Hormone Replacement Therapy

Do you remember those Once-upon-a-time stories from when you were a child? They seemed to promise so much and yet, when considered in the light of the next day, offered so little. Sometimes I think that the story of hormone replacement therapy (HRT) has a lot in common with those faerie tales. I mean it all seemed to make so much sense: replace what is no longer there. I even remember likening estrogen lack -menopause- to diabetes with its relative or absolute insulin lack: a disease for which good health mandates a replacement.

And it made sense that those things which seemed uncommon during menstrual life -heart attacks, memory loss, dementia and so on- should be treatable, if not in fact preventable with a mere whiff of estrogen. But of course, it was quickly appreciated that estrogen, as powerful as it seemed, was only half the equation; it needed its partner Progesterone to prevent inadvertent over-stimulation of estrogen sensitive cells like those in the uterus -and maybe elsewhere. Who knew?

That of course led to a struggle between the two giants: some people developed mood changes, irritability, or even depression with progesterone. And some synthetic progesterones carried their own baggage: they changed cholesterol and sometimes even triglycerides to levels that might indicate an increased risk for heart attacks and maybe strokes.

It quickly became a delicate dance of two partners, both used to control -or at least being controlled. Like two teenagers constrained when at home, managed as they were growing up with recognizable top-down authority, they were noticeably different when their parents were away: no rules. Even their roles were vague. Should enough progesterone be given to inhibit bleeding? For years it was administered  cyclically in an attempt to mimic the normal monthly pattern of periods. Then it became apparent that cyclic bleeding was not only unnecessary, but also confusing: could the bleeding be a sign of something other than progesterone withdrawal -cancer, for example? So continuous administration of both hormones became the norm.

Then the breast cancer scare. Progesterone seemed to have the special task of inducing cellular growth in normal breasts, so could it go one step further and..? Well, the dance continued -and continues. It’s a kind of Three -make that two- Bears story now: Just right baby bear. Not too much progesterone -just enough to do the job without getting into any other mischief.

Several large prospective studies were done that sort of took the wind out of the hormonal sails and the prospect of eternal youth with cardiovascular and neurologic protection as a bonus seemed to evaporate like early morning fog. Not only did they not protect against the ravaging teeth of age or dementia, there seemed to be a higher risk of heart attacks and strokes for at least the first year of their use. Not what anybody wanted to hear.

More recent evidence suggests that if the hormones are started early enough, there may be some degree of protection for maybe five years or so, but are you beginning to see a pattern in the retrenchment? We are determined to salvage some degree of credibility for hormone replacement even where the evidence is underwhelming.

And yet, it’s perhaps not that HRT is not helpful, but merely that it is not helpful enough in the areas where we had our greatest hopes: prevention. The elixir of youth was never attainable, but it did seem reasonable to hope that those things that often accompany the withdrawal of hormones -or maybe just the age at which it occurs- could be forestalled. Eliminated. Conquered. Youth, when hormones are raging, is seldom bothered by heart attacks, Alzheimer’s or strokes. There is a different world-view, a different expectation…

But menopause can be a traumatic time both psychologically as well as physically. There is a realization, sometimes resisted, that a different era has begun. A different life, even: one without the prospect of pregnancy, or natural periods, or even comfortable sex in some cases. A life that some might be tempted to live in retrospect: what was, and not what is… The tripartite curses of hot flushes, memory loss, and sleepless nights are for many, significant and insufferable.

Fortunately, that’s an arena in which HRT plays comfortably. No, there’s no magic potion; Ponce de Leon never visited this country. But hormones are fairly efficient at relieving hot flushes and the other menopausal symptoms that make daily life so uncomfortable. There are bonuses with maintaining bone health, and perhaps skin health, and maybe even vaginal health. Everybody’s different -all doctors say that (just in case)- but one could certainly argue that HRT should only be used for symptom relief and not preventative therapy. Know the risks and balance them with the benefits -another truism.

HRT has its place as do alternative therapies. But obviously if the alternative therapy wishes to address an estrogen lack, it has to have an estrogen effect and therein lies the problem. A phytoestrogen (plant-derived), for example, can be just as dangerous, unopposed by progesterone, as another more mainstream form of estrogen. The piper has to be paid. There are risks to all hormones, whether estrogen-substitutes or the real thing. Some are helpful in the short-term, and some are probably placebos but there is at least a choice -none miraculous, none infallible, some of even questionable value, but all are available for the choosing. Or not.

One can choose not to choose. All choices come with pitfalls; I certainly cannot make the choice. I am reminded of  Hortensio in the beginning of that delightful Shakespearean play The Taming of the Shrew. The context is irrelevant, but his comment is not: There’s small choice in rotten apples. Well, maybe, but at least there are apples…

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