Hormone Replacement Therapy - MedBroadcast.com

What is HRT, and what are the stats?

What is HRT?

HRT, or hormone replacement therapy, is used by people who are going through menopause or who have already been through it. Before menopause, the ovaries make 2 female hormones: estrogen and progestin. With menopause, a natural life stage for menstruating people, the ovaries stop producing these female hormones. This can lead to symptoms of menopause, including hot flashes, night sweats, mood swings, trouble sleeping, vaginal dryness and urinary incontinence (difficulty holding urine). HRT is used to replace estrogen and progestin and relieve the symptoms of menopause.

There are many different types of HRT. Most people receive both estrogen and progestin. Because estrogen can increase the risk of endometrial cancer (cancer of the lining of the uterus), progestin is taken to offset this risk. However, people without a uterus (i.e., those who have had a hysterectomy) do not need to take progestin. There are different types of estrogen (such as conjugated estrogen, estropipate, and estradiol) and progestin (such as medroxyprogesterone acetate and micronized progesterone). There is also a large variety of dosage forms (such as tablets, patches, creams, and vaginal rings).

At one time, HRT was also used to prevent heart disease. The results of the Women's Health Initiative (WHI) Study, a major US study that examined the risks and benefits of HRT in over 16,000 participants, have raised some concerns about the long-term safety of HRT. To date, it remains the largest, randomized clinical study on this question.

The study found that use of one type of HRT for more than 5 years led to increased risks of heart disease, breast cancer, stroke, and venous thromboembolism (a serious condition where blood clots break loose and lodge in the veins of the leg or the lung). HRT was also found to decrease the risk of osteoporosis and colorectal cancer. As a result of this study, HRT is no longer recommended for the prevention of heart disease.

It is important to note that not all forms of HRT have been linked to an increased risk and that these risks occurred with long-term versus short-term usage. Details are discussed below. If you are taking HRT or thinking of starting it, talk to your doctor about the benefits and risks.

What was the study about, and what does it mean for Canadians taking or considering taking HRT?

The Women's Health Initiative (WHI) Study looked at the benefits and risks of HRT in a large group of Americans. Over 16,000 healthy postmenopausal individuals aged 50 to 79 were enrolled in the study. These people were randomly assigned to one of 2 groups:

Treatment group: People in this group received estrogen (conjugated equine estrogen 0.625 mg) and progestin (medroxyprogesterone acetate 2.5 mg) by mouth once daily. This is one of the most common forms of HRT. They took the hormones continuously, without regular monthly breaks.
Placebo group: People in this group received a placebo (a tablet that contains no active ingredients and is designed to look like the treatment medication) by mouth once daily.

The study measured the effects of HRT on heart disease, stroke, venous thromboembolism (a serious condition where blood clots break loose and lodge in the veins of the legs or lungs), osteoporosis (bone loss), colorectal cancer, and breast cancer. The WHI planned to run the study for about 8 years but stopped it early, after only 5 years, for 2 reasons:

An increased risk of breast cancer was found with HRT treatment as compared to placebo.
The overall risk outweighed the benefits of HRT treatment as compared to placebo.

In women taking HRT in this study:

heart disease risk was 29% higher
stroke risk was 41% higher
breast cancer risk was 26% higher
the risk of venous thromboembolism was more than doubled
hip fracture risk was 33% lower
colorectal cancer risk was 37% lower

What does this mean? At first glance, these percentages seem quite high. But the risks of these conditions were very low to begin with, so the actual number of people experiencing them is still low. Every year, a group of 10,000 people taking HRT would have:

7 more heart attacks (37 vs. 30)
8 more strokes (29 vs. 21)
8 more cases of breast cancer (38 vs. 30)
18 more venous thromboembolisms (34 vs. 16)
5 fewer hip fractures (10 vs. 15)
6 fewer cases of colorectal cancer (10 vs. 16)

What did the experts say about this study?

Medical experts pointed out that the study only assessed one form of HRT. These results may not apply to people taking different estrogens or progestins, those using other dosage forms such as the estrogen patch, or those taking estrogen alone. People taking hormones in a cyclic fashion (with regular monthly breaks from hormones) may also have different HRT risks and benefits. In addition, the people in this study were 50 to 79 years of age, so the study results may not apply to people going through premature menopause (menopause before the age of 40 years).

In this study, people taking HRT were already faced with a slightly increased risk of heart attack and stroke after 2 years of treatment as compared to those taking the placebo. Their risk rose again after taking HRT for 3 years. Experts recommend that HRT should not be continued or started to prevent heart disease.

The balance of risk and benefit may be quite different for any individual, depending on their reasons for taking HRT, how long they will be taking it, and their medical history. Recent analyses of this study in combination with other smaller ones find that the degree of heart disease risk increase depends on the age that you start HRT relative to menopause. Each individual should consult their doctor to determine their own personal risks and benefits for HRT.

What should you do?

