Myth #3: Menopause Hormone Therapy is Bad for You
The question isn't should you or shouldn't you take hormones; it's what are the risks and benefits for YOU.
Hormone therapy is kind of like New Jersey. It gets a bad rap.
New Jersey is beautiful! It also boasts the most diners per capita in the world. Similarly, menopause hormone therapy (MHT) has a reputation for badness—inevitably causing breast cancer, weight gain, and blood clots.
But when prescribed appropriately, hormone therapy has the ability to extend and improve women’s lives.
Why all the hand-wringing about hormone therapy? It turns out there’s more to it than meets the eye.
First, what is menopause?
Menopause is technically defined as having gone a full calendar year without a menstrual period. The average age of menopause in the U.S. is 51 years, with 95% of women becoming menopausal between the ages of 45 and 55. Menopause occurs when the ovaries no longer make robust amounts of estrogen and progesterone.
What are the symptoms of menopause?
Women who are transitioning to—and fully in—menopause can experience symptoms like hot flashes, night sweats, vaginal dryness, frequent urinary tract infections, low libido, pain with sex, fatigue, forgetfulness, moodiness, irritability, heart palpitations, dry skin, among others.
The severity and duration of these symptoms is highly variable. Some of my patients experience only a month’s worth of body temperature fluctuations, while others are awakened every 20 minutes from hot flashes. Predicting a patient’s menopause story is like playing the slots in Atlantic City; it’s a losing proposition.
Over time, the absence of hormones can promote osteoporosis, cardiovascular disease, premature cognitive decline, and myriad other health issues depending on the patient’s risk factors, lifestyle, and other factors.
Fortunately, estrogen therapy after menopause is safe for the overwhelming majority of women. Of course the risk varies woman to woman, but supplemental estrogen is particularly safe when started within 10 years of menopause or before the age of 60 and when estrogen use is paired with careful attention to the patient’s underlying risks.
But doesn’t estrogen carry an increased risk of developing breast cancer?
The fact of the matter is this: estrogen doesn’t cause breast cancer in the vast majority of women. Are some breast cancers stimulated by estrogen and/or progesterone? Absolutely. But correlation is not causation.
The biggest risk factor for developing breast cancer is being a woman. Estrogen is part of being a woman. This does not mean that estrogen causes breast cancer.
That said, I completely understand why this remains the #1 concern from patients when we discuss hormones therapy. When the Women’s Health Initiative (WHI) came out in 2002, it created a lot of fear and false narratives.
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What did the WHI study show?
The enormous study compared, among of other things, the risk of breast cancer among women who took estrogen and synthetic progesterone to women who did not take hormones.
The headlines screamed, “Researchers conclude that hormone replacement increases the risk for breast cancer!” What wasn’t well reported back then was that in absolute numbers, the risk amounted to less than one additional breast cancer case per thousand women per year. It also didn’t prove causation.
Additionally, women studied in the WHI who took estrogen alone (i.e. not in combination with synthetic progesterone) actually had a decreased risk for breast cancer. This, too, was left out of much of the reporting.
Of course breast cancer is a top cause of morbidity and mortality. Medicine’s job is to help prevent, screen for, and treat breast cancer. But depriving women of the facts about hormone therapy is not okay—especially when the data are clear that the benefits for most women under the age of 60 outweigh the risks.
What are the other risks of estrogen therapy?
In general, estrogen has been shown to reduce the risk of cardiovascular disease if it is started within 10 years after the last menstrual period. Estrogen and progesterone together have been shown to reduce the risk of heart attack. This is important to know because women are more likely to die from heart attack or stroke than we are from breast cancer.
Of course in some women, estrogen may increase the risk for heart attack, stroke, and venous thromboembolism (deep vein thrombosis or “DVT” in the leg), among other things. As with any medical intervention, there is no one-size-fits-all recommendation for everyone.
