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The Hormone Replacement Therapy Controversy

What's a woman to do?...

That's the question many women have been asking given that one of the largest studies of hormone replacement therapy (HRT) ended several years early.

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Researchers found that women taking a combination of estrogen and progestin had a greater risk of breast cancer, heart disease, stroke and blood clots than women who did not take synthetic hormones.

The clinical trial involved 16,608 relatively healthy women, aged 50 to 79, who still had a uterus. Researchers followed them for 5.2 years, though the trial was slated for 8.5 years.

The study suggested that if 10,000 postmenopausal women take estrogen along with progestin in a given year, eight more will have invasive breast cancer, seven will have a heart attack, eight will have a stroke and 18 more will have blood clots than women not taking these hormones.

This is not the first study to suggest that a woman's risk of breast cancer rises the longer she is on HRT. In the Oct. 11, 1997 issue of The Lancet, researchers reported a substantial increase in the risk of breast cancer among women — particularly older women — on HRT, and noted that the addition of progesterone — a common form of HRT — failed to reduce that risk.

Hormone Replacement Therapy Risk in Perspective

When the larger HRT study ended this week, many women who take synthetic hormones immediately called their doctors to find out whether they should stop taking HRT for help with menopausal symptoms like hot flashes and night sweats, or to help prevent heart disease.

Discovery Health Online asked several doctors to put the risk in to perspective. Steven Goldstein, professor of obstetrics and gynecology at NYU School of Medicine, said: "First, this study hasn't changed my practice. We've known of breast cancer risk associated with HRT for some time, and we knew that women with heart disease didn't get any benefit from HRT."

But, Goldstein added, "this study never addressed the women who come to menopause with terrible symptoms." Goldstein believes women can still take HRT in the short term, but cautioned that it must be given on a "case-by-case basis. Patients are individuals and should be treated one at a time."

Despite its apparent downsides, HRT has helped thousands of women manage their menopausal symptoms. "Eighty percent of people after three to four years are devoid of symptoms," said Goldstein. "My advice is, after some period, HRT is totally arbitrary. I say we cut it in half and then let's see how the patient feels. If they're miserable and can't function, then we'll go back on something."

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Hormone Replacement Therapy For Quality of Life

Cardiologist Stephen Sinatra, founder of the New England Heart and Longevity Center in Manchester, Conn., agrees. For women who suffer with heart palpitations, mood swings, night sweats, or dryness of tissues (particularly vaginal), HRT can be a godsend.

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"If a woman takes HRT it must be for quality of life issues," said Sinatra. "It's important to realize that the stress from these symptoms alone can precipitate coronary disease. It's really a double-edged sword."

But Sinatra stressed, "HRT doesn't give you any coronary protection even though its been touted that way for years. If a woman has been taking HRT for a long time, I'd tell her to go off."

Sinatra does not suggest HRT for women who have had a heart attack because of the risk of recurrent heart problems, or for healthy women who have just entered menopause and have no quality of life issues, family history of heart disease, or cardiac risk factors.

"If you're unsure about HRT, discuss the risks and benefits with your doctor so that you can make the best decision," Sinatra said. "There is no pat answer to this question. Every woman is different. Every woman is unique. In other words, there is no one-size-fits all."

The Hormone Replacement Therapy Alternatives

"I think the women involved with the study did a great service," said Neal Sikka, M.D., who practices emergency medicine in Washington, D.C. "They've helped us put to rest use of this therapy [estrogen/progestin] in further treating women and now pursue some of the alternatives that are available to treat or prevent those diseases that women are at risk for during menopause."

So what are the alternatives?

"There may not be a one-pill answer anymore, but there are definitely other options," said Sikka. "Certainly, diet and exercise help prevent disease, as well as quitting smoking, but there are other estrogen drugs like selective estrogen receptor modulators (SERMs) that can help women with symptoms and have also proven effective in treating osteoporosis. While the long-term safety is unknown, there is a trial going on now," noted Sikka.

Sinatra, a strong proponent of alternative therapies, encourages his patients to include estrogen-based foods like soy, tofu, flax and fish oil into their diets. He also recommends herbs like black cohosh and Dong Quai, panax ginseng and chaste berry which — while no major trials have been conducted — have been shown in Europe and elsewhere to help ease menopausal symptoms.

These herbs, added Sinatra, are also a good alternative for women who suffer from premenstrual syndrome.

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