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Join us at noon CT (1 p.m. ET/10 a.m. PT) on Tuesday, February 8, to chat about hormone therapy and menopause with Chicago Tribune's health reporter Judy Graham and panelists Dr. Richard Santen and Dr. Cynthia A. Stuenkel.

Hormone therapy for women who've gone through menopause is in the news again, with several studies exploring associations between this therapy and breast cancer. Other recent studies have looked at hormone therapy and lung cancer, and the impact of hormone therapy on mortality. In this web chat, we talk to a leading national expert who can help explain the scientific evidence and translate it into practical advice for women.

Experts:

Dr. Richard Santen is a professor of medicine at the University of Virginia Health System and lead author of the Endocrine Society's recent revised statement on hormone therapy for menopausal women.



Dr. Cynthia A. Stuenkel is a clinical professor of medicine at the University of California, San Diego, and immediate past president of the North American Menopause Society. She participated on an advisory panels that prepared the Menopause Society's position statement on hormone therapy in 2010. She also serves on the editorial board of Pause, published by the American College of Obstetricians and Gynecologists.

Can't make the chat? E-mail questions in advance to jegraham@tribune.com.

Health Chat: Hormone therapy and menopause

(02/08/2011)

  

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11:50

Judy Graham:  Good afternoon and welcome to the Tribune’s web chat on hormone therapy for women who've undergone menopause. This is a complicated and important topic and we're lucky to have two of the nation's foremost experts on this topic joining us here today. Thank you so much, Dr. Santen and Dr. Stuenkel, for agreeing to participate in this chat. Tuesday February 8, 2011 11:50 Judy Graham

11:51

Judy Graham:  Give us a moment, folks. The chat will start at Noon. We can't wait! Tuesday February 8, 2011 11:51 Judy Graham

12:00

Judy Graham:  I've got a few questions to start things off. As for those of you joining us over the Web, feel free to send your questions at any time. We look forward to answering as many as possible. So, to start, Dr. Santen, can you tell us a little about the history of hormone therapy and its use in post-menopausal women? I know that's important background. Tuesday February 8, 2011 12:00 Judy Graham

12:00

Santen:  For the past 50 years, it has been standard practice for physicians to replace missing hormones when the glands making them stopped working. For example, when the thyroid gland stopped functioning, physicians prescribed thyroid hormone. When the adrenal gland was not working, they replaced hydrocortisone. When the pancreas stopped working in diabetes, they administered the missing hormone, insulin. In 1966, Robert A Wilson wrote an influential book entitled “Feminine forever” suggesting that all women of menopausal age should be treated with female hormones -- estrogens. At that time, it was thought this might prevent diseases such as osteoporosis and heart disease and at the same time, relieve symptoms. From then on until the results of the Women's Health Initiative were published in 2002, most post-menopausal women were advised to take "hormone replacement therapy." Tuesday February 8, 2011 12:00 Santen

12:00

Judy Graham:  What kinds of hormones are usually given to menopausal women, Dr. Stuenkel? Do we know how they work? Tuesday February 8, 2011 12:00 Judy Graham

12:01

Cynthia A. Stuenkel:  Two categories of hormones are prescribed to postmenopausal women: estrogens and progestogens. Estrogen is largely responsible for relief of hot flashes and vaginal dryness. It also prevents bone loss and potentially, fractures. Progestogens (including natural and synthetic progesterone) are only used to protect the lining of the uterus from the cancer-promoting effects of estrogen. Therefore, if a woman has no uterus, there is no need for a progestogen. Estrogen is carried through the blood stream to virtually all the tissues of the body. As a hormone, estrogen acts upon cells in several ways: through special receptors on the surface of cells for rapid response, and then, after being moved in partnership with special receptor molecules, through signals passed directly into the nucleus, or ‘command center -- of the cell. From the nucleus, depending upon which cell is involved (for example, uterus, bone, breast), specific proteins further tailor the instructions to the cell's DNA. Then the message is carried out step by step to slow bone loss, for example, or increase the thickness of the lining of the uterus. It's quite a system and reminds us of the beauty and complexity of biology! Tuesday February 8, 2011 12:01 Cynthia A. Stuenkel

12:01

Judy Graham:  Can you describe the Women's Health Initiative Study, Dr. Santen, what it was meant to do and the controversial findings that appeared in 2002? Tuesday February 8, 2011 12:01 Judy Graham

