When considering hormone therapy (HT) for menopause, it’s natural to have concerns. Over the years, conflicting information has been shared, leading many to feel uncertain about the benefits and risks of HT. A significant factor in this confusion is the Women’s Health Initiative (WHI) study, which has shaped much of the public's perception of hormone therapy. In the following years, researchers reexamined the Women's Health Initiative (WHI) trial and found new studies indicating that hormone replacement therapy (HRT) can have positive effects on the heart and overall health of younger women and those who are recently postmenopausal. This means that using HRT in these groups may help lower the risk of heart disease and improve life expectancy.
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The Women’s Health Initiative: Understanding Its Role
The WHI was a landmark study initiated in the 1990s to assess the long-term effects of hormone therapy, particularly its impact on heart disease, breast cancer, stroke, and osteoporosis. At that time, hormone therapy was commonly prescribed not only for managing menopause symptoms like hot flashes and night sweats but also for preventing heart disease and protecting bone health.
The study examined two types of hormone therapy: estrogen alone (for women who had undergone a hysterectomy) and estrogen combined with progestin (for women with an intact uterus). The goal was to determine whether HT offered protective health benefits.
The Results: Creating a Wave of Concern
In 2002, the WHI released its initial findings, which suggested an increased risk of breast cancer, heart attacks, strokes, and blood clots among women taking estrogen-progestin therapy. This news quickly made headlines, and hormone therapy prescriptions saw a dramatic decline as concerns about its safety spread.
While these findings raised valid concerns, they didn’t capture the full complexity of the situation. In fact, many nuances of the study were not widely discussed, and over time, re-evaluations of the WHI data have shed light on several key limitations of the study.
The Shortcomings of the WHI Study
One of the primary issues with the WHI study was the age of the participants. The average age of women enrolled in the study was 63, well beyond the typical age at which women begin menopause (between 45 and 55). Many participants were starting hormone therapy 10 or more years after menopause, which can significantly impact the risks associated with HT.
We now know that starting hormone therapy later in life, after a long period of estrogen deprivation, can increase the risk of heart disease and stroke. In contrast, starting hormone therapy earlier—closer to the onset of menopause—has a different risk profile and may offer protective benefits, especially for heart health.
Another key limitation was that the WHI focused on a specific type of hormone therapy: oral conjugated equine estrogen (CEE) combined with a synthetic progestin called medroxyprogesterone acetate (MPA). These are just one form of hormone therapy, and today, we have a broader range of options, including bioidentical hormones, transdermal patches, and micronized progesterone, which may have different safety profiles.
What We Know Now: A More Nuanced Understanding of Hormone Therapy for Menopause
Since the initial release of the WHI results, further research and re-analyses of the original data have provided a more balanced perspective on hormone therapy. One of the most important insights is the “timing hypothesis,” which suggests that the timing of when hormone therapy is initiated matters greatly. Women who begin hormone therapy within 10 years of menopause are less likely to experience negative cardiovascular effects and may even benefit from reduced heart disease risk. In contrast, starting HT later—after age 60—can increase these risks.
Moreover, hormone therapy has been shown to offer significant benefits for women experiencing moderate to severe menopause symptoms, such as hot flashes, night sweats, sleep disturbances, and vaginal dryness. These symptoms can profoundly impact quality of life, and for many women, hormone therapy can provide much-needed relief. Additionally, HT remains one of the most effective treatments for preventing osteoporosis and reducing fracture risk.
It’s also essential to recognize that the WHI study was not designed to assess the immediate quality-of-life improvements hormone therapy offers for menopause symptoms. The focus was on long-term health outcomes like heart disease and cancer. While these are critical considerations, they do not capture the full picture of how hormone therapy can help women navigate the often-challenging symptoms of menopause.
Finding Balance in Hormone Therapy for Menopause
Before the WHI study, hormone therapy was widely prescribed, often for long-term use. Many women were started on HT even in their 70s and 80s, with the belief that it could protect against heart disease. This widespread use wasn’t fully supported by evidence, and the WHI findings were a wake-up call to reassess hormone therapy's role.
After the WHI results, the pendulum swung sharply in the opposite direction. Many women were abruptly taken off hormone therapy, and fears about its risks became widespread. Unfortunately, this led to women who could benefit from hormone therapy avoiding it, even when it could have significantly improved their quality of life.
Today, we are moving toward a more individualized and balanced approach. Hormone therapy is not a one-size-fits-all solution. The decision to use hormone therapy should be based on each woman’s unique health profile, symptoms, and preferences, guided by the latest evidence.
What You Should Know When Considering Hormone Therapy
If you are considering hormone therapy, it’s important to work with a knowledgeable healthcare provider who can help you weigh the benefits and risks based on your individual health needs and goals. Here are a few key points to keep in mind:
Timing Matters: Starting hormone therapy within 10 years of menopause can reduce certain risks, while starting it later may increase the risk of heart disease and stroke.
