relieving menopausal symptoms? • How can you work effectively with your healthcare provider to manage the transition to menopause?
In short, this book is my attempt to clear the confusion regarding the latest scientific data on hormone therapy-to make sense of the seeming chaos, so to speak-and present the facts you need to help you decide if hormone therapy is right for you. We are still in the thick of the learning process, but the evidence is now sufficiently firm that you can make an informed choice about using hormones for relieving symptoms of menopause with the reasonable expectation of keeping healthy and active for many years to come.
Disclaimer: The Women's Health Initiative (WHI) study and Nurses' Health Study (NHS) are supported by the National Institutes of Health (NIH) and conducted in collaboration with study investigators. This book does not necessarily reflect the opinions or views of the NIH or of study coinvestigators. Guidelines in this book are not intended to replace advice and medical care provided by your personal physician or other healthcare provider.
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By Manson, JoAnn E. and Bassuk, Shari S. Hot Flashes, Hormones, and Your Health
JoAnn E. Manson, M.D., is a professor of medicine and the Elizabeth F. Brigham Professor of Women's Health at Harvard Medical School, Chief of Preventive Medicine at Brigham and Women's Hospital, and codirector of the Connors Center for Women's Health and Gender Biology. The only person to have served as a lead investigator on two of the most influential studies of women's health ever conducted-the Women's Health Initiative and the Harvard Nurses' Health Study-Dr. Manson is widely recognized as one of the world's leading authorities on women's health.
Shari S. Bassuk, Sc.D., is an epidemiologist and science writer at Brigham and Women's Hospital in Boston who frequently collaborates with Dr. Manson.
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