Web MD Commentary: The Dilemma of Menopause

Women today live a third of their lives in menopause. Have we ignored what this means?

Three years ago, researchers reported that hormone replacement therapy increased the risk of breast cancer and heart disease, which led to millions of women stopping their hormones. While the true risks attributed to hormone therapy in the study were low, the impact this would have on women's lives was largely forgotten.

Hormone Fallout

Here's what we heard three years ago:

In 2002, the Women's Health Initiative (WHI) showed that after five years of hormone replacement therapy (HRT), a woman's risk of having a heart attack jumped 24 percent.

That's one way of looking at the numbers.

Here's another way.

For every 10,000 women taking hormones (estrogen and a progestin), six more women would suffer a heart attack during a one-year period. In other words, 36 women taking estrogen plus progestin would have heart attacks compared with 30 women taking a placebo.

But these were preliminary data.

After all the results were analyzed, researchers found no overall increase in the risk of heart attack with HRT. Hormones also did not decrease the risk of heart disease - contrary to what was believed for many years.

We now know that HRT should not be used for heart disease prevention.But hormones are the most effective treatment of menopausal symptoms, such as hot flashes and vaginal dryness, which remain the primary reason for using HRT.

Breast Cancer and HRT

So what about breast cancer?

Many women are concerned about breast cancer more than heart disease -- a leading killer of women in the U.S.

The WHI study reported a 24 percent increase in breast cancer risk after five years of using HRT. Again, when described that way it sounds like a very high risk.

A typical woman going through menopause -- age 50 -- has about a 2.8 percent risk of developing breast cancer by the time she reaches the age of 60.

In other words, out of every 100 women aged 50 years old, 2.8 of them will develop breast cancer by the time they reach 60. With HRT, the risk increases to 3.5 women. Less than one additional woman is placed at risk because of HRT.

Another study describes women from the WHI study who took hormones to help preserve mental function. These women were also asked to stop HRT. The initial data showed that there was twice the risk of dementia with HRT use.

More than 4,500 women participated in this section of the study; half were given HRT.

Overall, twice the risk meant that 40 women in the HRT group developed probable dementia -- compared with 21 women who had not taken HRT.

The fallout from these studies was that millions of women stopped taking HRT due to their concerns about heart disease and breast cancer. This left many women living through the menopausal years with no treatment for their symptoms, such as hot flashes and vaginal dryness.

Unanswered Questions

It's unclear how all of these results relate to the average menopausal woman, particularly the woman having menopausal symptoms. When the WHI looked at the risks and benefits of HRT, it did not look at women having these symptoms - only at older women taking HRT for disease prevention.

One area that is unclear is whether or not younger women starting HRT for symptoms would have this same increase in breast cancer risk. But when researchers compiled results of multiple studies, they found that most studies looking at the risk of breast cancer in women on HRT have found no increased risk.

For Women With Symptoms

The most common reason women take HRT has been -- and continues to be -- for the relief of menopausal symptoms.

We know HRT is the most effective treatment for menopausal symptoms.

After stopping HRT, many women have troublesome symptoms including hot flashes, fatigue, difficulty sleeping, excess sweating, depression, and vaginal dryness.

The results of the WHI did not show that women should never take HRT for menopausal symptoms.

HRT can have a positive influence on other menopause-related factors, such as sleep quality, mood, sexual function, and skin changes.

When Hot Flashes Return

In a new study in The Journal of the American Medical Association, more than half the women taking HRT continued to have hot flashes almost one year after stopping treatment.

The study's author concludes "these findings should be considered when advising women to treat menopausal symptoms with hormone therapy for the shortest duration possible."

So what can we do for these women now - and for other women living with menopausal symptoms?

The study suggests that there is no short-term solution for menopausal symptoms.

But menopause does not last for just a year or two. Women live in menopause for a third of their lives.

How will this affect their aging bodies and their quality of life? At this point no one can predict.

While more and more women are turning to alternative therapies to control symptoms of menopause, there is little evidence regarding the safety and efficacy of many of these products.

Relaxation, herbal remedies like black cohosh, and dietary soy are commonly used to treat menopausal symptoms. These may provide relief of 'mild' symptoms in general, but moderate to severe hot flashes may not be relived with these treatments.

Sexual complaints affect a quarter to almost half of women and worsen with age. HRT is effective in preventing and treating these symptoms.

The FDA recommends hormone therapy for the shortest duration possible. The North American Menopause Society says extended use of hormone therapy is acceptable for women if - in their opinion -- the benefits of symptom relief outweigh the risks.

We should stop thinking in short terms. Menopause is not a short-term experience. Women suffering from the symptoms of menopause need to realize that treatment exists, especially in the form of hormone therapy. As doctors we need to continue to address women's fears and treat their symptoms with what is most effective.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have a question about your health, you should consult your personal physician. This event is meant for informational purposes only.

By Brunilda Nazario, MD