The Hormone Replacement Therapy (HRT) Decision: To Take or Not To Take

By: Joan Starker, M.S.W., Ph.D.

All menopausal women face a difficult decision: to take or not to take hormone replacement therapy or HRT. New studies appear daily and the data are overwhelming and confusing. How can a woman make an intelligent, educated decision?

A woman needs to be armed with enough solid information to take charge of this critical decision. She needs to weigh the costs and benefits, consider her family history, values, and the severity of her menopausal symptoms. Some women opt to take hormones on a short or long term basis. Other women prefer complementary approaches, such as herbs. Some women decide not to take anything.

HRT (Hormone replacement therapy)

HRT can help alleviate menopausal symptoms such as hot flashes, insomnia, and vaginal dryness. It can also help protect bones and prevent osteoporosis. For a woman with an intact uterus, it is essential to take both estrogen and progesterone to prevent uterine cancer. Women with risk factors such as a family history of osteoporosis, early menopause before 40, very fair skin, small bones, sedentary lifestyle, and diet low in Vitamin D and calcium should consider getting a baseline DEXA to measure bone density.

The usual dose of estrogen is .625 mg which is only about twenty five percent of the amount in oral contraceptives. However, recent research presented at the 22nd Annual American Society for Reproductive Medicine meeting showed that low-dose hormone replacement therapy (HRT) is as effective for easing menopausal symptoms such as hot flashes and vaginal dryness but with fewer adverse side effects. As an interim solution, many women choose to take low dose oral contraceptives during perimenopause as a way of regulating periods, and reducing menopausal symptoms. (Some women experience side effects from birth control pills such as breast tenderness, depression, and bloatedness.)

For many years, HRT was prescribed to prevent cardiovascular disease. However, preliminary findings from a major government study of 27,000 women (The Women=s Health Initiative) indicate that HRT may actually increase the risk of heart disease! Although the full results of the study will not be available until 2005, there was a Asmall increase@ in heart attacks, strokes, and blood clots in the hormone groups in contrast to the placebo. In addition, another study called HERS (Heart and Estrogen/Progestin Replacement Study) found that women who already had heart disease were not helped by taking HRT and, in fact, during the first year did worse. However, over time this result evened out. As a result, the researchers recommended that women with a history of cardiovascular disease should not begin HRT.

However, there are other factors to consider. Most women are fearful about developing breast cancer. Most experts agree that taking HRT for up to five years does not increase a woman=s risk in breast cancer. However, The National Women=s Health Network points out in a recent review of the literature that taking estrogen replacement therapy for five or more years increased the risk of breast cancer by about 35 percent. In addition, HRT results in breasts that appear denser on mammograms, so this diagnostic tool is less likely to detect small cancers.

Sometimes women experience side effects while taking HRT. Although often they are temporary, in some cases they may result in stopping HRT or trying a different dose or type of HRT. Common side effects include nausea, headaches, and breast tenderness. There are also different methods of delivery, including the pill, patch, cream, gel, and vaginal ring. In addition, there are different regimens including a combined, daily dose of both estrogen and progesterone, and a sequential approach that attempts to mimic a woman's natural cycle resulting in menstrual-like bleeding. Finding the right dose, and type of HRT often involves trial and error. If a woman decides to stop taking HRT, she needs to taper off rather than quit abruptly, which may result in the hot flashes returning with a vengeance.

Some women have found that alternative approaches can be effective in alleviating menopausal symptoms. For example, Vitamin E, natural progesterone cream, Promensil (made from red clover), increased dietary soy, and black cohosh have been reportedly beneficial in easing hot flashes.

The HRT decision is often fraught with anxiety. To make matters worse, it occurs at a time when women may be coping with severe menopausal discomfort and stressful life events. Nonetheless, it is critical for a woman to actively make a decision that fits her needs. Fortunately, it is a decision that can be reassessed based on how a woman is feeling, her level of discomfort, health profile, and the latest research.

In her private practice, Dr. Joan Starker specializes in midlife and menopause. She is also the A health expert@ for WebMD, answering questions online about menopause. She can be contacted by e-mail at: or at 503-246-7332.