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Answers by Jannet Huang, MD, FRCPC, FACE, ABHM., Menopause Clinician and board certified in Endocrinology & Metabolism

What are the benefits of menopausal hormone therapy proven by large studies?
Does HT help with sleep, mood and sexuality?
Will HT keep me looking and feeling young?
What are the risks of HT? Who should not take HT?
What about breast cancer risk?
How about the birth control pill – does it increase risk of cancer?
I have family history of breast cancer. Can I take HT?
I had a history of breast cancer. I was taken off my HT when my diagnosis was made, but I am miserable. Can I take HT?
I have family history of cardiovascular disease. I hear HT may increase heart attacks and stroke. Is that true?
Should every woman take HT? How long should I stay on HT?

What are the benefits of menopausal hormone therapy proven by large studies?

Menopausal hormone therapy (HT) is the most effective therapy to reduce hot flashes and night sweats. No other therapy is as effective as estrogen for these vasomotor symptoms. Estrogen also helps reduce vaginal dryness. Published studies have shown clear benefits of HT on prevention of bone loss and fractures as well as reduction of colon cancer risk. There is also study evidence that HT may reduce macular degeneration.

Does HT help with sleep, mood and sexuality?

Many women will derive benefits from HT on their sleep quality, mood and overall sense of wellbeing. There may also be improvement in sexual desire. Please keep in mind though multiple other factors affect our sleep, mood and libido. Stress (physical, emotional, social, economic, etc), in particular, play a critical role.

Will HT keep me looking and feeling young?

Collagen production declines with menopause and the resultant decline in estrogen levels. This translates to reduced skin elasticity (and therefore wrinkles), and joint stiffness and aching in many women. Estrogen replacement in many can e helpful in preserving skin elasticity and may reduce the joint aches. Women who take HT may therefore look and feel younger. However, it is important to have realistic expectations. Hormone therapy is certainly NOT the fountain of youth and should not be considered an “anti-aging” treatment. I prescribe HT to enhance quality of life, not to reverse or prevent aging, which I feel is an unrealistic goal.

What are the risks of HT? Who should not take HT?

In my opinion, the only unarguable risk of oral HT is an increase in blood clotting risk (venous thromboembolism). Transdermal delivery (patch, gel, mist applied on the skin) of estrogen is absorbed directly into the blood stream and thus avoids the liver first pass effect. Transdermal estrogen therefore does not increase clotting risk. Recent studies suggest that transdermal estrogen does not further increase in clotting risk even in women with genetic blood clotting disorders (eg. Factor V Leiden mutation).

Elevated triglycerides may be aggravated by oral estrogen therapy. Again, transdermal use of estrogen eliminates this issue. Women with severe liver or gallbladder diseases should not take oral estrogen therapy.

Women with active breast cancer, uterine cancer, or unexplained postmenopausal vaginal bleeding should not take HT.

What about breast cancer risk?

The fear of breast cancer is the most common concern that I hear from women when we discuss HT. I believe the literature findings suggest estrogen does not create breast cancer, but estrogen may act as a “fertilizer” and make pre-existing breast cancer cells grow faster. Some studies even show women who were diagnosed of breast cancer while on estrogen therapy may actually have a better prognosis than women who were not taking hormones. Breast cancers diagnosed in women on estrogen therapy tend to be less aggressive. Even if we the studies indicating a 30-40% increase in breast cancer in women using combined hormone therapy (estrogen and progestin) to be valid, we need to keep in mind there are a number of other factors that may increase breast cancer to the same degree — eg. gaining 20lbs or more in adulthood, drinking more than 1.5 alcoholic drinks a day, never having been pregnant, etc. An accepted theory about the formation of cancer is the “multiple hit theory” — multiple “insults” (eg. genetic susceptibility, environmental toxins, stress, etc) have to happen before a cancer develops. Some scientists believe that the “first hit” in breast cancer actually happens when a person is developing in the womb! Moreover, we need to keep the magnitude of risk in perspective. Let’s look at a well documented carcinogen - no one will argue about cigarette smoking being a cause of lung cancer. Cigarette smoking increases risk of lung cancer by 40 times, and that is 100-fold different than the magnitude we are talking about regarding hormone therapy and breast cancer. To further the “confusion” — a recent study (which confirms some very old findings) showed that the use of estrogen therapy may be helpful in some women whose breast cancer has become resistant to tamoxifen and metastasized. Ultimately a woman needs to evaluate her own needs and risk factors and make an informed decision together with her personal physician.

