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Estrogen vs. Estrogen and Progesterone

Estrogen or estrogen and progestogen – which form of hormone therapy to take? Whether a woman still has her uterus, or had hers removed by hysterectomy makes all the difference according to the 2012 Hormone Therapy Position Statement of The North American Menopause Society (NAMS).

Dr. Margery Gass, Executive Director at NAMS clarifies what the latest research findings mean for women who may be thinking of taking hormone therapy (HT) and want to separate the facts from fiction.

The position statement explains the two HT options:
*Women who still have a uterus need to take a combination of estrogen and progestrogen (EPT) hormones. The progestrogen protects against uterine cancer, which can develop when taking estrogen alone.
*Women who do not have a uterus may safely take estrogen therapy alone.

Dr. Gass: ‘The good news here is that especially with the estrogen therapy alone, that can be used by women who had hysterectomy, we don’t see an early increase in breast cancer. In the WHI report and some other studies such as the Nurses’ Health Study and the Worldwide Literature Review, there were statements that said estrogen taken on its own leads to increased risks of developing breast cancer. But the outcome tends to be much smaller and appears to be more delayed than women who took the combination of estrogen and progestrogen.

Women who still have their uterus need to take a combination of estrogen and progestrogen, the latter is to protect the endometrial lining and the associated increased risk for endometrial cancer.

One of the main points coming out of this last position statement was that we felt that duration could be individualized depending on whether or not the woman is able to take estrogen alone (again no uterus) in which case it may not be so necessary for her to stop at that three to five year point if she still feels like she needs to take hormones longer. Whereas our recommendation would be if women with a uterus who take the combination can get off in three to five years would be preferable because that is about when we started to see the increase in risk of breast cancer.’

I asked Dr. Gass to elaborate a bit more on the importance of the uterus in HT therapy.

Dr. Gass: ‘The uterus is of utmost importance, and is crucial in understanding the benefits and risks ratios of hormones. We learned that the hard way in the 1970s because back then the experts thought that estrogen was all that a woman needed because that will take care of all the hot flashes, the genital dryness all the things that we do know are related to menopause.

Then these clinicians who were observing began to notice higher incidences of endometrial cancer than before. Those women would bleed and so that was kind of linking it to hormone therapy and it turned out that was the case; that if you take estrogen and the longer you take it and the higher the dose the more likely that is to lead to endometrial cancer. That is when they realized if we add that progestrogen back in and give a woman both of those hormones the way the ovaries used to do it, there didn’t seem to be that increase in endometrial cancer.’

For women who need help dealing with menopausal symptoms, HT is one of many options available. Making the decision with a caring and open-minded healthcare provider means women no longer have to passively accept just any treatment, or be fearful about HT.

NAMS provides a clear language version of the 2012 Hormone Therapy Position Statement for menopausal women and this may be viewed and printed at: http://www.menopause.org/psht12patient.pdf

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