Ask An Expert: Taking Estrogen for menopausal symptoms

Q: Ever since a hysterectomy, I've taken estrogen to help with menopausal symptoms and to prevent heart disease – my mother died of a heart attack. But I heard about a study that said estrogen doesn't really protect against cardiovascular problems. What's going on?

Answer from Craig Walsh, M.P.H., M.D., Cardiologist, Columbia Cardiology:

Yes, the recommendations for women in your situation have changed, following the March 2004 results of a landmark trial that is part of a set of studies called the Women's Health Initiative, funded by the National Institutes of Health.

Here is the bottom line: Any woman who's had a hysterectomy and is on estrogen therapy – such as you – should ask her gynecologist or primary care doctor whether she should continue taking estrogen or not.

Together, you need to weigh the benefits and drawbacks, based on your personal history. But I can share pros, cons and neutrals that emerged from the study:

Pro: Some women have very severe post-menopausal symptoms, and estrogen is very effective at controlling them. If this is the case, the best general advice is to be on the lowest possible dose for the shortest possible time. (I say "general" because it probably would not apply to women who are at a high risk of stroke, as you'll see below.)

Pro: Estrogen increases bone density in women who have had hysterectomies and reduces the risk of hip fractures. Hip fractures are serious business. They can limit mobility, spelling the end of independent living. At worst, they can lead to lethal blood clots.

But estrogen isn't the only treatment for increasing bone density. Women predisposed to hip fractures should definitely ask their doctor about alternatives to estrogen.

Con: The women taking estrogen in the study had an increased risk of stroke. The overall risk, however, was low in both groups: Of 10,000 women taking placebo (fake estrogen), on average, 32 would suffer a stroke. Of 10,000 women taking estrogen, on average, 44 would suffer a stroke.

Women with severe post-menopausal symptoms can still consider taking estrogen if they remain on estrogen for the shortest time possible, at the lowest effective dose.

Con: Similarly, the women in the study taking estrogen had a slightly higher risk of developing a blood clot, most commonly in the deep veins of the leg. Again, the overall risk was very low: 21 per 10,000 for women on estrogen, and 15 per 10,000 for those on placebo.

Neutral: Estrogen neither increased nor decreased the risk of coronary heart disease.

That last item is very important for you. If you were largely motivated to take estrogen to protect against your family history of heart disease, it turns out estrogen isn't the answer. I don't know how severe your menopausal symptoms are, or if they would resolve with other approaches. If you don't need to take estrogen for menopausal symptoms, then don't take it. The estrogen costs money, exposes you to a higher stroke risk, doesn't protect against cardiac disease and is only one option for increasing bone density.

Why the about-face?

You may be skeptical, wondering if we doctors are going to change our minds again. I have talked to patients who are frustrated, angry or confused because of this. I'd like to explain. We previously thought estrogen protected against heart disease because women in the U.S. typically develop heart disease 10 years later than men.

When we compared the rate of stroke and heart attack in women taking estrogen vs. those who did not, the women taking estrogen were better off. But these were "observational studies," meaning we looked at women's experiences after the fact.

The Women's Health Initiative is just about as close as we can ever get to a definitive answer. The estrogen study involved more than 10,000 women at 40 locations around the country. Researchers followed the women for an average of 6.8 years. It, like the previous estrogen-progestin study, is a landmark study in understanding women's health.

We now know that those post-menopausal women who took estrogen engaged in other habits that were good for their heart: They didn't smoke, they exercised and they ate a healthy diet more often than the women who were not taking estrogen. So the estrogen was a marker of health consciousness, not a factor itself in heart health.

Again, I encourage you to set an appointment immediately to speak with your doctor about your own benefits and risks of continuing the estrogen. Every discussion with a patient is an individual one.

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