Don’t be afraid of HRT

When I went through menopause starting around 2010, my ob/gyn never uttered a word about hormone replacement therapy (HRT)—typically a combination of estrogen and progestin given to offset the loss of estrogen and get rid of symptoms like hot flashes, night sweats, mood swings, painful sex, urinary problems, sleep disturbances, etc. 

Yet until the very early aughts, HRT was “one of the most commonly prescribed treatments in the entire world,” says JoAnne Manson, MD, DRPH, Chief, Division of Preventive Medicine at Brigham and Women's Hospital, Harvard Medical School, and a principal investigator of the landmark Women’s Health Initiative study that started in the early 1990s, lasted until 2005 and spawned many extension studies. In fact, I remember talking to a friend around 1993, a biochemist also in her early 30s at the time, who said, “Well, of course, we’ll take HRT when we get there” as if it were a no-brainer.

But by 2002, HRT had gone from menopausal must-have to life-threatening menace. What happened?  Blame it on widely reported but flawed findings that emerged from a WHI study looking at HRT’s effects on heart disease and hip fracture . After it linked HRT to increased risk of breast cancer, stroke and heart attack, prescriptions plummeted from 15 million in the U.S. alone to practically zero. “At the time the report came out, I had been in practice less than 10 years,” says Diana Bitner, MD, MSCP, FACOG, an ob/gyn by training and Chief Medical Officer of true. Women’s Health, a concierge medical service that offers women holistic care at every stage of life. “My senior partners were like ‘Stop writing estrogen!’ I never read the WHI study; I just said okay!”

The fear “spread like wildfire,” says Dr. Bitner, so much so that “even doctors being trained now are scared by doctors who were scared in 2003.” Adds Dr. Mason, “Part of the problem is that there are many clinicians who have not had training in menopause management. Sometimes even when a patient asks for HRT, the clinician doesn’t have the experience or skills to  aid in decision-making.”

However, since 2002, lots has changed. For one, says, Dr. Mason, “we now have a more nuanced and refined understanding of the benefits and risks [of HRT], and the fact that women below age 60 have a favorable benefit-to-risk ratio if they have hot flashes, night sweats and other menopausal symptoms.” For another, newer HRT formulations are likely to be even safer: “Lower doses and transdermal patches, gels or sprays are less likely to cause blood clots,” says Dr. Mason.

The challenge remains getting the message out about HRT’s safety profile to patients and practitioners alike. Reports Dr. Bitner: “Some patients say, ‘I don’t feel good, but I don’t want hormones,’ or ‘My mom had breast cancer and she says don’t you dare take it!” And to clinicians who are still loath to prescribe it, Dr. Mason says, “The WHI findings should never be used as a reason to deny HRT to a woman in early menopause who has moderate to severe hot flashes and night sweats and is seeking relief.”

If you’re perimenopausal or menopausal, struggling with symptoms and wondering if HRT can help you, Dr. Bitner recommends having a talk with your doctor and asking questions like the following:

·      “What is your comfort level talking about options to treat symptoms of menopause? What are the pros and cons? Can you personalize this for me?

·      “If I decide to try HRT, how are we going to track whether it works?”

·      “Are you certified in treating menopause? What education have you had in this?”

Getting the care you deserve can do a lot more than just help you ditch hot flashes and night sweats. As a few of Dr. Bitner’s patients who missed out on HRT have said: “If I had been on estrogen, I wouldn’t be divorced!”

Note: HRT is undergoing something of a rebranding, now being called menopausal hormone therapy (MHT). For the purposes of this article, I stuck with the traditional name.