Following the release of the Women’s Health Initiative (WHI) press reports in the US in 2002, the use of hormone replacement therapy (HRT) among women throughout the globe dropped sharply. A new study by researchers at the Keck School of Medicine of the University of Southern California (USC; Los Angeles) has clarified the risks vs. benefits. They conducted a more balanced and evidence based review of more than 40 years of scientific studies and determined that estrogen is a medication that can decrease mortality, cardiovascular disease, osteoporosis fracture, urogenital atrophy, and dementia. When timing of administration, dose of therapy and route of administration are considered, estrogen is associated with low risks and substantial benefits. The authors noted that the decision of whether or not to take HRT for either short symptom relief or for long-term therapy should be based on an accurate risk-benefit analysis. Adjusting the dose of therapy and considering a transdermal (skin patch) approach, particularly in high-risk patients, are important considerations.
The authors made the following recommendations:
- Timing hormone therapy: when started in women under 60 years or within 10 years of their menopause, HRT is not associated with an increased risk of heart disease and many studies show that estrogen therapy actually protects the coronary vessels. Continuing therapy, at least through 65 years of age, appears to continue this protection.
- Minimizing the dose: using the lowest effective dose for menopausal symptoms lowers the risk of side effects and bleeding problems. Low-dose therapy is also associated with beneficial effects on bone metabolism and vaginal tissue.
- Delivery method may be important: Estrogen can be administered by patch, gel, mist, vaginal cream, vaginal suppository or vaginal rings. Use of these non-oral delivery methods minimizes the effect of estrogen on liver proteins. The non-oral delivery methods are recommended for women with suspected or known cardiovascular disease, clotting abnormalities, obesity, hypertension, diabetes, advanced age, or prolonged immobilization.
- Consider high risk factors: Women with a history of breast cancer or active liver disease are generally advised to avoid hormone therapy. Those with heart disease, a history of blood clots, advanced age, longstanding diabetes, longstanding hypertension or those with prolonged immobilization should fully evaluate a risk–benefit profile before initiating hormone therapy and consider low-dose transdermal therapy.
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