Hormone replacement: The good, bad, and in-between

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When I was in practice in the 1980s and 90s, the world was a simpler place. We internists had it figured out: Men had heart problems, often fatal, decades younger than their wives. It seemed obvious that a major factor in this advantage was the hormonal difference between the sexes. If not the estrogenic stew keeping women s hearts younger and healthier, what else could it be?
Thus, the era of hormone replacement therapy came to be. Doctors, both generalists and ob-gyns, enthusiastically followed the mantra of feminine forever. Gladly persuading our patients and ourselves that in addition to smoothing out wrinkles and keeping sex drives vibrant, an extra boost of estrogen and progesterone would retard the coronary sludge that took their men folk before the golden years.

But about 10 years ago, a large government study, the Women s Health Initiative, revealed the disappointing news: The women on the hormone replacement therapy (HRT) suffered not a reduction in heart problems, but an increase. This turned the tables on a lot of doctors, and their patients. While the study confirmed the benefits of HRT for menopausal symptoms, such as sweats, emotional swings and poor sleep and concentration, as well as keeping bones stronger, the negative findings on heart issues and the lingering fear of breast cancer caused over half of those on HRT to discontinue the treatment.

That was then. Over the past few years, the tide has turned again. That is the nature of medical research and science in general: Eternal Truth is subject to re-evaluation and revision. And few topics better exemplify this approach the commitment of science to evidence, not feelings as the HRT story.

Nowadays women are once again being treated with HRT for unpleasant menopausal symptoms, but no longer as a protection against heart disease. As long as the treatment is started early enough during menopause and continued for only a few years at most, the benefits are generally greater than the potential risks. In fact, the estrogen-only type of HRT has been shown to actually reduce slightly the risk of breast cancer. Who would have predicted that, back in the old days of the 1990s medicine marches on!