12:01

Santen:  It was common practice by 1990 to treat nearly all postmenopausal women with hormones to relieve symptoms of menopause. The studies at that time had also suggested that postmenopausal women receiving hormones had a reduced chance of developing heart disease. Yet, at the same time, there was evidence that hormone replacement in postmenopausal women might increase the risk of breast cancer. A group of experts felt that a carefully designed clinical trial was necessary to provide evidence to guide decisions about who should receive hormone therapy. The main goal was to obtain more information regarding breast cancer and heart disease risk. Because it was well known that hormone replacement therapy relieved symptoms of hot flashes and vaginal dryness, the study did not include evaluation of symptoms. Since the prevailing idea was that all postmenopausal women should receive hormone therapy as replacement for missing ovarian estrogens, the average age of women in the WHI trial was 63 and the range was from 50 to 80. The main findings were that hormone replacement therapy in postmenopausal women increased the risk of heart disease and increased the risk of breast cancer and stroke. The first report of these findings in 2002 led to an 80% reduction in the use of hormone replacement therapy in post-menopausal women . The first reports from the Women's Health Initiative study involved women who had received estrogen plus a progestin. A later study was published one year later that described findings in women who had had a hysterectomy and who were being treated only with estrogen. In these women, there was no increase in breast cancer risk and a suggestion that breast cancer risk was reduced. The findings regarding stroke were similar to those in women receiving estrogen plus a progestogen.. Older women taking estrogen plus a progestogen appeared to have a somewhat greater increase in cardiovascular disease than did women receiving estrogens alone. Tuesday February 8, 2011 12:01 Santen

12:02

Judy Graham:  Were all parts of the studies stopped or did some continue? Tuesday February 8, 2011 12:02 Judy Graham

12:02

Santen:  Both the estrogen plus progestin and the estrogen alone studies were designed with pre-planned stopping rules. When the risks exceeded the benefits, the studies were to stop. On that basis, both the estrogen plus progestin study and the estrogen alone study were stopped in 2002 and 2003. However, women in the estrogen plus progestin study who had stopped the medication or who had received placebo were asked to continue to be followed over the next six years. In October 2010, the 11 year follow-up of the WHI estrogen plus progestin study was published. Tuesday February 8, 2011 12:02 Santen

12:03

[Comment From GuestGuest: ]  What about bioidentical hormones? Are they safe? Tuesday February 8, 2011 12:03 Guest

12:04

Cynthia A. Stuenkel:  The bioidentical hormone industry came into prominence after the announcement in 2002 of the surprising initial results of the Women's Health Initiative (WHI) randomized controlled trial. Women (and some of their clinicians) were confused about the safety of hormone therapy and how to achieve symptom relief. In the discussions that followed, there was sometimes the general impression that the experts could not agree. In turn, proponents of bioidentical hormones conveyed a consistent (though unsubstantiated) message of safety, effectiveness, and sexiness. Add to the unproven claims the added factor that compounding pharmacies which produce and distribute bioidentical hormones are not regulated by the federal Food and Drug Administration but rather by individual state agencies. While the scientific community has struggled to convey the inconsistencies in the messages women are receiving, compounding bioidentical hormones has evolved to a billion-plus dollar business! One important point made by a number of medical organizations (The Endocrine Society, the American College of Obstetrics and Gynecology, The American Medical Association, and The North American Menopause Society), is that if a woman really wants to take a hormone that is identical in structure to those made by her body, FDA approved bioidentical hormones are readily available. Some oral estrogens, all transdermal patches, gels, and sprays, some vaginal estrogen creams, tablets, and rings, and micronized progesterone all qualify. For women, the availability of FDA approved bioidentical hormones is an opportunity to get the best of both worlds: the formula a woman desires along with the peace of mind that content, manufacturing standards, and labeling are all regulated and approved by the FDA. Tuesday February 8, 2011 12:04 Cynthia A. Stuenkel

12:05

Judy Graham:  Here's a resource for bioidentical hormones. http://nwhn.org/bio-identical-hormones-21st-century-ht-or-19th-century-snake-oil Tuesday February 8, 2011 12:05 Judy Graham

12:05

[Comment From lucretialucretia: ]  What is your opinion on the use of HRT for women who have had a hysterectomy at a younger age (say their early 40's)? Tuesday February 8, 2011 12:05 lucretia

12:07

Judy Graham:  Dt. Stuenkel is working on an answer. She'll be ready in just a moment. Tuesday February 8, 2011 12:07 Judy Graham

12:08

Judy Graham:  While we're waiting, the Web site for the Women's Health Initiative is a great resource. Here it is: http://www.nhlbi.nih.gov/whi/index.html Tuesday February 8, 2011 12:08 Judy Graham

12:09

Cynthia A. Stuenkel:  Women who have a hysterectomy at a younger age have different rules. The first issue is whether your uterus was removed, or your ovaries also. If only the uterus was removed, hormone therapy is not an immediate issue. If the ovaries were also removed, menopause becomes an instantaneous event! Most women feel better starting estrogen right away following the surgery, that is, as long as your surgery was not for cancer of the uterus, in which case most experts recommend avoiding estrogen therapy. The North American Menopause Society Hormone Therapy Position Statement (www.menopause.org) recommends that women without a contraindication continue estrogen therapy at least until the usual age of menopause, at which time reassessment of symptoms and health conditions is in order. Tuesday February 8, 2011 12:09 Cynthia A. Stuenkel

12:09

[Comment From JodyJody: ]  I've been on Effexor for my hot flashes for 2 months now with varied results. Does this particular drug take a long time to start working to relieve hot flashes or should I stop? Tuesday February 8, 2011 12:09 Jody

12:09

Santen:  Effexor should begin to work by 2 weeks to relieve hot flashes. The maximum effective dose is 75 mg daily. If this does not relieve the hot flashes, the usual next step is to use gabapentin under the direction of your physician Tuesday February 8, 2011 12:09 Santen

