Hormone Replacement Therapy: A discussion with Dr. Diana Hoppe

Background
In 2002, an article was published in the Journal of the American Medical Association entitled Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women's Health Initiative Randomized Controlled Trial. The article concluded that the “overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal US women. The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases, and the results indicate that this regimen should not be initiated or continued for primary prevention of chronic heart disease.”

Subsequent studies, including one published in a more recent issue of JAMA, have clarified the issue for menopausal women interested in finding out more about the advantages and disadvantages of hormone replacement therapy. In this interview, Dr. Diana Hoppe discusses the original WHI study and clarifies the benefits of hormone replacement therapy.

MDLinx: Let’s start by talking about the Women’s Health Initiative article published in the Journal of the American Medical Association over a decade ago. What did that article conclude?

Dr. Hoppe: It concluded that women taking hormone therapy post-menopausal had an increased risk of stroke, heart attack, and breast cancer. The problem with that article is that the average age of the women who were studied was about 63. The women in that trial did not have hot flashes. In addition, 50% of them smoked. So it was not representative of the population undergoing menopausal symptoms and looking for treatment of hot flashes, night sweats, etc. during the early menopausal years. It somewhat misguided a lot of people because a lot of women just went off of hormones at that time because of those results. When you look at more recent research, it ends up showing that the younger women in that study, those age 50 to 59, actually have less risk of heart disease. In addition, the estrogen plus progestin-only group, if you look at that study, had less breast cancer than the placebo group. So now what we are thinking is that perhaps the results from the WHI study were inappropriately extrapolated to younger women – healthy women who really could benefit from hormone therapy in the early years of menopause.

MDLinx: Based on that information, what is the current recommendation for hormone replacement therapy?

Dr. Hoppe: It depends on who you talk to because some organizations will still say that hormone therapy is not recommended for prevention of heart disease or stroke, but if someone is in symptomatic early menopause, having hot flashes, night sweats, and a decrease in sexual function, definitely hormone therapy can be a benefit. They still recommend using the lowest effective dose and the least amount of time.

MDLinx: For this group of women, what are the benefits of hormone replacement therapy?

Dr. Hoppe: For those younger women who are in early menopause, they have improvement in hot flashes, they have improvement of mood, they show a benefit in cardiovascular symptoms, they will have a benefit with sexual function, and for many it is also a quality-of-life issue. They feel overall much better with better mental clarity as well.

MDLinx: What is the best timing for hormone replacement therapy?

Dr. Hoppe: Now what we are recommending is therapy within the first 10 years of the onset of menopause. By definition, that would mean going 12 months without a period and as long as it is within that 10-year period of the onset of menopause, it is recommended that that is the window of opportunity in which we can really help these women. In addition, it helps with the risk of osteoporosis.

MDLinx: What are the risks of undergoing hormone replacement therapy?

Dr. Hoppe: I believe that the risks may have been overly emphasized. When we look at the WHI, there were a lot of issues with that study and some believe it was not that well done. But whatever we take from that study basically it said that for women in their 60s, maybe 10 years past menopause, we should not start hormone therapy to prevent cardiovascular disease in those women. I think some newer studies indicate that it can show prevention of cardiovascular disease in women who are younger and within 10 years of the onset of menopause and that it also helps with quality of life and other symptoms that they are experiencing.

About Dr. Hoppe: Dr. Diana Hoppe (www.drdianahoppe.com) is a distinguished physician in obstetrics/gynecology, highly respected clinical researcher and popular public speaker. She is in private practice in San Diego, California. She is also the founder of Amazing Over 40 Inc. (www.amazingover40.com), a health coaching certification program for women. In addition, she is the author of the book Healthy Sex Drive, Healthy You.