Hormone Replacement Therapy
Guest: Dr. David Soper - Obstetrics
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. David Soper who is Professor of OB/GYN at the Medical University of South Carolina. Dr. Soper, women are so confused these days about hormone replacement therapy. It seems like every other week there is another study and it just seems less clear who should be getting HRT. What is the current thinking?
Dr. David Soper: Well, Linda, I am not surprised that patients are confused because I think doctors are confused as well. But, I am going to try to just simplify the way I see the information today and the recommendations I can make. The take-home message is that, unlike the past in which there were blanket statements saying that every woman needed to be on hormones if they were postmenopausal, nowadays we are really emphasizing the need to be individual in our prescribing habits. So, there may be some patients that are great candidates for hormone replacement therapy and others that probably should not use it.
Let me talk about the patients that maybe should not use it. Women in their 50s that are not at risk for osteoporosis, who are not having significant menopausal symptoms like hot flashes or vaginal dryness, who may have a significant history of coronary artery disease in their family, are probably not good candidates for hormone replacement therapy. Likewise, if they have a family history of breast cancer or they have premalignant disease of the breast, they are probably not good candidates for hormone replacement therapy. On the other hand, women that have severe vasomotor symptoms and night sweats, are having trouble sleeping, they are having significant vaginal dryness and maybe some pain with sexual intercourse due to that, these women are great candidates for hormone replacement therapy, at least for the short term. By that, I mean you get started on pills or a patch with hormones. You make sure that your symptoms are improved or, essentially, resolved. Then, every year, you have a discussion with your doctor, how long do I need to be on this, what dose do I need to be on and can I get down to the lowest effective dose?
Dr. Linda Austin: There is a lot of talk these days, in some circles, about bioidentical hormones. What are these and do they offer any advantage?
Dr. David Soper: The bioidentical hormones tend to be transdermal in their vehicle. By that, I mean they are creams that are massaged into the arms or the back. They are not pills that are taken. The trouble with bioidentical hormones is that most physicians really do not know how to prescribe them. Right now, we are really not in a situation where we follow blood levels, because they do not really have meaning as far as being able to relieve a patient’s symptoms. So, I would counsel patients that they are probably much better off using a pharmacologically made hormone replacement regimen, many of which are “natural”, made from plants, but all essentially acting the same way. The mechanism of action for all of these hormone regimens is a molecule or a hormone binds with a receptor, which is the place in your body where it has its effect, and an effect then occurs. So, the body does not recognize the difference between a bioidentical hormone and even a synthetic hormone that might be made from a manufacturer. The key is the quality control that U.S. firms can exert in making sure you are getting the dose that your doctor has prescribed.
Dr. Linda Austin: And the bottom line is every woman needs to talk about this with her doctor. It is not a blanket statement, it is a highly individual decision.
Dr. David Soper: No doubt about it. An issue that has kind of come up is the difference between hormone replacement therapy in women who have a uterus. That means you need to take two hormones, one is estrogen which can build up the lining of the uterus, the other is progesterone which thins the lining of the uterus. By taking the two hormones together, it prevents you from bleeding. When you are postmenopausal, the last thing you are interested in is having your menstrual periods come back. Secondly, it prevents cancer of the lining of the uterus. However, combination therapy has been associated with some adverse events, including a small increase in breast cancer, some increase in cardiovascular events like stroke and heart attack.
Compare that, then, to the estrogen-alone replacement in women who have already had a hysterectomy. You do not see any increase in the risk of breast cancer, no increase in the risk of heart attack, a small increase in the risk of stroke. Maybe more important new information is that if women start this hormone early, when they are just going through the menopause, and continue on the hormone instead of just starting it all of a sudden when you are 65 years old, the protective effects are much more dramatic. So, again, I think the take-home message, when you are having significant symptoms, talk to your doctor, there is help for you. You will feel a heck of a lot better on hormones. You are not going to be taking them for the rest of your life and you are going to be taking the smallest dose possible to relieve the symptoms that you are complaining about.
Dr. Linda Austin: Dr. Soper, thank you so much.
Dr. David Soper: Thank you.
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