Not All Hormone Therapies Are the Same: Different forms of hormone therapy—such as bioidentical hormones, transdermal patches, and various types of progestogens—have different risk profiles. Your provider can help you choose the option that’s best for you.
Short-Term vs. Long-Term Use: For many women, hormone therapy is most beneficial when used for short-term symptom relief during menopause. However, for some, longer-term use may be appropriate for managing conditions like osteoporosis.
Personalized Care Is Key: The decision to use hormone therapy should be based on your personal health history, the severity of your symptoms, and your overall risk factors.
Moving Forward with Confidence
The WHI study sparked important conversations about the risks and benefits of hormone therapy, but it also created fear and confusion. Today, we know much more about the nuanced effects of hormone therapy, and the key takeaway is that individualized care matters.
Hormone therapy can be a powerful tool for managing menopause symptoms and protecting against certain health risks, but it’s not right for everyone. By working closely with your healthcare provider, you can make informed decisions that are right for your unique situation, ensuring you feel empowered and supported during this important phase of life.
If you’re considering hormone therapy or have questions about your options, don’t hesitate to reach out for expert guidance with our NAMS Certified Menopause Providers. Together, we can find the approach that works best for your health and well-being.
Common Questions About Starting Hormone Therapy for
Menopause
Do I need contraception or birth control?
If you want your hormone therapy to serve as contraception and treat menopause symptoms, options include an estrogen-containing oral contraceptive pill or a combination of an estrogen product with the 52 mg levonorgestrel IUD.
It's important to know that pregnancy is possible up until your last menstrual period.
What if I'm still having periods?
You can choose between estrogen-containing contraception and standard menopausal hormone therapy (MHT). Standard MHT (excluding the IUD) may lead to more bleeding irregularities than hormonal contraception, but individual experiences can vary.
Some may prefer hormonal contraception to avoid bleeding issues, while others may want to try MHT, which generally involves lower doses of estrogen. A notable option is the combination of estrogen with the 52 mg levonorgestrel IUD.
If you choose standard MHT, you can take progesterone daily or cyclically for 12-14 days per month. Many providers recommend the cyclic approach to potentially reduce bleeding irregularities, however, this can be individualized. Some women prefer to take a daily pill and find the cyclic approach confusing. Discuss your options with your healthcare provider to find the best approach for your needs.
Have your periods stopped, and are you under 45?
If your periods have ceased before this age, this may indicate primary ovarian insufficiency or premature menopause. A 100 mcg estradiol patch (or equivalent) is recommended until age 51, at which point the dose can be reduced to a moderate or low range.
Are you over 45 and experiencing bothersome menopausal symptoms?
For individuals in this age group, a 50 mcg estradiol patch is typically effective for alleviating hot flashes. Some may respond well to lower doses.
The standard starting doses of estradiol range from 25 mcg to 50 mcg. For those experiencing severe hot flashes, beginning with a 50 mcg patch is often recommended. The dosage can be adjusted later or started with a 25 mcg patch and increased as necessary.
If someone stopped having periods in their mid to late 40's and severe hot flashes are present, starting with a 50-75 mcg patch may be appropriate. For individuals who have undergone surgical menopause during the same age range and previously had regular cycles, initiating treatment with a 100 mcg patch may be considered, with the possibility of reducing the dose around ages 50-51.
Ultimately, the treatment should be tailored to individual symptoms and preferences regarding hormone therapy.
Are you experiencing heavy or frequent periods?
In this situation, your best options are likely oral contraception or a levonorgestrel IUD combined with estrogen.
If you decide to go with standard menopausal hormone therapy (MHT), progestins are usually better at controlling bleeding than progesterone. While progesterone is an option, it may be wise to start with a progestin. Once your periods stop, you can switch to progesterone if you prefer.
Do you have a peanut allergy?
If so, it's important to know that progesterone may not be suitable for you, as many brands contain peanut oil.
Are you at a higher risk for endometrial cancer?
Progestin is the recommended preferred option for the uterine lining protection.
Do you face an increased risk of blood clots or heart disease?
If you are still in the safe range for taking hormones, transdermal therapy the safest option for you, as it has a lower risk of complications compared to oral hormone therapy.
Are you suffering from PMD or PMDD?
If yes, consider oral contraception as it is the most effective treatment option.
References
North American Menopause Society. (2022). Hormone therapy position statement. Menopause, 29(7), 767-794.
Martin, K. A., & Barbieri, R. L. (2023). Treatment of menopausal symptoms with hormone therapy. In P. J. Snyder (Ed.), UpToDate. Literature review current through: Sep 2024. This topic last updated: Nov 20, 2023.
Cagnacci, A., & Venier, M. (2019). The controversial history of hormone replacement therapy. Medicina (Kaunas, Lithuania), 55(9), 602. https://doi.org/10.3390/medicina55090602
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