Transcript of a hormone therapy chat with Dr. JoAnn Manson

Dr. JoAnn E. Manson: Hi, I'm Dr. JoAnn Manson, an endocrinologist at Brigham and Women's Hospital and one of the Principal Investigators of the Women's Health Initiative. I'd be happy to answer any questions you may have about our recent study in the Journal of the American Medical Association. The study looks at how the effects of hormone therapy may vary according to a woman's age and time since menopause.

risky business: I, like most readers, I suspect, am pretty ignorant when it comes to medical terminology. Can you offer a "laywoman's definition" of what this hormone thing is all about?

Dr. JoAnn E. Manson: Hormone therapy is often taken after menopause to treat symptoms of hot flashes, night sweats, and other menopausal symptoms. It can include estrogen-alone (for women who have had a hysterectomy) or estrogen combined with a progestin (for women with an intact uterus). It has both benefits and risks and it can be a difficult decision for women to make an informed choice about its use.

Patty: to finish, at age 51, I have annual mammograms, easy to exam breasts. How long can I safely stay on HRT?

Dr. JoAnn E. Manson: We generally recommend the shortest treatment period necessary, usually only 3-4 years. The risk of breast cancer begins to increase after 4-5 years of combination estrogen plus progestin therapy, so we recommend using the lowest effective dose to relieve symptoms and using the hormones for the shortest duration of time necessary. Most women are able to discontinue hormone therapy after 3-4 years of use. Women who have a hysterectomy and removal of their ovaries at an early age may need a longer duration of treatment, though.

Jo: Can you describe the new findings and how they are revising what was revealed in 2002?

Dr. JoAnn E. Manson: Thanks for this question, Jo. The new findings are a more detailed look at the health effects of hormone therapy in younger vs older women. Combining the results from the two WHI hormone therapy trials (the estrogen plus progestin trial and the estrogen-alone trial), we have an improved and refined understanding of how a woman's age and time since menopause influence her health outcomes on hormone therapy. Overall, we found more favorable results for younger than older women, in terms of heart disease and total mortality. The findings provide some reassurance for recently menopausal women who are considering hormone therapy for treatment of menopausal symptoms.

Patty: How does family history of breast cancer enter into the decision? My mother had post-menopausal node negative breast cancer. She has 4 sisters. One had pre-menopausal node positive breast cancer. There is no other breast cancer among her sisters or among my 2 sisters. Dose annual mammography seem to be enough monitoring while on HRT?

Dr. JoAnn E. Manson: Women who have a family history of breast cancer should avoid long duration of hormone therapy. If hot flashes are very severe, it may still be reasonable to take the hormones for 2-3 years but it would be best to avoid longer use. While on hormone therapy and afterward, it's very important to have regular mammograms, clinician breast exams, and to do breast self-exam.

cgcmitch: I am currently take prgestrin for endometriosis and it does not seem to be helping t all

Dr. JoAnn E. Manson: There are many other treatments available for endometriosis. Not all women will respond to progestin or to any specific treatment. It's important to see a specialist in this area and to discuss all the treatment options that are available to you. Hope you're able to find a treatment that's effective.

mia: Please comment on the risks associated with HRT for women who experience surgical menopause in their early 40's and begin HRT immediately after surgery. Assume no family history of breast cancer.

Dr. JoAnn E. Manson: That's a great question, Mia! Women who have an early surgical menopause (removal of ovaries before age 40 or 45) may be able to take estrogen for a longer period of time than women undergoing natural menopause at a later age. First, she can take estrogen-alone without the addition of a progestin (the progestin is added onlty to protect the lining of the uterus, so it's not necessary in women who have had a hysterectomy). Also, the early loss of estrogen might lead to an increased risk of osteoporosis and heart disease, and some experts believe that taking estrogen may be helpful to prevent these complications. Lastly, estrogen-alone is less likely than estrogen plus progestin to increase risk of breast cancer, so it may be possible to take it for a longer time. Many experts think it's reasonable to treat women with early surgical menopause until ~ age 50 or 51, the average age at menopause. However, estrogen shouldn't be taken indefinitely and it's still very important to have regular monitoring for breast cancer and other possible risks of hormone therapy.

janie: I had a total hysterectomy at age 38 and was on premarin 6.25 mg for 14 yrs. when results of the 2002 study came out, I immediately stopped taking the premarin. That was 4 yrs ago and I have had no problems. Had bone density scan and that was fine. Do you think I did the right thing by stopping the hormones?

