Weighing the benefits and risks of hormone replacement therapy (HRT) related to menopause can be one of the most confusing decisions a woman will make over the age of 50.  There is no one-size-fits-all recommendation that can make the choice simple, or standardized chart to reference “if this, then that” scenarios.  Every decision about HRT should be individual, and best when made between a patient and her health care provider.  

Additionally, the care and treatment of menopausal women is complicated by the varied level of training and specialized experience of health care providers related to menopause. Not all OB/GYN’s or other health care providers have studied the latest research related to the potential benefits and risks of HRT in accordance with personal and family health history - research that increasingly demonstrates a window of time where HRT can provide both symptom relief and, in some cases, delay or ward off disease.  

Most problematic is the legacy effect of how providers understand and interpret the seminal research that has been the basis for standardized care for HRT—a study completed two decades ago—called the Women’s Health Initiative (WHI). The 2002 study was conducted with women at an average age of 64- 65, and cited health risks associated with HRT around cancer, blood clots, and heart disease. Many healthcare providers have not kept up with subsequent publications on this data that showed that in women who were younger when they started, the risks are fewer and benefits greater. This has come at a cost to menopausal women suffering from sleepless nights, brain fog, painful sex, and hot flashes.  

Thankfully, attitudes are shifting as new research surfaces.  Both the Endocrine Society and the North American Menopause Society state that for symptom relief, the benefits of FDA-approved hormone therapy outweigh the risks in women younger than 60 or within 10 years of their last period, absent health issues such as a high risk of breast cancer or heart disease. The menopause society position statement adds that there are also benefits of HRT for women at high risk of bone loss or fracture.

With a bit of education, and having an informed conversation with a doctor, OB/GYN, or a menopause specialist, women are moving beyond the decades-old stigma of the HRT health concerns.  They are creating personalized preparedness plans with their doctors as to when hormone therapy, if used as directed, might deliver more benefits than risks.  

3 questions to ask your doctor about HRT

To evaluate with your doctor whether hormone therapy could be right for you, at what age, for how long, and what type, see the below set of questions and considerations to review in advance of your appointment, or to guide conversations with your doctor.  

Based on the severity of how my menopause symptoms are impacting my quality of life and daily routine, would HRT potentially deliver relief?  

  • There are 40+ symptoms associated with menopause.  The most common include hot flashes, vaginal dryness, painful sex, insomnia, fatigue, headaches, joint pain, anxiety, mood swings, memory lapses, digestive problems, and brittle nails.
  • It is up to each individual woman to decide when and how her symptoms are impacting her quality of life and need addressing to provide relief.
  • As some of the above symptoms can be related to other health issues, it is helpful to discuss which tests and screenings could be done to rule out other health concerns.

How might my health history, and that of my family, such as heart disease, strokes, dementia, osteoporosis, etc. factor into the benefits or risks of HRT?  

  • HRT may be especially beneficial if you have a family history of osteoporosis, high cholesterol, and heart disease. On the other hand, it may not be best if you have gynecologic cancer,  or a blood clotting disorder.
  • There is increasing evidence that starting HRT at the transition to Menopause can reduce the risk of Alzheimer’s, as discovered in studies by Dr. Lisa Mosconi.
  • Research on cardiovascular health shows increasing evidence that starting HRT in the early years of menopause can provide cardiovascular benefit with reduced risk of cardiovascular disease. This benefit changes with age, and HRT may become riskier as you get further into menopause.  
  • There is evidence that HRT can help prevent osteoporosis.  
  • If you still have a uterus, Progesterone is recommended along with Estrogen to avoid the risk of uterine cancer. However, progesterone does slightly impact the incidence of breast cancer. The increase in risk is actually very low.  
  • If you have a family history of breast cancer, hormone therapy will not impact your risk (which is based on family history and genetics), and may be a valid choice for you.

Given my symptoms and family history, why type of HRT is best and for how long?  

  • Some of the options for HRT include topical, vaginal, oral pills, and patches—all with pros and cons and are described here.
  • FDA regulated forms are always safest, and your doctor should be recommending these.
  • Length of use of HRT is based on your symptoms and benefits from HRT, and varies woman to woman. There is no set stop date or number of years after which you must stop.  

As research continues to emerge that demonstrates the benefits of hormone therapy for short term symptom relief and long-term risks related to heart, bone, and brain disease, there is no doubt decision making will become easier and standards will shift. Until that time, women at the age of 45 can start a conversation with their doctors about how HRT might be considered as they move through menopause, and under what scenarios.  This can set a valuable benchmark to inform treatment, if needed, in line with their own personal and family health history, and their individual health goals.    

The information on the Gennev site is never meant to replace the care of a qualified medical professional.  Hormonal shifts throughout menopause can prompt a lot of changes in your body, and simply assuming something is “just menopause” can leave you vulnerable to other possible causes. Always consult with your physician or schedule an appointment with one of Gennev's telemedicine doctors before beginning any new treatment or therapy.

 

Author

Wendy Norman

September 13, 2022

Medically Reviewed By

Dr. Rebecca Dunsmoor-Su

Chief Medical Officer

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