If you are already taking HRT, or thinking about starting, talk to your doctor. Depending on your reasons for taking HRT, your medical history and the length of time that you may need to take HRT, it may still be a viable option for you. Together with your doctor, you can chart out your personal risks and benefits and choose the most appropriate therapy. The Society of Obstetricians and Gynecologists of Canada (SOGC) recommends that people meet with their doctors at least once a year to re-evaluate whether they still need HRT. Your doctor may also be able to recommend alternatives to HRT.

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Frequently asked questions on HRT risks

Medication Management

How long should estrogen and progestin combinations be taken?

The right duration for you depends on why you’re taking HRT. Each person has unique needs and concerns. For all forms of HRT, you should take the smallest dose for the shortest amount of time to improve your quality of life. And the need for HRT should be re-evaluated at an annual check-up.

If someone is considering taking HRT to help alleviate serious menopausal symptoms, should they begin therapy?

Many people take HRT to alleviate serious symptoms of menopause. For these individuals, the treatment is still an effective method to alleviate symptoms. But talk to your doctor and re-evaluate your need for HRT each year.

What about people who are considering HRT to prevent heart disease and osteoporosis?

Most doctors do not recommend taking HRT to reduce the risk of heart disease. If you’re considering HRT to prevent heart disease, you should talk to your doctors about lifestyle issues and other medications.

To prevent osteoporosis, HRT is only one of several options (including diet, exercise and other medications). Talk to your doctor about your specific risks for developing osteoporosis.

For those taking HRT to relieve menopausal symptoms, after how many years does their risk of breast cancer and heart disease increase?

The current thought is that the risk of developing breast cancer increases after 5 years of taking HRT. The risk of developing heart diseases depends on the age that you start HRT relative to menopause. If HRT is started 10 years after menopause or after the age of 60, your risk of developing heart disease may be higher than if it were to be started earlier.

Because some symptoms of menopause subside after 2 to 3 years, you should re-evaluate your need for HRT each year. You may be able to stop taking HRT after 2 to 3 years.

Alternatives to HRT

Medication Management

Hormone replacement therapy (HRT) is a medical treatment that replaces the hormones your ovaries stop making during and after menopause (estrogen and progestin). In the past, HRT had been prescribed for both its short-term and long-term benefits. In the short term, HRT relieves hot flashes, night sweats and insomnia, fatigue, and mood disturbances including depression. In the long term, HRT was recommended to reduce vaginal dryness and help reduce the risk of osteoporosis (bone loss), heart disease, colon cancer, and Alzheimer's disease. Those benefits were weighed against the already-known increased risk of developing endometrial and breast cancer.

However, large clinical studies have found that the use of a certain combination of estrogen and progestin taken in pill form significantly increases the risk of breast cancer, heart disease, and stroke. It is important to note that not all forms of HRT have been linked to an increased risk and that these risks occurred with long-term versus short-term usage. The decision to start HRT is an individual one, based on the risks and benefits to the person taking HRT. Every person is different.

For those whom the risks outweigh the benefits, other options can be considered, including the following:

Other types of HRT can be considered for both short- and long-term therapy. Another option is to switch to the lowest-dose form of the HRT you are taking. The best way to take hormones (including estrogen and progestin) is to take the lowest possible dose that helps relieve your symptoms. Ask your doctor about changing your dose and about taking HRT in a patch or skin cream.

For osteoporosis prevention or treatment: HRT is not the only way to prevent the loss of bone that occurs when levels of estrogen decline. In fact, the best way is early prevention with regular physical activity and a well-balanced diet rich in calcium and vitamin D. Talk to your doctor about other classes of osteoporosis medications, for example Selective Estrogen Receptor Modulators (SERMs) such as raloxifene, and bisphosphonates such as risedronate and alendronate.

For heart disease prevention and treatment: After menopause, your risk of heart attack and stroke increases because of the lack of a protecting effect from estrogen. Dietary and lifestyle changes, including regular exercise and stopping smoking, can help reduce your risk of heart disease. If you have diabetes, make sure you're managing your condition and taking any medications to help prevent high blood pressure as prescribed by your doctor. In addition, you may reduce your risk of heart attacks and strokes with certain medications, including drugs that lower cholesterol levels (called statins) and blood-pressure medications.

For breast cancer prevention: Lifestyle factors are important: maintain a healthy diet, control your weight, stop smoking, restrict alcohol intake to 2 drinks or fewer a day up to a weekly maximum of 9 drinks, and get regular physical exercise. As well, make sure you have regular mammograms and breast exams. Learn how to perform breast exams at home.

Managing symptoms of menopause

Medication Management

Symptoms of menopause can be managed by different means. A change in your lifestyle can make a difference in how you feel and can help reduce symptoms of menopause. You can have an excellent start to healthier living by eating a well-balanced diet and exercising regularly. You should also consider reducing your alcohol intake, limiting your caffeine intake and, if you're a smoker, quitting.

Besides HRT, there are other medications available to help manage the symptoms of menopause. Consult with your doctor and pharmacist to find the treatment that is most suitable for you while meeting your lifestyle needs.

Although there are many herbal remedies available, you should talk to your doctor and pharmacist before taking them on your own. They may not be suitable for you because of other medical conditions you may have, and they may interact with other medications you are taking, affecting how these medications work or increasing the risk of side effects.