12:10

Judy Graham:  When is hormone therapy indicated as a possible menopausal treatment? Please give details. Tuesday February 8, 2011 12:10 Judy Graham

12:11

Cynthia A. Stuenkel:  The Food and Drug Administration currently lists three indications for the use of hormone therapy: 1. Relief of hot flashes; 2. Relief of vaginal dryness and pain with intercourse; 3. Prevention of bone loss in women for whom other therapies are not acceptable. Symptoms of hot flashes and vaginal dryness can occur during the transition to menopause as well as in the years after the last menstrual period. It really is up to the judgment of each individual woman how bothered she is by the symptoms and whether or not she wants to consider a trial of hormone therapy. She should partner with her health care clinician to decide if her benefits will outweigh risks specific to her based upon her medical history. Some women find hot flash relief by keeping their environment cooler (while freezing everyone around them!), dressing in layers, and identifying and avoiding personal hot flash triggers (for example hot coffee, spicy foods, alcohol). When these don't work, a woman might consider hormone therapy or other prescription medications for relief. For some women, nonprescription vaginal moisturizers and lubricants can provide relief from vaginal dryness and uncomfortable intercourse. While estrogen treatment to relieve hot flashes also usually relieves vaginal dryness, some women, particularly those not bothered by hot flashes or who want to avoid the effects of estrogen throughout their entire system, might wish to use vaginal estrogen. Tuesday February 8, 2011 12:11 Cynthia A. Stuenkel

12:12

[Comment From erinerin: ]  Would you comment on the very recent research that seemed to indicate for women taking estrogen only that there may actually be a decrease in cancer risk? I believe the researcher made a hypothetical distinction between endogenous and exogenous estrogen. Thank you. Tuesday February 8, 2011 12:12 erin

12:12

Santen:  The studies regarding estrogen alone show that women starting hormone therapy 10 or more years after the menopause appear to have a reduction of risk of breast cancer. This was particularly true for localized breast cancer. Notably, in women who continued to adhere to treatment and did not drop out of the study, the reduction in risk of breast cancer was about 30% and was significant on a statistical basis. On the other hand, estrogen alone in women just starting menopause appears to cause neither an increase nor a decrease in breast cancer risk over the first five years. The Endocrine Society's scientific statement concluded that estrogens could increase the risk of breast cancer after more than five years of use, particularly in recently postmenopausal women. This effect of estrogen in increased breast cancer risk becomes greater when women have taken estrogen over a long period of time of 10, 15, or 20 years. An important finding regarding the use of estrogen plus a progestin is that the increased risk goes away within five years of discontinuing hormone therapy. Tuesday February 8, 2011 12:12 Santen

12:13

[Comment From Barbara GulanskiBarbara Gulanski: ]  Can Drs Santan and Stunkel summarize the findings of the 11 year follow-up studies? Are there any new findings since the initial WHI publications? Tuesday February 8, 2011 12:13 Barbara Gulanski

12:15

Judy Graham:  Hang on while Dr. Santan prepares his answer. We'll be with you in a moment. Tuesday February 8, 2011 12:15 Judy Graham

12:17

Judy Graham:  Another resource that might be helpful is the National Institutes of Health web site on hormone therapy for post-menopausal women: http://www.nih.gov/PHTindex.htm Tuesday February 8, 2011 12:17 Judy Graham

12:18

Santen:  A recent publication described the 11 year follow up of women randomized to estrogen plus a progestogen for 5 years when they stopped the hormones. They then were followed for another 6 years. There was a 25% increase in the relative risk of breast cancer over that period of time. This actually represented only 4 women out of 1000 who developed a breast cancer that they would not have otherwise experienced. There was a small increase in the death rate from cancer in the group who took hormones. After hormonal therapy was stopped after 5 years, there was no further increased risk in breast cancer. This indicates that once the hormone therapy is stopped, the risk of breast cancer goes away after 2-3 years. Tuesday February 8, 2011 12:18 Santen

12:18

Judy Graham:  Dr. Stuenkel, are there certain women who've gone through menopause who shouldn't go on hormone therapy? If the answer is yes, can you give more details? Tuesday February 8, 2011 12:18 Judy Graham

12:19

Cynthia A. Stuenkel:  Indeed, there are women for whom hormone therapy should not be used. A careful evaluation before starting hormones is essential. Pregnancy, the major reason for missed periods, should be ruled out. A woman with irregular vaginal bleeding should be evaluated to be certain she does not have medical concerns with the vagina, cervix, or uterus prior to starting hormone therapy. Women who have a history of cancers that grow in response to estrogen (uterus and breast) should avoid estrogen therapy. We know that risks for cardiovascular disease can increase in women with a history of these conditions, so anyone who has had a stroke, heart attack, or blood clot in the legs or lungs should not use hormone therapy. Finally, since the liver metabolizes estrogen, women with liver disorders should also be cautious (check with your doctor to discuss your specific condition). Following the publication of the very large Women's Health Initiative randomized controlled trial, we have also learned that it is usually not advisable for women to start hormone therapy for the very first time after the age of 60 years because of increased risk of stroke or after 70 years because of increased risk of heart attack. Tuesday February 8, 2011 12:19 Cynthia A. Stuenkel