Also note that it’s possible to reduce one’s risk for cardiovascular disease with lifestyle modifications (like smoking cessation, a low-sugar/high-fiber diet, and regular exercise)—plus medications as needed. Taking estrogen in a patch form instead of pills, for example, can reduce the risk for blood clots.
In other words, health is about knowing our unique risk profile—and then accepting the risks we cannot control while working on the risks we can change.
Do you have to take estrogen and progesterone together?
Yes, if you have a uterus. Estrogen therapy, when taken alone, increases the risk of developing cancer of the uterus. Adding progesterone essentially abolishes that increased risk. Women who have had a hysterectomy (removal of the uterus) do not need to take progesterone to offset the increased risk from “unopposed” estrogen.
The other upsides of progesterone is that it can help with anxiety, mood, sleep, and other menopausal symptoms.
Is HRT prohibited in women over age 60?
No. The risks are higher—and the likelihood of estrogen helping with symptoms lower—however the decision to start hormones at any age should be individualized and centered on the patient’s unique symptoms, risks, and potential benefits. In other words, I never say never.
Want more good news about hormones?
A recent new study out of the U.K. looked at over 40 thousand women with breast cancer, comparing them to over 400 thousand women who had never taken hormones. The study was conducted over the course of 29 years and found that:
Women who used estrogen alone (without progesterone) did not have an increased risk of developing breast cancer compared to women who did not take hormones. This confirms exactly what the WHI found in 2002.
An increased risk of breast cancer was observed only in the group of women who took estrogen and a synthetic progesterone. Women who took estrogen and micronized progesterone had no increased risk of breast cancer. Why didn’t the WHI find that micronized progesterone had no effect on breast cancer? Because they didn’t study it! (They only studied synthetic progesterone.)
What about weight gain?
This is the second most common concern that my patients have when considering HRT. Of course it’s always easier to gain weight than to lose weight, but HRT itself isn’t thought to be associated with weight gain. In fact, hormones can actually promote retention of lean body weight, especially if paired with a healthy diet and resistance/strength training as part of a regular exercise routine.
What about cognitive decline, sex drive, bone health, and all the other things that can happen to women after menopause?
Hormones are not a panacea, but suffice it to say that they can help with all of the above. In my humble opinion, women deserve an honest conversation with their health care providers about evidence-based reasons not to take hormones given the myriad potential benefits. Even the Northern American Menopause Society issued a new statement trying to reverse the narrative about the dangers of MHT and allow for more nuanced conversations about risks and benefits!
Menopause is defined as having gone a full calendar year without a menstrual period. A woman’s midlife decline in estrogen and progesterone levels can cause short-term symptoms and can increase the risk for long-term health problems.
In general, menopausal hormone therapy (MHT) is considered safe for most healthy women who are within 10 years of menopause or are under age 60 and who do not have contraindications.
Estrogen itself does not seem to increase the risk of breast cancer for the vast majority of women.
Unless she has had a hysterectomy, a woman should take estrogen and progesterone together.
Micronized (aka “bioidentical”) progesterone does not increase the risk of breast cancer; synthetic progesterone does seem to increase the risk, but only slightly.
Too many women needlessly suffer through menopause because of false narratives about the safety of MHT and because discussions about quality of life often aren’t prioritized.
Don’t take it from me! I encourage you to share the latest expert statement from the North American Menopause Society with your own doctor to help guide your decision-making process.
Women are entitled to make their own decision about hormones, armed with the data, and with an understanding of their unique risks and benefits.
And now…the queen of nuance herself joins me this week on Beyond the Prescription.
My dear friend, journalist Meghan Daum has never been one to mince her words. In her best-selling books and on her podcast, The Unspeakable, she tackles some of life’s thorniest issues—from gender politics to death and dying—with bold honesty and humor.
In this episode of Beyond the Prescription, Meghan gives me an unreserved look into some of her most vulnerable moments, including losing her mother and being placed into a medically-induced coma. Meghan’s fresh take on life, death, and health are just what the doctor ordered.
I will see you next week. Until then, be well.