Three years ago this month, millions of women taking menopausal hormone therapy to improve their heart health got the news that the treatment may be doing them more harm than good.
In the months following the unexpected halting of the now famous Women's Health Initiative (WHI) trial in July 2002, many of these older women were abruptly taken off menopausal hormone therapy. Now a look-back study involving WHI participants provides the clearest picture yet of how they fared.
The review found that more than half of the women who reported hot flashes, night sweats, and other menopausal symptoms when they started taking hormones experienced a recurrence of these symptoms after being taken off the therapy.
North American Menopause Society founder and president Wulf Utian, MD, PhD, tells WebMD that it is not uncommon for women to experience hot flashes and other symptoms associated with menopause for a decade or more. He says a small percentage of women have them for the rest of their lives.
"I have women in their 80s and even 90s who still experience hot flashes and other symptoms," he says. "These women may need to stay on hormones indefinitely."
The new study, which appears in the July 13 issue of The Journal of the American Medical Association, showswomen taking estrogen or estrogen plus a progestin were six times more likely to report moderate to severe hot flashes and night sweats following discontinuation of treatment compared with women taking placebo.
These women were also more than twice as likely to report an increase in overall stiffness and pain.
Read Web MD's "Get the Facts about Hormone Therapy."
Surprising Findings
The findings came as a surprise to researcher Judith K. Ockene, PhD, because most of the WHI participants were well past the age of menopause when they were taken off hormone therapy.
The average age of the WHI participants when the trial was stopped was 69, and the average time on hormone therapy was 5.7 years.
"The common belief has been that menopause symptoms last for just a few years, but in this study women were older and on hormones much longer," she tells WebMD. "It was a bit of a shock that so many of them still experienced symptoms."
Prior to the publication of the WHI findings, physicians often kept postmenopausal women on estrogen therapy for decades with the belief that the treatment helped reduced their risk of age-related illnesses, including heart disease.
But the large government study revealed that hormone therapy did not prevent heart disease in older women. The study also showed an increased risk of stokes, blood clots, and breast cancer.
Read Web MD's "A Fresh Look at Hormone Therapy."
Alternative Treatments
Women who don't want to take hormones have options, including lifestyle changes and behavioral interventions, says researcher Diana Petitti, MD, of Kaiser Permanente Southern California.
Widely recommended strategies to cope with hot flashes and night sweats include:
—Wearing layered cotton clothing
—Avoiding coffee, alcohol, and spicy foods
—Reducing stress with deep breathing exercises, medication, or yoga Sipping cool drinks throughout the day and using ice packs Getting regular exercise
Aerobic exercise was found to reduce hot flashes in one study, and working out with weights also helps maintain strong bones.
Many women swear by other treatments such as vitamin E, soy, and a host of over-the-counter products that contain botanicals like black cohosh and red clover. But the research on these treatments is inconclusive.
"Unfortunately, most of these alternative treatments have not been well tested," says clinical psychologist Judith Ockene, PhD, who headed the newly published study on WHI outcomes.
Ockene has received funding from the NIH's National Center for Complementary and Alternative Medicine to study the impact of soy and meditation on menopause symptoms.
"It is important to look at the evidence scientifically," she tells WebMD. "The studies on soy, for example, have been small and have included many different formulations."
There is also no good evidence that a wildly popular alternative to traditional hormone therapy is any safer or effective, Wulf Utian says.
So-called "bioidentical hormones" are custom compounded formulations supposedly tailored to a woman's individual hormonal needs.
Promoters say this makes them safer, but Utian says there is no good clinical evidence to back up the claim.
"The fact is these are the same hormones in different combination and permutations, and they are therefore subject to the same risks and benefits," he says.
Read Web MD's "Get Tips for Managing Hot Flashes."
Smallest Dose, Shortest Time Revisited
Since the study, the conventional wisdom among women's health experts has been that hormone therapy should be used to treat menopausal symptoms — hot flashes and vaginal dryness — only and that it should be given in the lowest effective dosage for the shortest possible time.
But there seems to be little official guidance to help women and their physicians understand what that means.
In a 2004 task force report on hormone therapy, the American College of Obstetricians and Gynecologists recommended only that women taking hormones for menopause symptoms have an annual discussion with their doctor about whether they are ready to stop.
Ockene and colleagues concluded that short-term treatment, whether that means a few months or a few years, may not be enough for many women.
"Some women may not be able to follow the advice to take hormones for only a short time, because their symptoms will last for many years," Ockene says.
Web Quiz: Test Your Menopause Smarts
How Long Is Too Long for Hormone Therapy?
Utian agrees that women should use the lowest effective dose of hormone therapy. He adds that it is increasingly clear that the combination of progestin and estrogen may pose more health risks than estrogen alone. Progestin is recommended for women who have not had hysterectomies.
All the experts contacted by WebMD agreed that there is no clear answer to the question, "How long can a woman safely stay on hormone therapy?"
"It is a personal decision that has to be made by a woman and her doctor taking her individual risk factors into account," Ockene says. "Right now, medical science can't really say how long is too long."
Visit WebMD's Menopause Health Center
By Salynn Boyles, reviewed by Brunilda Nazario, MD
SOURCES: Wulf Utian, MD, PhD, president and founder, North American Menopause Society; professor of gynecology, Case Western Reserve University, Cleveland. Grady, D. Obstetrics and Gynecology, December 2003. Petitti, D.B. The Journal of the American Medical Association, July 13, 2005; vol 294: pp 245-246. Diana B. Petitti, MD, department of research and evaluation. Kaiser Permanente Southern California, Pasadena. Marilyn Bayer, Worcester, Mass. Blanche Turner, Mansfield Center, Conn. NIH panel report on menopause, March 2005.
SOURCES: Ockene, J.K. The Journal of the American Medical Association, July 13, 2005; vol 294: pp 183-193. Judith K. Ockene, PhD, MEd, clinical psychologist, division of preventive and behavioral medicine, University of Massachusetts Medical School, Worcester, Mass. Wulf H. Utian, MD, PhD, president, North American Menopause Society; professor of gynecology, Case Western Reserve University, Cleveland. ACOG task force report on hormone therapy, October 2004.
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