12:19

[Comment From SheryleSheryle: ]  what about the companies advertising HRT. Is it safe? I take prem-pro (have for about 4 years) and still have hot flashes. Tuesday February 8, 2011 12:19 Sheryle

12:21

Cynthia A. Stuenkel:  The example you give, Prempro, is a preparation of conjugated estrogens coupled with daily medroxyprogesterone acetate. With the lower doses we are currently recommending, hot flashes might not be completely eliminated. We think that is a reasonable trade off. If you are really bothered, you might ask your physician about increasing the dose. The other trick is to make certain that your symptoms are really hot flashes and not due to other disorders such as thyroid concerns, etc. Tuesday February 8, 2011 12:21 Cynthia A. Stuenkel

12:21

Judy Graham:  We've got a lot of questions coming in and that's great. Keep them coming. Tuesday February 8, 2011 12:21 Judy Graham

12:22

[Comment From erinerin: ]  It seems that progesterone is looking like the culprit for increased risk of breast cancer in hrt. Would you comment on whether that is correct? And, if progesterone puts a woman at higher risk, would use of a non-systemic progesterone like the mirena iud...possibly put the woman at lower risk of breast cancer?Thank you. Tuesday February 8, 2011 12:22 erin

12:24

Santen:  The information from the estrogen plus progestogen component of the Women's Health Initiative study does suggest that the progestogen is the major culprit. However, there is some indication that the use of estrogen alone for 10-20 years can also increase the risk of breast cancer. Therefore, the progestogen is the main culprit but estrogen is probably also involved. It was suggested many years ago that none systemic use of a progestogen might reduce the problem of increased breast cancer risk. One suggestion was to use mirena, a device to deliver progesterone locally to the uterus. We do not yet have data studying this possibility but it remains a possible approach. Tuesday February 8, 2011 12:24 Santen

12:24

Judy Graham:  Here's a question submitted by a reader in advance: My wife, age 40, has been experiencing "peri-menopause" related symptoms for the past several years, such as moody aggressive behavior preceding her period (2 weeks prior) then levels to her normal self after. We have been to both her gynecologist and family GP who prescribed an antidepressant to take, which really has not worked. The GP suggested she take birth control to balance out her hormones if the antidepressant's did not work. I also understand that there is a new antidepressant that has no sexual side effects. Can you provide any other information on this and this estrogen dominant cycle? Respectfully, Jason Tuesday February 8, 2011 12:24 Judy Graham

12:24

Cynthia A. Stuenkel:  Lucky wife to have such a concerned partner! If you liked puberty, you'll love the perimenopause, the phase during which estrogen production by the ovary varies widely from much higher levels than women usually experience during their reproductive years, to very low levels characteristic of the postmenopause. Among symptoms such as irregular bleeding and hot flashes, some women experience mood disturbances—ranging from depression to anxiety to severe premenstrual syndrome (now formally described as premenstrual dysphoric disorder -- PMDD). For many women, these symptoms fall in the nuisance category and simply require patience and reassurance. For others, though, the symptoms can become quite disabling and stress life at home, at work, and beyond! Relaxation and stress reduction techniques, including lifestyle modifications such as healthful diet, regular exercise, and moderation in caffeine and alcohol, provide adequate relief for some women. Others benefit from prescription therapies such as antidepressants, specifically of the selective serotonin reuptake inhibitor (SSRI) category. Women might also benefit from the use of an oral contraceptive which helps to smooth mood by shutting down the erratic fluctuations in estrogen secretion by the ovary. A number of drugs in these categories have been FDA approved specifically to treat PMDD. While effective at lifting mood, the SSRIs can occasionally mute sexual interest and responsiveness. But with everything else going on in the life of most women during the menopause transition, sex can fall to the bottom of the priority list. So before laying blame on the SSRI, a careful look at the relationship, overall health concerns, and other stressors is in order. While newer antidepressants with less effect on sexuality might be an option, when faced with a challenging perimenopause, especially one dominated by severe mood changes, referral to a mental health professional can be of great help. A careful evaluation of your unique situation can help focus therapy most effectively. Tuesday February 8, 2011 12:24 Cynthia A. Stuenkel

12:25

[Comment From Susan GryzabowskiSusan Gryzabowski: ]  I have heard that hormone therapy can be good for memory and preventing dementia, is that true? Tuesday February 8, 2011 12:25 Susan Gryzabowski

