Hormone therapy questions answered

By Tanya Bricking and Beverly Creamer
Advertiser Staff Writers

Ever since a government study released last month spotlighted the risks of long-term use of hormone replacement therapy, women have been flooding doctors' offices with questions about what this means to them.

Last week, The Honolulu Advertiser explored some of the issues related to hormone replacement therapy — known as HRT — and alternatives for women reaching menopause. We also asked for your questions for the experts.

Today, we're sharing answers from doctors and other women's health practitioners.

Q. I have been reading everything I can find on HRT therapy since the recent studies came to an end. I suffer from hot flashes and mood swings and need to find an alternative before I stop HRT therapy. I have been on it for four years. I recently read about a HRT that contains a unique combination of two plant-derived hormones — an estrogen and a progestin called "Activella." It would be covered under my health insurance because it has to be prescribed by a doctor. Have you heard of it, and would you recommend it?

A. The study that was released earlier this month used a combination of products which were animal-based. However, the study probably applies to all estrogen/progersterone products regardless of how they were derived, said Dr. Laura Weldon Hoque, medical director of Kai'olani Breast Center. Plant-based estrogens are still estrogens, and many practitioners believe they have similar risks to animal-based estrogen.

Q. I have been on HRT since 1991. My grandmother on my mother's side died of breast cancer, and my mother's father and brother died of heart attacks. For the last three months I have had a complete loss of libido, and my doctor just prescribed Estratest H.S. and Provera to replace the standard HRT treatment. My question is: Is it safe for me to take the Estratest and Provera due to the problems discovered with HRT?

A. Loss of libido is a common side effect of menopause, Hoque said, and HRT is an excellent treatment for that. Hoque says the combination products are safe and the risks that are associated with the HRT are minimal. The most important thing to know is that HRT does not PREVENT heart disease or breast cancer. There are some other remedies for loss of interest in sex and that would be something to talk to your doctor about.

Q. What about HRT programs that do not use the hormone treatment with the brand name Prempro? For example: 1 tablet of Premarin 0.3 mg. daily, and 1 tablet of 2.5 mg. medroxyprogesterone on days 20 to 31 of each month. Have studies been done on this or other lower-dose therapies?

A. There are no other large studies of preparations other than Prempro, said Dr. Jennifer Frank, a Honolulu family-practice physician. But, she says, it certainly seems prudent to take as low a dose as possible of each drug: Premarin 0.3mg is half the dose in Prempro, and this dose has been shown to be effective in preventing osteoporosis. Since the major culprit in causing the increased risk seemed to be the progesterone component, and medroxyprogesterone IS the same as the progesterone in prempro, Frank would suggest a different progesterone, and take it for fewer days a month; for example, the days 20 to 31 protocol is a good one.

Q. I am taking a formulated estrogen cream that includes three types of estrogen. It's called Tri-Est and includes estriol, estradiol and estrone. Is this natural hormone included in the study of synthetic HRT? What about the progesterone Prometrium? I'm told these are bio-identical hormones and are different from the traditional HRT. Is this true?

A. The Tri-Est cream seems a good preparation, Frank said. The progesterone Prometrium has not been studied like the medroxyprogesterone component of Prempro, and there is no guarantee it would be any better, but Frank said it makes sense to take it rather than the one studied, which is known to cause the increased risk. There is no absolute certainty about these preparations, however. Each woman needs to assess her own risks with the help of her doctor. There is no right answer for everyone.

Q. I decided not to take synthetic estrogen (such as Premarin) and decided to go the route of natural estrogen replacement.ÊI am taking a natural, human bio-identical estrogen hormone (Estradiol)from the Women's International Pharmacy.I am also taking Prometrium, a natural progesterone.ÊIs there still a risk of heart disease and breast cancer?

A. "Studies from Europe and The Nurses' Health Study, where estradiol is the commonly prescribed form of estrogen, suggest that estrogen at lower doses may confer similar benefits," said research cardiologist Dr. Fredric Pashkow, director of the Heart Institute at Queen's Medical Center. "However, data from both epidemiologic (population) studies and at least one secondary-prevention trial indicate there is an increased risk of venous thromboembolism (heart disease) with hormone use. Natural progesterone and some of its derivatives reportedly have little negative impact on cholesterol levels, implying they may produce better outcomes than the medroxyprogesterone acetate preparations used in most of the studies published to date."

But Pashkow said there is really nothing in mainstream cardiology to give completely clear answers yet. "Studies with other treatment regimens are needed and should consider the various hormonal combinations commonly used in different countries."

Q. My understanding is that the study results involve estrogen/progestin HRT. Do the results apply similarly to someone who takes an estrogen/testosterone HRT (the drug "Estratest")?

A. The Women's Health Initiative studied a combination of hormones called Prempro which is Premarin (an estrogen derived from the urine of pregnant horses) and synthetic progesterone (Provera), said Laurie Steelsmith, a naturopathic physician and licensed acupuncturist in Honolulu. The study did not look specifically at Estratest, which is synthetic estrogen and synthetic testosterone. At this time, Steelsmith said, we cannot say whether Estratest will have the same side-effects as Prempro.

