Hormones, Hot Flashes and Total Health for Midlife Women

Q:  I had a hysterectomy more than 30 years ago. About 10 years ago I started taking Premarin (estrogen) for hot flashes, but I stopped taking it last year after all the negative news about it.

Now the hot flashes are back and I'm not sure what to do to get rid of them once and for all. My doctor said I could go back on Premarin, take an antidepressant or try vitamin E. I have been taking vitamin E but it hasn't helped me. I've never tried an antidepressant and I'm concerned about the safety of Premarin. What should I do?

A:  Last July, the very large Women's Health Initiative trial found that taking the combination of estrogen and progestin for five years caused more harm (in the form of more heart disease, strokes, blood clots and breast cancer) than good (in the form of fewer osteoporotic fractures and less colon cancer). The general conclusion has been that, unless you are taking estrogen and progestin specifically to prevent osteoporosis or to alleviate hot flashes, it's best not to take it at all.

In your case, the anti-depressants like Paxil (paroxetine) or Effexor (venlafaxine) are worth a try, as is waiting it out a bit more.

You may get relief from hot flashes only with estrogen. For women who choose to go back on estrogen, the individual risks are relatively small: seven more heart attacks, eight more strokes and eight more breast cancer cases per 10,000 women per year. These risks apply only to the combination of estrogen and progestin, and since you have had a hysterectomy, you can take estrogen alone.

However, this week the National Institutes of Health (NIH) announced that the estrogen-alone trial of the landmark WHI study is being halted because the data indicate that estrogen-alone does not affect (either increase or decrease) heart disease, the major question being evaluated in the study.

In addition, estrogen alone appears to increase the risk of stroke and decrease the risk of hip fracture. The increased risk of stroke with estrogen alone outweighs any benefits found in the study. At the same time, estrogen alone did not appear to increase the risk of breast cancer during the time period of the study. The estrogen-alone study included 11,000 healthy postmenopausal women who had had a hysterectomy.

Finally, you can be assured that, with your dilemma about menopausal hormone therapy, you are in good company. To help address just such issues, Froedtert & Medical College opened the Total Health for Midlife Women program last year on the 4th floor of the Froedtert East Clinics. The program is a multi-disciplinary, comprehensive resource devoted to the overall health concerns of women 40 to 60 years old.

Total Health for Midlife Women was developed to help women take a proactive role in their own health by focusing on prevention, wellness, health-risk assessments and health education. Vanessa Barnabei, MD, PhD, Associate Professor of Obstetrics and Gynecology, is Medical Director of the program, and its advisory board includes nurses and physicians from a broad spectrum of disciplines - including primary care, gynecology, sports medicine, surgery, psychiatry, research, pediatrics and patient education.

Program specialists conduct a series of assessments to determine each patient's particular risk in areas such as cancer, heart disease, osteoporosis and depression. Assessments also are done in the areas of perimenopausal and menopausal symptoms, nutrition, general wellness, breast health, stress and weight management.

A nurse specialist then works with the patient to outline a customized health plan that includes goals for healthy lifestyle changes and a comprehensive approach to address identified health concerns. Assessment results are shared with the patient's primary care physician, and if further treatment is required, the nurse specialist coordinates referrals to the appropriate physician. The program also offers educational seminars.

If you would like more information about Total Health for Midlife Women, or would like to schedule an appointment, call (414) 272-3666.

"Dear Doctor" is a compilation of patient questions answered by doctors from the Medical College of Wisconsin.