12:25

Santen:  The Women's Health Initiative randomized control trial provided the best information we have on cognitive function in women. A sub-study was conducted to try to answer this in detail. Somewhat surprisingly, cognitive function declined in women over age 65 who were receiving hormonal therapy. Most experts believe that this effect on cognitive function probably results from an increase in small blood clots in the brain or small strokes that are caused by effects of hormone therapy on blood clotting mechanisms. The major controversy at this time is what effect hormone therapy has in younger women just starting hormone therapy. Information from observational studies---studies that explore associations but that are weaker than randomized trials--has in general showed that hormone therapy improves cognitive function. At the present time, this controversy has not been resolved. One explanation for the controversy is that hormone therapy may be beneficial for cognitive function in younger women who are not susceptible to the small stroke or blood clotting mechanisms as are older women. In support of this possibility, women with premature menopause who are treated with hormone therapy in their 40s, clearly appear to have improved cognitive function. This is in direct contrast to older post-menopausal women in whom cognitive function is reduced in those using hormone therapy. At the present time, there is no definitive evidence either way on this issue. The Endocrine Society, a 12,000 member scientific society, recently published a scientific statement trying to evaluate the evidence regarding hormone therapy. Regarding cognitive decline and dementia, the scientific statement indicated that menopausal hormonal therapy probably has no important effect on cognitive function in younger women. The statement indicated that estrogen therapy started at the time of surgical menopause appears to benefit verbal memory over the short term. Hormone therapy after about age 60 does not improve memory or other cognitive skills. The statement concluded that hormonal therapy started after age 65 increases the risk of dementia and lowers cognitive function. It also concluded the effects of hormonal therapy on dementia when started and used during the early menopausal period (short gap) are unclear. As for the long term risk of dementia, the statement suggested that it may be reduced by menopausal hormonal therapy if started early--that is, in the 40s if menopause occurs early or just after onset of menopause in women in their 50s. However, the evidence for this early benefit, late harm effect was judged to be weak and of low quality. Tuesday February 8, 2011 12:25 Santen

12:26

Judy Graham:  I have a question: Is there a period of time during or after menopause when it's best to start hormone therapy, Dr. Stuenkel? Tuesday February 8, 2011 12:26 Judy Graham

12:27

Cynthia A. Stuenkel:  The results of the Women's Health Initiative study strongly suggest that hormone therapy has the least risk for women in their 50s or within the first 10 years following menopause. This makes sense, given that symptoms of menopause will be more severe in younger women closer to the time of menopause, so that is the group of women most likely to seek relief. Baseline risks of heart attack, stroke, and blood clots are also much lower in younger women. However, starting HT sooner does not reduce the risk of breast cancer and could in fact increase that risk slightly above what was reported in the Women's Health Initiative. Tuesday February 8, 2011 12:27 Cynthia A. Stuenkel

12:27

[Comment From GuestGuest: ]  You've talked about estrogen and progesterone replacement. What about testosterone replacement? I have virtually no testosterone and am receiving bioidentical testosterone replacement in addition to the estrogen and progesterone replacement. Do have any concerns about replacing testosterone in post-menopausal women who have not had a hysterectomy? Tuesday February 8, 2011 12:27 Guest

12:27

[Comment From KimberlyKimberly: ]  Are testostoren pellets a good idea for a 45 year old female, complete hysterectomy, and extremly dry skin? taking oral estrogen. Tuesday February 8, 2011 12:27 Kimberly

12:28

Judy Graham:  Dr. Santen is going to answer these questions, both of which deal with testosterone. Tuesday February 8, 2011 12:28 Judy Graham

12:32

Santen:  The question frequently comes up whether testosterone made by the ovary should be replaced in women who have had a hysterectomy with both ovaries removed at the same time. This question usually comes up in women who have had this operation between the ages of 30 and 50. The best approach appears to be the use of a testosterone patch which delivers a small amount of testosterone. Randomized controlled trials have shown that this approach improves libido by about 30% compared to women receiving a patch with no testosterone. The FDA has not approved this approach and would like more long-term safety data before approval. In Australia and in other countries, a pellet containing testosterone is implanted under the skin. This approach also improves libido but concern remains about safety. If a physician prescribes either form of testosterone, it is important to demonstrate that the levels of testosterone in the blood do not go above the normal range for premenopausal women. Tuesday February 8, 2011 12:32 Santen

12:32

[Comment From erinerin: ]  Would you clarify when menopause starts? I have heard that menopause commences 1yr. after a woman's last period . Alternatively , I have heard that menopause starts at the time of the last period. Thank you. Tuesday February 8, 2011 12:32 erin

12:32

Judy Graham:  We'll let Dr. Stuenkel take that one on. Tuesday February 8, 2011 12:32 Judy Graham

12:32

Cynthia A. Stuenkel:  Menopause, by definition, refers to the last menstrual period. Unfortunately, women cannot know this with certainty until some time has passed. Again, by definition, one year after the last period is the time designated to enable a woman to say with certainty that she is postmenopausal. That year of waiting formally fits in the category of perimenopause. Tuesday February 8, 2011 12:32 Cynthia A. Stuenkel

12:33

Judy Graham:  Some new research has looked at hormone therapy and lung cancer, Dr. Santen. Can you tell us about that? Tuesday February 8, 2011 12:33 Judy Graham

