Q: Is hormone replacement therapy for women going through perimenopause or menopause safe? It seems like the story keeps changing.
Let’s start by defining those two stages. Menopause is 12 consecutive months without a period. Perimenopause is the time leading up to that, in which hormones are constantly shifting. For most women, that’s between the mid-40s and early 50s. Your estrogen level doesn’t start at peak level and then gradually decrease in a linear fashion — it fluctuates up and down until it reaches a point where you stop menstruating entirely.
Those hormonal changes can bring about all kinds of symptoms — hot flashes, night sweats, mood swings, disturbed sleep. Periods during this time can range from light to very heavy or they may disappear for many weeks at a time. Because these kinds of changes often seem dramatic, women may associate them with illness. The biggest challenge of this phase is accepting that unpredictability is, in fact, “normal” and shouldn’t be pathologized.
Doctors used to tell nearly all women in this stage to take hormone replacement therapy (HRT) to protect their cardiac and bone health. We now know that was a mistake. A study called the Women’s Health Initiative in 2002 showed us that HRT does have risks — including a small but significant increase in the chance of heart attack, stroke and breast cancer (those risks increase for women who take HRT for many years). And there is no evidence that “natural” or “bioidentical” hormones are safer. So our decisions about hormone therapy have to be individualized and take into account other risk factors. It shouldn’t be thought of as “prevention” medicine, and it shouldn’t be taken just to deal with irregular periods.
HRT is very effective in treating hot flashes, so it can help women whose experience of these is so severe that they have trouble functioning. It’s also effective in treating vaginal dryness and atrophy — and it does prevent bone loss.
But we have to balance the potential benefits against the risks for that woman. If she has a family history of heart attack or stroke, has experienced blood clots in the legs or lungs, or is a breast, ovarian or endometrial cancer survivor — in other words, if risk factors start piling up — we would have a conversation about whether it’s wise to further increase her risk by taking HRT.
So while HRT doesn’t “fix” perimenopause or menopause, there is a role for it. The only way to know if it’s right for you is through an individualized assessment with your doctor.
Danielle Martin is a family physician and vice-president, medical affairs and health system solutions, at Women’s College Hospital in Toronto.
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