Q. Are the following conditions affected by lack of estrogen and/or progestin:

• Tendency for bladder infection (cystisitis) in older women
• Incontinence (occasional and chronic)
• Sexual drive (libido). Note: a speaker on public radio recently said that testosterone is suppressed by either estrogen. What about Progestin? And therefore, is sexual drive better without HRT?

A. Honolulu fertility expert Dr. Kenneth Vu had this to say:

• Cystitis: Estrogen deficiency associated with menopause sometimes results in atrophy (poor lining) of the genital-urinary tract, affecting the urethra (the connecting structure from bladder to exterior) and possibly the bladder epithelium (lining). Women have short urethra (about 2.5-3.0 cm), and atrophy of this genital-urinary tract structure predisposes women to frequent urinary tract infection (cystitis).
• Incontinence: That depends on what type of incontinence. However, in general, well-developed and well-estrogenized urogenital tissue contributes to better bladder support and less incontinence while atrophied (poorly estrogenized) tract contributes to more incontinent problems, especially in older women with other existing contributing factors.
• Sex in menopause: This depends on libido, comfort, and motivation. Testosterone is the major determining factor in libido. Pain during intercourse (dyspareunia) in menopausal women from vaginal dryness is common, but there are alternative methods to relieve this problem. The issue of testosterone production or mechanism of action, with regard to libido and sexual activity in menopause, is either inhibited or facilitated by presence of estrogen and/or progestin in HRT is very controversial and unclear. Further research is required to delineate such action.

Q. I'm writing as a husband who has had to get involved because my wife is Japanese from Japan, and doesn't have enough command of English to follow the convulutions of medical talk. There's more here than just questions, but I'll get to those. Feedback on your article: Repeatedly it was said to consult with your doctor. Sadly, we have done that and with others and I don't think they know much more than a lay reader.

Here are my questions in the form I had asked of our doctor (with her response for your interest). Can you answer them?

I asked if this study was on both synthetic and bioidentical hormones (natural), and she said she didn't know.

A. The study was based on Prempro, which is made up of synthetic progesterone (Provera) and on Premarin, which is estrogen derived from the urine of pregnant horses. It is natural or biologically identical for a horse, but not for a woman, Steelsmith said.

Q. I asked if it was on specific brands, or all types. She didn't know. I asked in people in the test were from the United States or the United States and Europe, since Europe has been at this longer than us. She didn't know.

A. The study was done on women in the United States on a specific type of hormone replacement therapy known as Prempro.

Q. I asked if the risks were for high and/or low dose. She didn't know.

A. The risks were found in women who took the most commonly prescribed daily dose of .625 milligrams of Premarin and 2.5 milligrams of Provera. This dose is the standard dose, not high or low, Steelsmith said.

Q. I asked if the study compared oral meds (which are processed through the liver) with skin patches or creams (which don't go to the liver). She didn't know.

A. The study only looked at the oral hormone medication, Prempro, in pill form.

Q. I asked if switching to plant hormone creams was safer, she didn't know. I mentioned that in all the accompanying literature that comes with the prescriptions, it says this should be taken for the symptoms period of time, not indefinitely, but that she had never said that to us. She was more/less silent on this.

A. Natural plant-derived hormones are considered "safer" because they are biologically identical to the hormones a women produces in her own body, Steelsmith said. The natural hormone creams are one route of administering hormones, and they work for some women but not for others. Others ways of taking natural hormones include oral pills, sublingual (under the tongue) drops and vaginal suppositories. Christiane Northrup M.D., in her book "The Wisdom of Menopause," cites numerous studies that validate the efficacy and safety of these hormones. However, long-term studies on thousands of women have yet to be done in the United States.

It is true that when hormones are used long-term they can increase a woman's risk of side effects. When looking at an analysis of many studies on HRT, the bottom line is: High-dose hormones plus long duration of ingestion equals a higher potential risk of side effects. Logic tells us that the inverse would most likely also be true: Low-dose hormones for a short duration (for instance, to ease menopausal symptoms) result in less potential risk of side effects. Other options include using herbal medicines to ease menopausal symptoms.

Q. When my wife started HRT about a year ago, her only symptoms are vaginal pain on intercourse because of thinning of vaginal walls and dryness (she was checked out for other causes of this and came up clear). Her doctor put her on a full dose of synthetic HRT. A year later, after some side effects (mostly skin itching around joints), her doctor told us of vaginal estrogen inserts. The question for you is: Is there anything in the study mentioning just direct vaginal treatment? I believe she is supposed to take Progestin with it, but in what form? Oral? cream? patch?

A. The study did not look at vaginal estrogen inserts. It only looked at the oral ingestion of Prempro. According to medical researchers, vaginal estrogens are not absorbed into the systemic circulation at significant enough amounts to warrant prescribing progesterone, Steelsmith said.

Q. Finally, I asked our doctor if she was going to stop prescribing HRT in light of this study. She said it's the patient's choice. This made me angry, but I refrained from saying what I was thinking, which was, "what if I wanted a prescription of rat poison, would you tell me it's my choice or would you recommend against it based on risk factors?"

A. For women, the question of whether to take HRT is a confusing one, and the most recent study results made it even more so, Steelsmith said. If the risks of taking HRT outweigh the benefits, a woman should seek out an alternative to HRT to help her through her menopause and beyond. If the benefits, such as significantly improved quality of life, outweigh the risks, then choosing HRT may be worth it, Steelsmith said.