Menopause hormone therapy for hot flashes has a long and complicated history.
Oestrogen was first approved for use in menopause in the early 1940s. But hormone therapy became really popular following claims by a certain Dr Robert Wilson, that the direct cause of all women’s midlife discomforts was a “deficiency” of oestrogen, resulting from the end of ovulation that happens with menopause.
Dr Wilson described menopause as an “oestrogen deficiency disease” that leaves all women as castrates(1)! Unsurprisingly this misogynist approach has since been debunked, though arguably its shadow remains in people’s unconscious minds, even today.
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Oestrogen remains the most effective therapy for relieving hot flushes and to some extent vaginal symptoms. But worries about side effects, particularly in the long term, mean that many women prefer to avoid this route. Side effects of hormone therapy vary from mild and annoying (weight gain, breast tenderness, uterine bleeding), to potentially life-threatening (breast cancer, heart attacks and strokes). Menopause hormone therapy is known as HT (Hormone Therapy) or HRT (Hormone Replacement Therapy).
The exact method of action of oestrogen in controlling flushes is not fully understood. And although HT controls flushes, many women find that when they stop taking it, the hot flushes return.
The Great Hormone Debate
Unfortunately for us women, there’s still huge debate about the dangers of menopause hormone therapy. The debate is complicated because the risks seem to be different for oestrogen therapy alone and for oestrogen in combination with progesterone. Oestrogen alone may be less risky but is only suitable for women who have had a hysterectomy.
Many gynaecologists today feel that the risks of taking hormones have been exaggerated, especially in younger women who are just going through menopause. When a woman is suffering from unbearable hot flashes, oestrogen may be the best course of action, and in these individual cases, the benefits may outweigh the risks. Equally if a woman is at especially high risk of osteoporosis, some physicians argue that there is a case for taking extra hormones (2).
Other doctors however, continue to emphasise the risks of menopause hormone therapy and advise against it (3). These experts argue that anyone who refutes the evidence that HRT causes breast cancer, may be doing so because of conflicting commercial interests (4).
Why all the controversy?
You may wonder why it’s so difficult for scientists to reach a firm and uncontroversial conclusion about risks and benefits of hormone therapy.
One problem is that the big research trials are all open to criticism, partly because of the groups of women who were involved (ages and menopausal status) and partly the types of hormone therapy that were tested. You can read more about the arguments for and against hormone therapy here.
The other problem is that there are many vested interests in the debate (hormone therapy is a Big Money business) and it’s sometimes very difficult to untangle the truth from competing commercial interests.
Lies, damned lies and statistics
Times have also moved on from HRT’s heydays and women are now much less keen to participate in medical trials of menopause hormone therapy – even if ethical approval could be obtained.
So we are left with trying to draw conclusions from the studies that have already done. And … as with many things in science and medicine … this relies on interpreting complex statistics, which is not only beyond most normal people, but also beyond the average physician.
So we have to believe what the experts say … and the experts don’t agree.
Making your decision – an individual approach
The general recommendation for menopause hormone therapy is:
"the lowest possible dose, for the shorted duration needed to relieve symptoms." (5).
The North American Menopause Society issued new recommendations in 2012, recommending the use of oestrogen therapy for women with severe menopause symptoms and at high risk of osteoporosis (6).
Deciding whether to take hormonal therapy for severe menopause problems is a personal decision that a woman should take in consultation with her doctor. Making your decision means weighing up the severity of your symptoms together with your personal health profile, your attitude to risk and your own beliefs about what menopause is all about.
You can read more about what the US National Institute of Health recommends about hormone therapy here: NIH Hormones and Menopause.
Although you can now purchase so-called “bio-identical” hormone therapies on the internet – these are NOT recommended by medical experts. These products are neither safer nor more "natural" than most conventional HRT products (7).
A qualified physician should always be consulted before starting any kind of menopause hormone therapy, whether tablet, cream, patch or pessary, so that your individual risk profile can be assessed.
There's no doubt that hot flushes can cause a great deal of bother, but until medicine finds a safer solution we must ask ourselves which is worse: putting up with the flushes, or the alternative: taking hormones whose long term safety is in doubt and which human evolution decided over the millennia, that we don't need.
Remember: whatever you do, hot flushes mostly go away on their own - or we learn take control of them mindfully.
1) Wilson RA, Wilson TA. The Fate of the Nontreated Postmenopausal Woman: A plea for the maintenance of adequate estrogen from puberty to the grave. J American Geriatrics Soc 1963;11:347-62.
2) Panay N, Fenton A. Does HRT increase the risk of breast cancer? Don’t forget the menopausal woman! Climacteric 2012;15:103–104
3) Chlewbowski et al. Breast cancer in postmenopausal women after hormone therapy. JAMA 2011; 305:466-7.
4) Kmietowicz Z. Articles disputing link between HRT and breast cancer are ‘ridiculous’. BMJ 2012;344:e513
5) Nelson H. Menopause. Lancet 2008.1;371:760-70.
Published August 2012