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Estrogen: Yes, No or Maybe

Posted Nov 30 2008 12:20pm
The New England Journal of Medicine recently reported from the Women's Health Initiative that Estrogen may be beneficial for the heart when started within 10 years of menopause. Now women are confused again and providers are getting calls.

The latest from US News and World Report may help clarify this most recent research on Estrogen.

Estrogen Use: Less Confusion, More Clarity
By Bernadine Healy, M.D.
Posted 6/21/07

Estrogen is not risky and looks to be beneficial for women's hearts when it's begun within 10 years of menopause, says the latest report from the Women's Health Initiative appearing in this week's New England Journal of Medicine. Confused? This sure sounds different from the WHI findings that shook the world a few years back—that hormones brought heart risk, not benefit—and overnight changed how medicine and women viewed what had been seen as a fountain of health.

But if you look closely, you'll see that beneath the confusion is powerful information for post-menopausal women to take to heart (no pun intended) if they're troubled by bouts of drenching sweat or sleepless nights and are trying to figure out whether to give hormones a try. A note, too, is that the mixed messages from hormone studies mostly reflect biological differences among women and the different hormone preparations they've been using. Some key points:

Age matters: In the current study, WHI participants ages 50 to 59 taking estrogen alone (the choice for women who have had hysterectomies) showed up with cleaner coronary arteries and less atherosclerotic plaque, as measured by the amount of calcium detected by a CT scan of the heart. This mirrors the WHI study reported almost three months ago showing that hormones were not at all risky for younger women's hearts and brought some benefit. The studies reinforce each other and explain positive past observational studies of women who seemed to have less heart disease later on—they took up hormones at menopause.

Here is the critical biological difference. Doctors extrapolated from the young women to older women as if they were the same. Hormone therapy became a must for all women, even those in their 70s and 80s—specifically to save their hearts. Accordingly, the WHI had to study women in this older age group. And its first report using combined estrogen and progesterone showing hearts were harmed was a shocker, putting the brakes on hormone use.

Hormone used: But the WHI study using estrogen alone, which came out later and drew far less attention, showed there was no adverse heart effect and may be a benefit. But what the parallel studies taught us is that adding on progesterone to protect the uterus brought with it the heart risk. This failure to show convincing reduction in heart attacks as expected led to an immediate drop in the use of hormones and stopped cold the practice of starting up hormones years after menopause. When they are used for symptoms, it's now at lower doses and for shorter periods.

No free lunch: Does this redeem estrogen? Perhaps. But even more so, it reinforces the notion that there is no one-for-all medicine. Like most medical treatments, hormones can be beneficial for some, neutral for others, and harmful to a few. Hormone replacement reliably relieves post-menopausal symptoms and strengthens bones; it may hurt or help the heart, increase breast cancer risk and lower colon cancer risk; affect the blood so that clots in the legs and lungs are increased. And in older women, estrogen alone or combined with progesterone increases the chance of stroke. This body of information delivered at once may seem overwhelming, but it offers the details that help you and your doctor decide what's best for you, and why.

The Women's Sexual Health Foundation recommends that you always understand the risks and benefits of taking any medication, and to ask your provider what alternatives are available. Do not be shy about asking questions and getting answers. Read the package insert. Talk to women who have taken the medication. Only take a medication if you truly need it. Knowledge is power and it enables you to be your own best advocate for your health and sexual health.
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