Hormone therapy making comeback; Doctors say risks can be minimized

The once-feared hormone therapy is now offered in smaller doses and for a shorter time period, said Dr. Christopher Englert, director of obstetrics and gynecology at Holy Name Medical Center in Teaneck, N.J. "More and more women are coming back to it."

Englert is among the physicians who think too many doctors and patients backed completely away from hormone replacement therapy when really what was needed was some "fine-tuning of our approach to using it."

In the 1980s and 1990s, women going through or approaching the change of life were routinely prescribed estrogen and progestin tablets as a way to prevent severe hot flashes, night sweats, insomnia and other miserable symptoms. Replacing the estrogen their bodies lost in menopause also helped in preventing osteoporosis, and, at the time, hormone therapy was believed to offer a host of other benefits, from preventing heart disease to improving memory and mental alertness.

But in 2002, a watershed study from the Women's Health Initiative found a higher incidence of breast cancer, heart attack and stroke among women using a commonly prescribed estrogen-progestin pill.

The news alarmed women across the country, and they stopped their hormone regimens.

"When the data first came out, most patients took it upon themselves to go off it," said Dr. Joshua Weidman, an OB-GYN on staff at The Valley Hospital in Ridgewood, N.J. "They were just scared by what they were reading and hearing in the news reports. A lot of women still are scared" of the therapy.

In the past nine years, however, the study has continued to be examined. Views about whether the risks of hormone replacement therapy outweigh the benefits - and at what age and for what duration of use women might be negatively affected - have evolved along with that research.

"It's now recommended for treatment of moderate and severe menopausal symptoms," said Dr. Margery Gass, a former Women's Health Initiative principal investigator and current executive director of the North American Menopause Society. "It's not recommended that all menopausal women take it like a vitamin pill to prevent many conditions of aging, which was how it was being recommended 20 years ago."

The WHI research has prompted pharmaceutical companies to offer lower doses of the medication and to make it available in topical forms, such patches and creams, which are believed to offer fewer blood-clot risks than the pills.

But the research is still vague on how long women can be on these lower doses of hormones before their risk of stroke, heart attack or breast cancer increases. Gass said in general doctors seem to put the "safe" number at between three and five years, although the decision is considered dependent on each individual's symptoms and history.

"I think everyone, including providers, get frustrated with the evolving data reports," Gass said.

What's least understood by researchers is the impact estrogen supplements might have on a woman's likelihood of developing breast cancer. While WHI data showed a higher incidence of heart disease among women in their 70s who were on hormone therapy, women in their 50s were found to have lower mortality rates, prompting many to view hormone therapy as safer for women in the peri-menopausal stage and in the first few years after onset.

When Johanna Dolce, 64, entered menopause at 51, she sank into a depression and became prone to angry outbursts. She tried an antidepressant, but what really helped was hormone therapy. She stayed on the estrogen pills for more than a decade, until 2009, when she was diagnosed with breast cancer and underwent a mastectomy.

Her doctors shrugged their shoulders when she asked if the hormone replacement therapy could have fed the cancer's growth, "but in my heart, I know that's what it was," Dolce said. "I tell my daughter and daughter-in-law that they should stay away from estrogen replacement therapy."

Some physicians say they still believe the best approach is to avoid hormone therapy for women who are able to function without it.

"I advise women if they can stay off it, they might be better off," said Dr. Gerson Weiss, chairman of the department of obstetrics, gynecology and women's health at UMDNJ-New Jersey Medical School.

Weiss's concern is that many women, once on hormone therapy, find it hard to wean themselves off. "Once they stop taking it, their symptoms come right back, so they find it hard to give up," Weiss said.

Englert said he knows some physicians who won't prescribe HRT, fearing they'll be held liable if a patient develops heart trouble or breast cancer.

But Englert said he's always believed that the initial study overstated the risks to women, in particular because the average age of the women in the study was 63, a good decade older than the age most women start going through menopause and experiencing the worst symptoms.

He estimates that 15 percent of the menopausal-age patients at his Englewood, N.J., practice are now taking a low-dose form of estrogen, usually in combination with progestin in order to prevent uterine cancer. That's about half the percentage of his patients who were undergoing hormone replacement therapy before 2002.

Englert thinks more women could be spared severe symptoms that alter their ability to enjoy life and remain active if they were more open to the idea of a "judicious use" of hormone treatment.

"You've got a whole generation that thinks estrogen is the Darth Vader of all drugs, and that's a shame," Englert said.

One thing many physicians do agree on in this debate is that the decision to use hormone replacement therapy must be viewed by women and their doctors as matter of personal choice rather than one scripted by medical protocols. That's largely because menopause has different effects on women and because one's risk for other diseases can depend greatly on family history and other health factors.

"This is very much a quality-of-life decision that is individual to each woman," said Linda Klempner, a Teaneck psychologist who specializes in women's reproductive health issues.

Dr. Michelle DeAntonio, a 56-year-old pediatrician with a practice in Haworth, N.J., puts herself in that category. DeAntonio reached menopause early, at age 40, and began taking estrogen pills to control severe symptoms. Four year later, a suspicious lesion was spotted on her mammogram. A lumpectomy revealed atypical cell growth, and she was advised to stop taking hormones to prevent growth of cancer. After six or years of trying to ease her hot flashes and insomnia with diet, exercise and herbal remedies, "I said, 'I can't live like this anymore,'" DeAntonio said.

She was prescribed a low-dose estrogen patch. She doesn't replace it every week as indicated but instead waits eight to 10 days, until she feels her symptoms start to resume.

"I'm really keeping it to as low a level as possible," said DeAntonio, who also has regular mammograms and MRIs. "Everything's a balance, and I'm comfortable with this balance."

(c)2011 The Record (Hackensack, N.J.)
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