Consider risks before using hormone replacement therapy, experts say

A physician discussion hormone therapy with a patient
Personal health history and cancer risk should be carefully weighed by women considering hormone replacement therapy to manage symptoms of menopause, experts say.

Hormone replacement therapy (HRT) is the dinner party equivalent of politics and religion: a subject with strong and divided opinions certain to evoke spirited debate. Conflicting clinical data and discrepancies among studies have left the medical community with little to agree on. With a bevy of misinformation on the internet adding to the confusion, women, particularly those who have had a female cancer, may have no idea whether it’s safe to consider HRT to alleviate the symptoms of menopause, such as hot flashes, fatigue, bone loss, vaginal dryness, painful intercourse and difficulty sleeping.

Women considering HRT should carefully consider the pros and cons unique to their personal health history, experts say. “It’s a trade-off of risks versus benefits. In addition to cancer, there are other issues, such as blood clots, that can occur. But there are circumstances when HRT may help control menopausal symptoms and improve a woman’s quality of life. In addition to reducing symptoms of menopause, HRT has other health benefits, such as a decreased risk of colon cancer and osteoporosis,” says Justin Chura, MD, Chief of Surgery & Director of Gynecologic Oncology and Robotic Surgery at our Philadelphia hospital. 

But for women who have had estrogen-positive breast cancer, HRT is not advised, he says. And for those with a history of ovarian or endometrial cancer, Dr. Chura says he would only consider prescribing HRT for “very short-term use by young women with very bad menopausal symptoms.” That advice is consistent with recommendations issued by the U.S. Food and Drug Administration (FDA), which advises women who “have or have had certain cancers such as breast cancer or uterine cancer” not to use HRT and cautions those who opt for the therapy to take the lowest dose necessary to relieve symptoms for the shortest period of time needed.

HRT typically involves estrogen-only or combination therapy, which contains both estrogen and progestin. Though the treatment has been around for decades, its popularity has waxed and waned as new information has surfaced. Between 1960 and 1975, HRT soared in popularity, until two 1975 studies found an increased risk of endometrial cancer, the New England Journal of Medicine reported in 2007. More concern followed in 2002, with the results of a large, long-term Women’s Health Initiative (WHI) clinical trial that studied 27,347 U.S. women ages 50-79 between 1993 and 1998 and found an increased risk of breast cancer. In 2013, an update to the Women’s Health Initiative Hormone Trials was published, this time with 13 years of data for researchers to study, and the investigators concluded that HRT “may remain a reasonable option for the short-term management of menopausal symptoms for younger women.”

Breast cancer organization Susan G. Komen credits the WHI study for showing that “taking estrogen plus progestin for more than 5 years did more harm than good,” noting that combination HRT raises the risk of both breast cancer and breast cancer death.

“When women take these hormones, their risk of having an abnormal mammogram increases within the first year of use,” the Komen website states. “And, their risk of breast cancer increases within the first 5 years of use. The risk of breast cancer goes up slightly with each year a woman takes estrogen plus progestin. Small yearly increases in risk can add up over time. Some large studies have found women who use estrogen plus progestin for 5 or more years (and are still taking it) about double their breast cancer risk.”

Komen points to multiple studies that suggest a 30 percent increase in breast cancer risk for women using estrogen-only HRT. A 2011 National Cancer Institute summary of the WHI study found that, in addition to an increased risk of endometrial cancer in women with an intact uterus who take estrogen-only HRT, women on combination HRT “were more likely to be diagnosed with breast cancer,” and “the breast cancers in these women were larger and more likely to have spread to the lymph nodes by the time they were diagnosed.”

Other evidence-based risks associated with HRT, according to the National Cancer Institute summary of the WHI results, include urinary incontinence, dementia, blood clots, stroke and heart attacks. The studies also found mammography exams to be less effective in detecting breast cancer early in women who used either combination or estrogen-only therapies.

No matter her situation or eventual decision, each woman should talk to her doctor about whether it’s safe and appropriate for her to consider using HRT, Dr. Chura says. Even if she does opt to take it, HRT remains a short-term solution. “It’s probably not a good idea to take it for more than three to five years,” Dr. Chura says, noting other options are available for women to consider cycling through before resorting to HRT, such as vaginal moisturizers, lubricants and certain antidepressants and anti-seizure medications that may help with hot flashes and mood swings. He encourages women to speak to their doctor about hormone therapies with lower rates of absorption (patches, sprays and vaginal rings, for example) that may be safer than systemic, oral therapy. 

“It comes down to why a woman is taking HRT medication,” says Dr. Chura. “For women whose symptoms are making her quality of life miserable, short-duration hormone therapy may be very appropriate. For others, it may not be an option. Talk to your doctor.”