Perspective on the Risks of HRT

by Marcelle Pick, OB/GYN NP

Over a year has passed since the publication of the first of the Women’s Health Initiative studies on the risks of HRT, and newer studies regularly appear, all adding to the impression that synthetic HRT is dangerous to your health. This seems a good time to put some perspective on the findings that caused such concern and confusion – among women as well as among their health care providers.

There is no loss of urgency on the issue. Over 13 million women were on some form of HRT before the initial studies were published. Millions quit “cold turkey” and saw their symptoms rebound. Millions stayed on HRT but live in fear of the consequences. And millions of women have been moved onto antidepressants as pharmaceutical companies have campaigned to position those drugs as substitute products – even though most of these women are not depressed and are thereby exposed to a new set of potential side effects.

While we agree that women should consider alternatives to synthetic HRT, most of the fear and confusion is unnecessary. Let’s start with the point of view that in light of the studies, all HRT is bad and no one should use it.

Before the WHI study, about 8 million women who had had hysterectomies were on estrogen therapy, and another 6 million were on a combination of estrogen and progesterone, as recommended by their practitioners. The great majority of these women were on either Prempro or some other combination of Premarin, and because Prempro was the drug used in the WHI study, it’s understandable that so many felt some combination of fear and panic.

First, note that the studies published to date all concern synthetic HRT, specifically Premarin and Prempro. They say nothing about bio-identical hormones.

Second, the women in the WHI studies were on HRT after menopause, which is most often unnecessary therapeutically and obviously unnatural. The most common therapeutic use of HRT is for perimenopausal symptoms. So we can’t say the WHI studies really predict the health risks for women in their 40’s who are the typical users of synthetic HRT.

Third, there clearly are women who want HRT – even synthetic HRT. We believe they are entitled to make that choice for themselves.

Now let’s turn to the other point of view – those that say HRT should still be considered safe because the absolute risks are small, and, as they claim, there’s no good alternative.

First, consider that there is a mountain of evidence indicting synthetic HRT. Alternative practitioners have recognized the problems with synthetic HRT for many years. There are dozens of studies documenting its adverse health risks. In fact, it’s disappointing that it’s taken a massive government program like the Women’s Health Initiative to change the standard of care.

Second, while the higher risks are small in absolute terms, the increases in relative risk are significant. To take heart attack as one example, the study means that out of 10,000 women on Prempro, an extra 6 would have a heart attack each year compared to women not on Prempro. That may not seem like a substantial risk. But it is a much greater relative risk.

The WHI study indicated that the increase in the relative risk for breast cancer was 26%, for heart attack 29%, for stroke 41%, for blood clots 100%, and for Alzheimer’s or dementia, over 100%. Many of the top problems in women’s health are on that list.

Third, there are good alternatives to synthetic HRT. Most women don’t even require hormone therapy. (As one writer put it, saying hot flashes are the result of an estrogen deficiency is like saying a headache is the result of an aspirin deficiency.) For those who do, they will generally get better results from bio-identical hormones, for which there are no known health risks.

I generally recommend that women on Prempro or Premarin consider other options. The foundation should be a program of nutritional and endocrine support such as Women to Women’s Personal Program. If that is not sufficient to bring relief of your symptoms, or if you are a woman under 40 who has had her uterus or ovaries removed, the other option is a compounded form of estrogen and progesterone that is bio-identical to the formulation found naturally in the human female body.

When switching over from Premarin or Prempro to a natural form of estrogen, there is a transition period, as the estrogen receptors have been primed by the synthetic molecule and cannot accept other forms, even a woman’s own. When a woman chooses to go off Premarin, I generally recommend that they take two to four months, and not stop “cold turkey”. If they do stop abruptly, they may experience extreme hot flashes and vaginal dryness, or any of the other symptoms that caused them to turn to HRT in the first place. (There is a special version of the Personal Program for women transitioning off HRT. Click here for more information.)

There are a number of nutritional supplements available that can be extremely helpful. A good quality multivitamin combined with calcium, magnesium and essential fatty acids (such as in Women to Women’s Essential Nutrients) are critical in diminishing the number of symptoms that occur after one stops hormone replacement therapy.

Besides the nutritional and endocrine support provided in the Personal Program, I would like to emphasize the importance of regular exercise, and perhaps even weight training. Although this may seem like a lot of things to do for oneself, it will make a huge difference in terms of the number and intensity of symptoms one experiences after stopping Premarin or Provera.

The use of black cohosh as well as soy (80-160 mg of isoflavones a day) will also help abate the symptoms of hot flashes. (Be sure to avoid genetically modified soy; choose products labeled “Non-GMO”.) The lovely thing about soy is that it has also been noted to be helpful in reducing the risk of heart disease; some studies have demonstrated improved bone density; and most recently studies have shown its ability to decrease the response of insulin in the body, which is particularly important for those who are insulin resistant or diabetic.

Women take control of their health in stages. You begin by reading and increasing your awareness. Next comes working with your practitioner, or perhaps finding a more appropriate practitioner. You also begin to help yourself, taking action across your whole life to improve your nutrition and metabolism, reduce stress and make time for yourself. These steps unlock your body’s ability to heal itself. And it’s never too late to begin to heal.