by Patrick J. Naples, M.D.

In last month’s article “In Defense of Estrogen” I tried to explain how estrogen therapy for treatment of menopausal symptoms is a good and safe therapy for the majority of women.  Estrogen is the only treatment proven to address the myriad symptoms associated with menopause and is the most effective treatment for hot flashes and night sweats.  Medications such as Effexor, Neurontin, and natural supplements with phytoestrogens found in soy, black cohash, etc. may diminish hot flashes but not to the same extent as estrogen nor do they treat other problems associated with menopause. During the perimenopausal transition, ovarian production of estrogen, progesterone, and testosterone firsts begins to fluctuate and eventually stops altogether. The initial and most obvious results of this are irregular bleeding, intermittent hot flashes and night sweats, concentration difficulties, sleep disturbance, and fatigue. The long term result from the lack of estrogen may result in an increased risk for heart disease, stroke, osteoporosis, colon cancer, macular degeneration, urinary urgency, vaginal dryness, redistribution of fatty tissue to the abdomen, diminished sex drive, changes in skin appearance, and insulin insensitivity with possible development of diabetes. Estrogen receptors are contained in tissue throughout the body, that is why there is such a widespread impact from menopause and reduced estrogen production.

The “Woman’s Health Initiative” (WHI) study first released in 2002 was looking at estrogen to see if it should be given to all menopausal women to lower their risk for heart disease which is the number one cause of death in women after menopause. This study determined that it was not safe to recommend it uniformly to all menopausal women. What was lost in the release of the results is that it is a safe and effective treatment for the majority of women for specific indications. In other words, the woman and her doctor need to consider the risks and benefits for that particular individual to see if the benefits outweigh the risks. In the vast majority of women the benefits do outweigh the risks.

What are the risks associated with estrogen use? The biggest fear that women have concerning estrogen is that it causes breast cancer. The WHI study showed an increased occurrence of breast cancer in women who used a combination of estrogen and progesterone (EPT) for 5 years; there was no increased occurrence of breast cancer in women who took only estrogen replacement. In those women on EPT it is more likely that the EPT unmasked already existing breast cancer and did not actually cause breast cancer. The increased occurrence also was not large. The baseline risk for a woman 51 years old of developing breast cancer in her lifetime is 2% or in other words she has a 98% chance of not developing breast cancer. The increased occurrence with EPT is 25% which means her new lifetime risk for developing breast cancer is 2.5% or she now has a 97.5% chance of not developing breast cancer in her lifetime. You can see that this possible increased risk of developing breast cancer on EPT is extremely small.  Even this level of risk is now being questioned. The other most common risk associated with estrogen use is the development of blood clots that may result in pulmonary embolism or stroke. This risk is of a similar magnitude as the risk of breast cancer, higher but not excessive. Another risk of estrogen therapy is uterine cancer in women who still have their uterus; the addition of progesterone prevents this risk. In women who have had a hysterectomy, there is no proven benefit of taking a progesterone hormone after menopause.

What are the benefits of estrogen therapy? The main benefit, and the only approved indication, of estrogen therapy is for the treatment of symptoms of the perimenopausal transition and early menopause. It should not be used to primarily prevent heart disease or dementia. It is highly effective in reducing hot flashes, night sweats, mood changes, sleep disturbance, and any other symptoms that result from diminished estrogen production.  Estrogen is also approved for the prevention of osteoporosis. Osteoporosis is the most common condition afflicting women after menopause. Women lose the highest percentage of their bone mass in the first 5 years of menopause. Estrogen therapy is effective in preventing this loss. Other benefits of estrogen therapy are the prevention of vaginal dryness that occurs after menopause which leads to discomfort with intercourse. It also reduces the occurrence of hyperactive or irritable bladder, lowers a woman’s risk for colon cancer, reduces the accumulation of fat tissue around the waist, helps maintain the health and vitality of the skin, and reduces macular degeneration.

Estrogen replacement, like everything else we do in life, has risks and benefits. What each woman needs to determine is do the benefits of taking estrogen outweigh the risks; it is a quality of life decision.  This is a decision that should be made with the assistance of her doctor. The lowest effective dose of estrogen should be used for the shortest time period necessary to help with the transition through menopause. Certainly some women will choose to remain on estrogen indefinitely because they feel better on it. This is acceptable as long as they are aware of the potential risks verses the benefits. Women who definitely should not use estrogen are those who have a history of previous breast cancer,  a genetic predisposition to breast cancer, uterine cancer, heart disease, stroke, blood clots, or a blood disorder that predisposes them to clots.

Related posts:

1. In Defense of Estrogen Therapy