12:33

Santen:  The Women's Health Initiative study suggests that the number of women with a diagnosis of lung cancer is not significantly increased in women taking estrogen alone or estrogen plus a progestin. There was however, a slight trend toward more lung cancers, particularly in women over 70 taking an estrogen plus a progestogen. On the other hand, death from lung cancer appeared top be greater in women receiving estrogen plus a progestin. Over the last five years, it has been shown that a type of lung cancer called non-small cell lung cancer contains receptors for estrogen and all cells are capable of making estrogen directly in the lung cancer tissue through an enzyme called aromatase. Studies in cancer cells in the test tube show that hormones can stimulate the growth of non-small cell lung cancers. All of this information suggests that some lung cancers have the ability to respond to hormones with increased growth. A recent study just published (Bouchardy C, et al, Cancer, 2011) showed that women taking the anti-estrogen Tamoxifen had a reduction in mortality from lung cancer compared to those who were not taking Tamoxifen. On the other hand, the number of women who developed breast cancer while receiving Tamoxifen was not different from those not receiving Tamoxifen. While this information needs further study, it would suggest that hormone therapy does not increase the number of women who develop lung cancer but it alters the growth of existing lung cancers. For this reason, overall death rate from lung cancer is increased in women taking hormone therapy. Tuesday February 8, 2011 12:33 Santen

12:35

[Comment From GuestGuest: ]  My doctor has just prescribed HRT after a brief experience with postmenopausal bleeding after 14 months without a period. The lining of my uterus was checked for thickness and is 4.9 mm. What are the advantages of HRT for me at this point. I am somewhat reluctant to begin due to the controversy on this subject. Tuesday February 8, 2011 12:35 Guest

12:35

Judy Graham:  Dr. Stuenkel is going to address this one. Tuesday February 8, 2011 12:35 Judy Graham

12:37

Cynthia A. Stuenkel:  You bring up an important point about the need to report any bleeding that occurs after the menopause. It occasionally happens that women have a rogue 'period' with premenstrual symptoms, breast tenderness, and bleeding more than a year beyond menopause. But the onus is on your physician to be certain that possible problems with the uterus, especially uterine cancer, or the cervix are ruled out. An ultrasound of the lining of the uterus is one way to accomplish this. The other is taking a small sample of tissue, an endometrial biopsy, to examine under the microscope and rule out any pathology. Tuesday February 8, 2011 12:37 Cynthia A. Stuenkel

12:37

Judy Graham:  I know that the timing hypothesis has been much discussed by researchers. What is this hypothesis? Is it well established or not? Tuesday February 8, 2011 12:37 Judy Graham

12:37

Santen:  The timing hypothesis suggests that older women already have some degree of underlying heart disease. In these women, hormones cause an increased rate of clotting of the blood. When the blood clots around a pre-existing heart disease lesion in the arteries, a heart attack could occur. Most investigators believe that this explains the increased risk of heart disease in older women. On the other hand, in women who are younger and have not developed early heart disease, estrogens act on the blood vessels to reduce the development of heart disease. For this reason, younger women either experience a reduction of heart disease or no increase when given hormones. The evidence to support the timing hypothesis comes primarily from studies of monkeys in whom the ovaries have been taken out surgically. In this model system, hormones given late after removal of the ovaries causes heart disease but prevents it in animals given hormones shortly after surgically-induced menopause. Examination of the Women's Health Initiative study supports the timing hypothesis in that estrogen alone appears to reduce the risk of heart disease in younger women but increases it in older women. The information is not as clear for estrogen plus a progestin for older women who clearly have a higher risk of heart disease. A study called Kronos is currently trying to test the timing hypothesis directly. Tuesday February 8, 2011 12:37 Santen

12:37

Judy Graham:  What are the implications of the timing hypothesis for menopausal women? Tuesday February 8, 2011 12:37 Judy Graham

12:37

Santen:  In younger women just entering menopause, estrogen alone probably reduces the risk of heart disease whereas estrogen plus progestin does not increase that risk. In older women, 56 and above, both estrogen alone and estrogen plus a progestogen increase heart disease risk. For this reason, younger women need not fear an increase in heart disease if they take hormone therapy. In viewing all of the information regarding the timing hypothesis, nearly all experts agree that more definitive information is needed. In the meantime, the guidelines for nearly all scientific societies suggest that hormones not be used solely to reduce the risk of heart disease in younger women. Tuesday February 8, 2011 12:37 Santen

12:38

[Comment From erinerin: ]  Dr. Stuenkel...Thank you for your response on when menopause starts. Yet, it is still unclear to me. When seeking to know how many years into menopause that you are...do you start from your last period OR one year after your last period? Tuesday February 8, 2011 12:38 erin

12:38

Cynthia A. Stuenkel:  I see your point. For most studies, etc, we ask about how many years since the last menstrual period. So in your case, I'd count since the last menstrual period. Hope that clarifies! Tuesday February 8, 2011 12:38 Cynthia A. Stuenkel

12:39

[Comment From DanaDana: ]  I am a 50 year old women, I have had a full hysterectomy 18 months ago & I still suffer from hot flashes. Because of the breast cancer history in my family & my own dense breast tissue, my Ob-Gyn has advised against hormone therapy. What does either of the doctors recommend to help with the symptoms Tuesday February 8, 2011 12:39 Dana

12:42

Judy Graham:  Dr. Santen drafted a thorough answer to this question. Hold on just a moment. Tuesday February 8, 2011 12:42 Judy Graham

