West Virginia University students El Didden, Lia Farrell and Bri Caison demonstrate medical procedures needed for hormone replacement therapy, in Morgantown, W.Va., on March 8.Kathleen Batten/The Associated Press
Hormone replacement therapy should be the first treatment offered to women under the age of 60 who are suffering from hot flashes, night sweats and other disruptive symptoms of menopause, according to a review of the scientific literature released Monday.
The new study, published in the Canadian Medical Association Journal, reinforces a shift that was already under way. Hormone replacement therapy (HRT), once considered too risky for most women, is now back in the good graces of many doctors who say an influential trial from two decades ago exaggerated the dangers of the treatment, particularly for younger women.
“There was at the time – which was now 20 years ago – a massive reduction in hormone therapy prescription and a great amount of fear,” said Iliana Lega, an endocrinologist at Women’s College Hospital in Toronto and one of the authors of the new paper. “Frankly, what happened in the medical community is that there became a real lack of education. People stopped teaching and learning about menopausal treatments and hormone therapy.”
Dr. Lega and her co-authors are hoping to help rectify that with their review, which synthesized the evidence from every study of the subject published in a medical journal database up to April of last year and includes concise recommendations for other doctors.
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Their conclusion was that HRT should be offered as the first choice to women grappling with menopause symptoms, so long as patients are younger than 60 or less than 10 years out from their last period and don’t have specific risk factors such as a personal history of breast cancer, coronary artery disease or stroke.
That aligns with recent recommendations from major medical groups such as the Society of Obstetricians and Gynaecologists of Canada, the Canadian Menopause Society and the North American Menopause Society.
“For many women, this has been a very big issue,” said Wendy Wolfman, director of the menopause and premature ovarian insufficiency clinics at Mount Sinai Hospital in Toronto. She was not involved in the new study.
“It’s also an issue for our society because women reach the peak of their productivity right around the time when they become symptomatic. They’ve worked all these years to be good at their job or their career and they can’t advance if they feel awful all the time.”
Although menopause is defined as the point one year after a woman’s last period, the symptoms leading up to and following that milestone – including hot flashes, night sweats, sleep disruption, mood swings, brain fog and vaginal dryness – can last up to a decade as estrogen levels drop.
Some women find the symptoms tolerable and don’t seek treatment, said Michelle Jacobson, a menopause specialist at Women’s College and another author of the new study. But others experience debilitating ailments.
“There are studies that have tried to compare and quantify the impact of symptoms,” said Dr. Jacobson. “For some women, this is as bad as needing to be on dialysis for kidney failure.” (Dr. Jacobson disclosed in the paper that she has received funding from pharmaceutical companies that sell hormone replacement therapies.)
Hormone replacement therapy is a medication that consists of either estrogen or a combination of estrogen and progestin, a synthetic form of progesterone. The therapy was widely prescribed until 2002, when the initial findings of a large, randomized control trial called the Women’s Health Initiative dealt a near-death blow to HRT.
The trial, which enrolled more than 27,000 women, was designed to see if HRT could help prevent chronic disease in women 50 to 79. But researchers overseeing the trial stopped it early when they learned the opposite appeared to be true: Participants on HRT had more cases of breast cancer, blood clots, heart disease and stroke than those taking a placebo.
Women in the HRT arm of the trial also had fewer cases of colorectal cancer and hip fractures, but the risks of HRT were deemed to outweigh its benefits. HRT prescribing fell off a cliff.
Since then, reanalyses and follow-up of the initial WHI data have zeroed in on the differences between how women under 60 (or less than 10 years out from menopause) and those over 60 fared on HRT. Those studies found that the benefits of relief from hot flashes, night sweats and other menopause symptoms outweighed the risks if started in healthy women at the right age.
Some organizations are still wary of HRT. The Canadian Cancer Society, for instance, recommends “women avoid taking HRT for any reason other than to relieve severe menopausal symptoms that have not responded to other treatment.” If they do choose HRT, they should take the lowest dose for the shortest time possible, the society says.
However, Michelle Bilton, a spokeswoman for the Canadian Cancer Society, said that statement is being reviewed.