Dr. JoAnn E. Manson: I think you did just the right thing. You took estrogen up until the average age at onset of menopause and then you stopped. If you haven't had any problems since and you're not having moderate-to-severe hot flashes or night sweats, I wouldn't recommend restarting.

caitaly: Dr Manson, are there risks for menopausal women with a history of colorectal cancer to take hormones for the hot flashes and other discomforts?

Dr. JoAnn E. Manson: This is a very interesting question. Several studies have suggested that combination estrogen plus progestin may lower (not raise) the risk of colorectal cancer, although it isn't recommended that you take it for this express purpose. To my knowledge, there's no convincing evidence that it will increase risk of colorectal cancer, especially if taken short-term. Overall, I'd recommend that you check this out carefully with your doctor and your oncologist, but short-term hormone therapy for your symptoms may be a reasonable choice.

Patty: How do these finding effect the decision to remove ones ovaries during hysterectomy? Assuming the problem is not related to the ovaries? Should women request the option of retaining their ovaries? Is there an age or point that the ovaries should come out regardless?

Dr. JoAnn E. Manson: This is a good question, Patty, and there's a lot of controversy about this. Most doctors would recommend leaving in the ovaries (unless there's a family history of ovarian cancer or other concerns about increased risk) until at least age 50 in women having a hysterectomy. Some experts would even recommend leaving them in when hysterectomy is done at age 60 or 65. However, many experts recommend taking them out at older ages. Overall, there's still a lot of controversy about what to do when women are in the 50-65 year range.

Andrea: Hi Dr. Manson. I'm 45 years old. I've been on birth-control pills nearly all of my adult life. I'm experiencing some symptoms of perimenopause at this point, and have little or no bleeding anymore during the time of the month when I would get my period. My gynecologist says it's safe -- and perhaps even beneficial -- for me to stay on the pill for now. What do you think? How will I know when I'm menopausal since I already don't menstruate?

Dr. JoAnn E. Manson: Another great question! I do think low-dose birth control pills are a reasonable option under these circumstances. It may be necessary to discontinue the pills for at least a cycle in order to check an FSH level and to see if your menstrual bleeding returns. Admittedly, this can be a little tricky. If you switch to hormone therapy before you're menopausal, you won't get the same contraceptive benefits that you get from the birth control pills (believe it or not, unplanned pregnancies can occur at a fairly high rate in this scenario). You may have to work closely with your doctor to figure out the best timing for a switch, if you decide you'd like to take hormone therapy.

caitaly: Follow-up question, a woman treated for colorectal cancer enters menopause due to the radiation treatments, are there additional risks because of the preexisting cancer?

Dr. JoAnn E. Manson: Probably not, but it's very important to check this out carefully with the oncologist. As previously mentioned, there's even some evidence for lower risk of colorectal cancer with E+P, but I don't think hormone therapy should be taken for that specific reason. Depending on tumor characteristics, the oncologist may be able to advise you. Women with estrogen-sensitive (or progestin-sensitive) tumors should not take hormone therapy. In general, preexisting cancer may be associated with an increased risk of clotting, and this would be a reason to avoid taking hormone therapy (particularly oral treatment, which can increase clotting factors).

mare: what natural methods do you recommend for mild menopause?

Dr. JoAnn E. Manson: For mild-to-moderate symptoms, there are several lifestyle modifications and natural remedies that may be helpful. Wearing layered clothing, lowering room temperatures, using fans and air conditioning, regular physical activity, and avoiding spicy foods, alcohol, and caffeine can be helpful for some women. Increasing soy in the diet (soy milk, soy nuts, tofu, etc) can also be helpful. Some prescription antidepressants and an antiseizure medication have also shown some efficacy in clinical trials. But, for severe symptoms, most studies show that estrogen tends to be the most effective option available.

Maryd410: I had a surgical menopause at age 46. I am now 49. due to an oversight, I was not given estrogen (my original diagnosis was endo cancer) and I now have severe endocrine issues. Could this have been the cause??? I was without estrogen for 5 months.

Dr. JoAnn E. Manson: This is a difficult question to answer but, if you didn't have endometrial cancer and you have moderate-to-severe symptoms of menopause, you may still be a reasonable candidate for hormone therapy. I'd certainly avoid taking it if you had any evidence of endometrial cancer (usually an estrogen-sensitive tumor). If you would like to take hormone therapy to treat menopausal symptoms, being 3 years past menopause would not disqualify you (you're still very young and even below the average age of menopause in the U.S. -- which is 51 years).