Question: I’m 53 and had a hysterectomy two years ago due to fibroids. I recently moved so I had to go to a new OB-GYN. She wants me to consider starting hormone therapy. She said that it would help my hot flashes and vaginal dryness. She also told me that recent studies have shown that by starting estrogen now, my risks of some diseases (even breast cancer!) would be reduced. But my friends and family are all against it because they believe hormone therapy is unhealthy. Can you offer any advice?
Reply: You are facing a common dilemma. For many years, more than 90 percent of women who had a hysterectomy took estrogen therapy. But in 2002, the results of a large study the Women’s Health Initiative (WHI) came out with reported scary results. These results were for only one-half of the WHI study – the half that studied women who still had a uterus and who took one particular combined estrogen/MPA pill. MPA is a form of progesterone, and some progesterone is needed to protect the uterine lining from too much estrogen stimulation. Millions of women, including women without a uterus, just stopped taking ANY kind of menopause hormones.
In 2004, when WHI’s results for women who’d had a hysterectomy came out, the findings did not show these increased risks for estrogen-only treatment. After following the estrogen-treated women for almost 10 years, lo-and-behold, it showed these women had a lower risk for breast cancer and osteoporosis (bone loss predisposing to fractures). In addition, heart attacks and overall lower death rate were reduced if they started estrogen when they were in their fifties. You might think this would make women who had hysterectomies and their doctors decide to use estrogen-only therapy. But it’s very hard to convince people that a drug they thought was harmful is actually helpful. Negative ideas that induce fear tend to stay front-and-center in our minds. Bad news trumps good.
Your friends and family are typical; they heard the bad news in 2002 and that’s all they remember. They (and you too, perhaps) will not easily give up the idea that all forms of menopausal hormone therapy are dangerous. Even going online or reading up-to-date books will not necessarily change what you believe. People tend to stick with what they already believe; they don’t like to admit they were wrong. And people like to believe what their peer group believes. We tend to feel anxious when our views make us feel we are outside the group.
We can only tell you what research now shows to be true. With regard to your hot flashes and vaginal dryness, estrogen therapy is very effective in treating those symptoms. Concerning your health, estrogen therapy would offer you a lower risk of osteoporosis, urogenital atrophy, heart disease, breast cancer, depression, and possibly Alzheimer’s disease and Parkinson’s disease, plus a better chance of living past age 70. Maybe appearance shouldn’t factor into your decision, but estrogen therapy also supports collagen in the skin and helps you avoid tummy weight gain. What are the risks? One risk is developing a blood clot, but there is evidence that using an estrogen patch rather than pills reduces that risk. The original WHI report of an increased risk for stroke is still reported for women who start estrogen after the age of 60.
Why should you believe what this article says? It’s true that hormone advice has flip-flopped a lot. There’s simply no cure for the fact that science is never “done.” All you can do is read widely while trying to evaluate the sources of the information. Always check the dates of articles or blogs. If you have no reason to mistrust your doctor, try to have a decision-making session with her. A list of scientific, peer-reviewed articles is appended to this article in case you and/or your doctor are interested.
As for your friends and family, if you decide to use estrogen therapy, you can try to explain how you arrived at the decision so they will know how thoughtful you are being. You may change some minds. But in the end, this is your body and your life, and you are the decider-in-chief.
References:
Sarrel, P, Njike V, Vinante V, Katz DL. The mortality toll of estrogen avoidance: an analysis of excess deaths among hysterectomized women aged 50 to 59 years. AmJnlPublicHealth 2013; 103:1583-1588. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780684/
The Women’s Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA 2004; 291:1701-1712. http://jama.jamanetwork.com/article.aspx?articleid=198540
LaCroix AZ, Chlebowski RT, Manson JE, et al. Health outcomes after stopping conjugated equine estrogens among postmenopausal women with hysterectomy: A randomized controlled trial. JAMA 2011; 305:1305-1314. http://jama.jamanetwork.com/article.aspx?articleid=896193
Kahneman, Daniel: Thinking, Fast and Slow;Farrar,Straus and Giroux; 2011.p.411.
Ross, Howard J.: Everday Bias; Rowman and Littlefield, 2014 pp14-15 and 31.
Zandi PP, Carlson MC, Plassman BL, et al. Hormone replacement therapy and incidence of Alzheimer’s Disease in older women. JAMA. 2002; 288(17):2123-2129. http://jama.jamanetwork.com/article.aspx?articleid=195464
Thornton MJ. Estrogens and aging skin. Dermatoendocrinol. 2013 Apr 1;5(2):264-70. http://www.tandfonline.com/doi/full/10.4161/derm.23872
Scarabin PY, Oger E, Plu-Bureai G. On behalf of the EStrogen and THromboEmbolism Risk (ESTHER) Study Group. Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk. Lancet 2003;362:428-432. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)14066-4/abstract
Reviewed January 22, 2016
By Michele Blacksberg RN