How about the birth control pill — does it increase risk of cancer?

No. The worldwide experience of birth control pill use has not shown any increase risk of breast cancer. The use of the birth control pill may actually protect from the risk of ovarian cancer. It is safe to use a low dose birth control pill (or contraceptive patch / vaginal ring) in perimenopausal women up to the age of about 52, and is actually a good choice for women who need contraception in addition to relief of perimenopausal symptoms.

I have family history of breast cancer. Can I take HT?

There has actually been NO evidence that estrogen therapy increases the risk of breast cancer in women with a family history of breast cancer. In women who have the BRCA (1/2) mutations which place them at very high risk of breast cancer, bilateral oophorectomy (removal of both ovaries) prior to menopause has been found to significantly reduce their risk of breast and ovarian cancer. The use of estrogen therapy in these high risk women has been shown in a study released in 2008 to NOT affect the reduction in risk they derive from oophorectomy. In fact, I highly recommend women who have had oophorectomy for breast cancer risk reduction take estrogen therapy since the surgical removal of ovaries (especially at a young age of <50) increases the risk of cardiovascular disease and dementia. I don’t think it would be fair for women to undergo a drastic surgery to reduce their risk of breast cancer to end up getting elevated risk of another big problem!

I had a history of breast cancer. I was taken off my HT when my diagnosis was made, but I am miserable. Can I take HT?

This is a much trickier question. Of course oncologists say absolutely no estrogen therapy for women with a history of breast cancer. However, there has actually been NO study evidence that use of estrogen after breast cancer would increase the risk of recurrence. In the much older literature, there were even studies suggesting a decreased risk of recurrence in women who took estrogen after breast cancer. In a woman with “hormone-sensitive” breast cancer positive for ER (estrogen receptor) or PR (progesterone receptor) should probably not take HT. However, this should be an individual decision. We all have different philosophies. I think that women with a very compromised quality of life due to estrogen loss should be “allowed” to make the decision for herself whether she wants to take HT or not. Again, this is a challenging situation that I would not suggest making a decision lightly.

I have family history of cardiovascular disease. I hear HT may increase heart attacks and stroke. Is that true?

WHI (Women’s Health Initiative) study found an increase in heart attacks and strokes in women taking premarin-provera as combined hormone therapy. However, WHI has many flaws. I believe the reason why they found an elevated risk of heart attacks and strokes is because they studied the “wrong” population of women. The women who participated in WHI were on average aged 63 and on average 10-20 years beyond menopause when they started on HT. 40% of the participants were smokers, 34% of them were obese and more than a third had high blood pressure at the beginning of the study. This was really not the right group of women to evaluate the question of whether HT can prevent cardiovascular disease. The analysis of the women aged 50-59 (representing 10% of the study participants) in WHI who took HT had less plaque in their coronary arteries as shown on coronary calcium scanning, suggesting a protective benefit in women who initiated HT closer to the time of menopause.

Should every woman take HT? How long should I stay on HT?

No. HT is not the panacea for women. Each woman must look at her own individual needs and risk factors and their own priorities / philosophies to make an informed decision, together with her own personal physician with expertise in menopausal hormone management. I believe that women who do well on HT should stay on HT for the rest of their lives. If a woman who benefits and feels well on HT, her body is telling her that she needs HT. If she stops her HT, then she is putting her body through menopause again. Whereas for a woman who does not feel well (or have side effects) on HT, their body is giving them a different message so HT would not be appropriate for her. (On a personal note, I won’t let my mother come off HT. She tells me on the phone from time to time that her doctor wants her off HT. My response to her is “You are staying on HT. If your doctor really wants to take you off HT, have him talk to me first! I will educate him.”)

Answers by Jannet Huang, MD, FRCPC, FACE, ABHM., Menopause Clinician and board certified in Endocrinology & Metabolism