Women Must Weigh Risks and Benefits of Estrogen Replacement

Q:  I am concerned about the questions being raised as to the benefits of estrogen for women after menopause. I thought that it was not only safe to take, but essential for women to prevent heart disease and osteoporosis. New reports seem to be less supportive of those benefits. I hope to live to a healthy old age and need some insight on this.

A:  As you correctly point out, hormone replacement therapy (HRT) has long been recommended for women entering menopause. The benefits included relief from the symptoms of menopause including sweating, hot flushes, and mood swings. The prevention of osteoporosis and heart disease were two of the more compelling medical reasons behind the long-term benefits of this recommendation. Prevention of heart disease was a particularly compelling reason, as it remains the number one cause by far of death in women. Some women also believe that HRT delays the effects of aging and helps them to look younger longer. The “down” side includes risks for stroke, blood clots, and the development of breast and uterine cancers.

As physicians, we were asked to look at this in the context of risk vs. benefit ratios. For example, the benefits of a reduced risk of heart disease or a hip fracture were believed to outweigh the statistically much smaller risks of cancer and strokes. Try as I may, I’ve never been able to convert that argument into very convincing terms for my patients, especially in light of this new information.

A recent study has determined that HRT should not be initiated for the prevention of cardiovascular disease either in women with a previous history of heart disease or those who are currently disease free. There is some concern that HRT in women with heart disease may actually place them at an increase risk for a cardiac event. There is as well not enough information to recommend that women begin HRT for the purposes of the prevention of heart disease.

If you are on HRT, ask your doctor to review the benefits for which the medication was initiated. If the main reason is the prevention of heart disease, you may want to discontinue therapy and instead consider lifestyle changes and aggressive treatment for high blood pressure and elevated blood lipids. If you have a history of heart disease, blood thinning agents and other medications used to lower the risk of heart disease might be a less risky substitute.

There are other medications to slow the progression of osteoporosis such as raloxifine, alendronate, and calcitonin to name a few that are all augmented by the use of 1000-1200mg of daily supplemental calcium.

There is still an indication for short-term use (3-6months) for the management of the symptoms of menopause. There are a number of herbal substitutes that in my reading so far provide few if any of the benefits of HRT and may lead to a false sense of security for women using them.

Dr. Russell Robertson is Associate Dean for Faculty Affairs and Associate Professor of Family and Community Medicine at the Medical College of Wisconsin. His biweekly column of medical advice also appears in the CNI Community Newspapers throughout metropolitan Milwaukee.