2010, the Pill turns 50, but What's a Baby Boomer to do with her Hormones Once She Turns 50?
NAMS puts out it's position on hormone therapy and in a word, thumbs up, in two words, thumbs up, for women around the time of menopause. As you get older, if you didn't start, don't. The largest group of menopause clinicians which has been going for about 20 years began issuing statements on hormone therapy right after all the controversy about beginning hormones broke in 2000-2001. and in Oct 20002 they put out their first statement, and it's been updated to try to clarify the role of treating menopausal women with estrogen or progesterone or both. This statement doesn't cover an opinion on testosterone (they do have another paper on that), the SERMS, the plant based estrogen or the over the counter estrogens, but tries to give (physicians and menopause clinicians)perspective on the risks and benefits of the primary estrogen and progesterone therapy as women enter, cross over and age beyond menopause.
Feminine Forever (stealing the term) wasn't meant to be natural, it was meant to beat nature. The group is science based and reaching out to other science based groups, including the Endocrine Society which has it's own Scientific Statement in development.Straight off the group notes that there really are no long term studies. If you renew each year you and your physician are stepping into the great unknown of "clinical medicine" realizing that no study will ever truly cover all populations and all situations. So we're both in the unnatural and the unscientific realms to some extent. Recognizing that, these are powerful medications which have provided millions of women with health, happiness and benefit based on the ratio of benefit to risk.
Uniform terminology has been called for in the practice of menopause medicine, and you and your gyno have probably not been noticing some of these subtle differences. HT Timing of initiation: this is the length of time after menopause when HT is initiated. Tricky, Tricky Tricky. If you went from pills to pills...the Birthday Pill might have masked your actual cross over date into menopause. So who knows your initiation date. But do your best to work that out with your gyno.
As Bobby Fisher used to say when asked about what is the best 7th move in a chess game, "well, tell me the first 6 moves", actually can you even see anyone speaking to him? But the point is, you do have to understand your baseline risk to understand what your potential for benefit is. Those with strong bones aren't likely to have less osteoporosis and those with very advanced heart disease won't cure it.
Vaginal therapies are indicated for the treatment of local vaginal menopausal problems and one oral therapy is indicated for the same, but none are recommended as "sole treatment" for sexuality problems including diminished libido. None of these products has regulatory approval for the prevention of UTIs but the statement concludes that menopausal women given vaginal estrogen can reduce recurrent UTIs.
Women will weigh their most from 50 to 59 and HT won't help and won't hurt. If you sleep poorly and have poor mood HT may improve your quality of life. No estrogens have approval for the treatment of osteoporosis although fracture prevention has been demonstrated and can be expected from hormone use.
The heart health statement and estrogen use is long and complex. If you are young, and begin as you go through menopause and stay on long enough, you probably will have benefit as you probably will have less calcium in the blood vessels around your heart. If you are older, just begin hormones, and have some risk factors on top of that, HT is detrimental to heart health. Stroke specific risks were almost impossible to tease out of the research studies as risks are small, confused by other factors and confused by the fact that some strokes are due to clots and some to bleeds.The risks of deep blood clots with in the legs known as DVTs are probably greater in pretty much all groups with hormone use, but thinner, women without genetic predisposition who take estrogen by the transdermal (skin) route are probably in the lowest risk group. Don't use hormone therapy for CVD risk reduction, but it reduces your CVD risk if you start earlier enough.
Special categories of discussion like those with diabetes and risk for uterine cancer were covered in the statement and then they launch into discussions of breast, ovarian and lung cancer risk. Breast cancers take years to grow. When a woman begins therapy the experts point out that the breast cells grow in number, the breast hurts more, and the breast gains fluid making the mammograms, which are an x ray, more dense. By reason then, starting therapy would make it easier to find an early cancer, but didn't necessarily cause the cancer to be there in the first place. This is why, about three years into taking your pills, there's no increased risk, the cancers that were "bloomed" as it were, have been found. Don't take if you have survived a breast cancer according to these experts, although some studies have indicated it might be safer than we thought. As for ovarian cancer, it probably is slightly increased by hormone use, but the long term risks are apparently small. Lung cancers may also be promoted by estrogen use. As for most gynos, nothing to discuss on this front: stop smoking and take away cigarettes from anyone you know that has them. And that is strictly an editorial comment here!
Cognition, thinking, thoughts, and knowledge use and acquisition, suffers with aging. Menopause doesn't help, but newest thinking, may not help. (Then again, I think all the researchers were menopausal age, should we trust them, or is it just ironic!).
There are some sections on premature menopause and total mortality and then they go into the fact that probably differences in relative potency, how bioavailable compounds are and how they act on various receptors (I'm very much paraphrasing here) exist, but way over the top for this statement and they didn't get into it. But less is more, as we know, and yet if you still have symptoms, you need more.
And then there is a section clarifying the NAMS position on Bioidentical hormones, starting off with the term "so-called bioidentical hormone preparations" that is medical speak for "they call them that, we would prefer not to". I have been dying to get some terms coined in the public sector, so let me float this one "human-identical" , yeah yeah, I know, not catchy. I'm working on it. Anyway. the "so called" got right there inot the official statement. Well, the confusion is Compounded vs non-compounded formulations that are similar to hormones that can be extracted from humans...as opposed to compounds that clearly are only from non-human species. Compounded medications can get a dose and route that you can't buy pre-packaged. And it can get a product that won't have some of the nonhormonal ingredients that you may be trying to avoid. But since it's also not standardized or tested for impurities it's hard to be recommended by the larger organizations like the FDA. So the FDA, and NAMS, following suit, have come down fairly hard on these formulations.
Basic history and physical examinations were discussed and any other testing is pretty much at the discretion of your own physician. So the complex testing that ensues in some centers, also not endorsed. And into the future: NAMS says, partner with your provider. Rely on them to lay out risks and you are to give an opinion on perceived benefit and go forth together into the future years of therapy. But what if you do stop. 50/50 you will likely recur in HF. Cold turkey or taper, apparently no different! And there are lots of tables and the specifics of all these conclusions. A really remarkable effort by an outstanding team, and women with questions and a bit of the yearning for the science behind the recommendations are urged to get out there and read it!