12:46

Santen:  Many women have severe hot flashes and cannot use hormone therapy because they have had breast cancer or are at high risk of developing breast cancer. Over the past several years, many different treatments for these patients have been developed. If the hot flashes are bothersome mainly during the daytime, the best approach is to use one of the drugs that are more commonly used for depression. One of these is called Effexor, another is Zoloft, and another is Prozac. Effexor is preferred if a woman is taking tamoxifen as treatment for breast cancer. If the hot flashes are predominately bothersome at nighttime, a drug called gabapentin is used. There was recently a direct comparison of Effexor with gabapentin showing that both worked equally. However, 60% of women preferred Effexor. The lay literature suggests that vitamin E, black cohosh, and other herbal medicines are effective. However, every study shows a 30% reduction of hot flashes with a placebo. It is thought by experts that most of the effects of these alternatives, vitamin E, etc. are related to the placebo effect. None of the effective agents work as well as hormone therapy but they still are associated with a marked improvement in hot flashes. Tuesday February 8, 2011 12:46 Santen

12:46

[Comment From erinerin: ]  There is an epidemic of obesity in this country. I am wondering if the increased heart disease and stroke risks of hrt may possibly be lessened if someone maintains a very healthy bmd, exercises regularly and eats in a healthy manner? Tuesday February 8, 2011 12:46 erin

12:46

Judy Graham:  Dr. Stuenkel will take that on. Tuesday February 8, 2011 12:46 Judy Graham

12:49

Cynthia A. Stuenkel:  The increase of obesity is certainly a concern: it effects almost half of women in the menopausal age groups! We know that obesity in and of itself increases a woman's risk of heart disease and stroke, so the pros and cons of hormone therapy should be carefully evaluated. A transdermal therapy might be the better choice because it has a metabolically friendlier profile than oral preparations. Healthy eating, exercise, stress reduction, and avoiding smoking all help keep the heart healthy. A healthy woman at menopause is definitely a safer candidate for hormone therapy. Tuesday February 8, 2011 12:49 Cynthia A. Stuenkel

12:49

Judy Graham:  Dr. Santen, I'm wondering which questions have been left unanswered by the Womens Health Initiative studies? Tuesday February 8, 2011 12:49 Judy Graham

12:50

Santen:  A major problem with the Women's Health Initiative studies was that the average age of women was 63. Only 5% of women were between the ages of 50 and 55 when the study was started. Many experts then suggested that the information from the Women's Health Initiative study didn't provide sufficient guidance for women just planning to start hormone therapy. The average age of menopause is 51 and most women decide on taking hormone therapy between the ages of 50 and 55. There were not enough women in the WHI studies to determine what the risks and benefits were for hormone therapy in this group of younger women who would be deciding whether to use hormone therapy. Tuesday February 8, 2011 12:50 Santen

12:52

[Comment From JeanneJeanne: ]  Sorry just popped in late but I have to tell you that without the topical testosterone I apply I wouldn't have a sex life at all.....I think more woman my age need it after a complete hysterectomy. Seems like doctors are a bit more concerned with stats rather than quality of life for us older women. Why are doctors so ignorant about testosterone needs in woman? Tuesday February 8, 2011 12:52 Jeanne

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Cynthia A. Stuenkel:  Jeanne, you bring up a sensitive point with many professionals who care for women in your situation. In the wake of the WHI, the FDA has become increasingly cautious about heart health. They have thusly held off on approving a transdermal patch which has been shown to be effective at increasing sex drive and enjoyment in postmenopausal women. In the meanwhile, another preparation for women, applied as a testosterone gel, is under study. A large group has been enrolled to carefully look for cardiovascular effects. Hopefully, within the next year or so we will see a well tested testosterone option available for women. Tuesday February 8, 2011 12:53 Cynthia A. Stuenkel

12:53

Judy Graham:  As we draw to a close here, I wonder if you can summarize the benefits of hormone therapy for us, Dr. Santen? Tuesday February 8, 2011 12:53 Judy Graham

12:53

Santen:  A number of additional analyses of the WHI studies have been conducted over the last nine years. A critical finding is that the risks and benefits of hormone therapy are different for women who start hormone therapy just after the menopause when compared to those starting hormone therapy 10 or 15 years later. The terms long gap and short gap have been introduced. Long gap means that there is a period of time of 10 or more years between the onset of menopause and when a woman starts on hormone therapy. The short gap reflects women who have gone through the menopause and start hormone therapy within five years of their last menstrual period. In the women with short gap, there appears to be no increased risk of heart disease. The risk of stroke is also much less because stroke is much less common in younger than in older women. With respect to breast cancer, the women in the short gap group continue to have an increased risk of breast cancer when receiving estrogens plus a progestin. In the women receiving estrogen alone, there is no decrease in the risk of breast cancer on the one hand but no increased risk on the other when estrogen is taken for five years. Interestingly, women less than age 60 receiving hormone therapy (pooling the data from both the E alone and E+P groups) have a 40% reduction in death rate during the first five years of taking hormone therapy. This fact has largely gone unnoticed by the media. When examining women in the long GAP group ( > 20 years after menopause) , there was an increase in heart disease in women receiving estrogen plus a progestogen and trends suggested this for the E alone group as well Tuesday February 8, 2011 12:53 Santen

12:54

[Comment From guestguest: ]  I have repeatedly read and it has been stated in this chat by one of the doctors that if you have had a hysterectomy progesterone is not needed as it is for those with a uterus. But, what if the dr. left ovaries in at the time of hysterectomy, would that be any reason to have progesterone along with estrogen? Tuesday February 8, 2011 12:54 guest

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Cynthia A. Stuenkel:  Good question. No uterus, no progestogen. Other than protecting the lining of the uterus, we know of no benefit. Tuesday February 8, 2011 12:55 Cynthia A. Stuenkel

12:55

[Comment From kaykay: ]  Can a woman aged 49 going through menopause become pregnant? Tuesday February 8, 2011 12:55 kay

12:57

Cynthia A. Stuenkel:  Kay, they don't call them change of life babies for no reason! YES, absolutely a women in the menopause transition can become pregnant. That is why contraception is so important, particularly because periods can become so irregular. For many long-term couples, one or the other partner has been sterilized. But if you are in a new relationship or back on the market, using a reliable contraceptive consistently is essential. Also, don't forget that STDs can definitely be a midlife issue, so take appropriate barrier precautions as well! Tuesday February 8, 2011 12:57 Cynthia A. Stuenkel

12:57

[Comment From guestguest: ]  This is a follow up on the testosterone question from Jeanne...does testosterone as part of hrt increase breast cancer risk? Tuesday February 8, 2011 12:57 guest

12:59

Santen:  The question of testosterone as part of hormone therapy and breast cancer risk is a controversial issue. This was fully discussed in the Scientific Statement on hormone therapy published by the Endocrine Society in July 2010. One issue was that women with high testosterone levels in their blood have a higher risk of developing breast cancer than women with low testosterone levels. In all of the studies examining the risk of breast cancer in women taking testosterone as part of hormonal therapy, there were no consistent findings. One-half of the studies showed an increased risk and the others did not. The Endocrine Society advises caution in the use of testosterone in women who are otherwise at increased risk of breast cancer because of family history and other factors. Tuesday February 8, 2011 12:59 Santen

1:00	Judy Graham:  Dr. Santen, in the spirit of summarizing, can you give us an overview of the risks associated with hormonal therapy for postmenopausal women? Tuesday February 8, 2011 1:00 Judy Graham

1:00

Santen:  In the long gap group of women who start hormone therapy 10 or more years after the menopause, the risks clearly outweigh the benefits. The risks in this age group are increased risk of breast cancer, heart disease, and stroke and the benefits are reduction of fractures of the bones and improvement in symptoms due to vaginal atrophy. In the short gap women starting hormonal therapy within five years of menopause, the risks and benefits are different. The scientific statement of the Endocrine Society looks specifically at women ages 50-59 or less than 10 years after the onset of menopause. In this group of women, both estrogens alone or estrogens plus a progestin reduce the rate of fractures, diabetes, and overall mortality, Some evidence suggest a reduction of coronary heart disease but this has not been firmly established. Estrogen alone does not increase the risk of breast cancer whereas estrogen plus a progestin increases that risk. To put that risk in perspective, if 1000 women take estrogen plus a progestin for a total of five years, approximately seven women will develop a breast cancer they would not otherwise have developed because of taking estrogen plus a progestin. In the short gap patients, there is a small increased risk of stroke from the pro-coagulant effect on blood clotting, blood clots in the lung, and gallbladder disease. On the other hand, nearly all women have improvement of hot flashes and symptoms related to vaginal atrophy if they use hormone therapy. Tuesday February 8, 2011 1:00 Santen

1:01	Judy Graham:  A final question for you, Dr. Stuenkel. I've heard that you should take hormones for the least amount of time possible. is that true? How do you determine when is long enough? Tuesday February 8, 2011 1:01 Judy Graham

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Cynthia A. Stuenkel:  How long is long enough is an individual decision. There are women who feel that symptom relief supercedes any concern with risks of hormone therapy. In the 2010 Hormone Therapy Position Statement, The North American Menopause Society says that "Provided that the lowest effective dose is used, that the woman is well aware of the potential benefits and risks, and that there is clinical supervision, extending hormone therapy use for an individual woman's treatment goals is acceptable under some circumstances, including: - The woman, for whom, in her own opinion, the benefits of menopause symptom relief outweigh risks, notably after failing an attempt to stop hormone therapy - The woman with established reduction in bone mass for whom alternate therapies are not appropriate or cause unacceptable side effects, or the benefit-risk ratio of extended use is unknown. -- (available at www.menopause.org) Tuesday February 8, 2011 1:02 Cynthia A. Stuenkel

1:02	[Comment From erinerin: ]  I just wanted to thank the doctors for an excellent and informative chat! We were so lucky to be part of this. Thank you both. Tuesday February 8, 2011 1:02 erin

1:02	Judy Graham:  Thank you so much for an incredibly informative, lively chat. I can't tell you how valuable this information is. Tune in next week for another Chicago Tribune web chat, same time, same place. Tuesday February 8, 2011 1:02 Judy Graham

1:02	Cynthia A. Stuenkel:  Thanks for all your thoughtful questions! Best of luck as you navigate this exciting time of life. Tuesday February 8, 2011 1:02 Cynthia A. Stuenkel

1:03