“Girl help me, please!” she said as I sat down to introduce myself to my new patient. “If you don’t help me, I am going to end up in an orange jumpsuit.”
“What’s wrong?” I asked. She then proceeded to tell me her story about debilitating hot flashes and how they were ruining her life. She said she they were driving her so crazy she thought she might go mad and commit a crime. She was actually fanning herself in the office while complaining that she could not sleep at night, that she was tired all the time, and that intercourse had become painful. These issues were beginning to interfere with her job performance and her marriage. She literally was a “hot mess.”
She had previously approached her primary care doctor and had discussed hormone replacement therapy (HRT). With “all the new evidence regarding HRT” this physician said he did not feel like it was a good idea. And so she ended up seeing me, and I am happy to report that she is crime-free and not wearing an orange prison jumpsuit today.
Unfortunately, this scenario is not uncommon. Hot flashes are the most common menopausal symptom, affecting as many as 60 to 80 percent of women. Prior to the last decade, HRT was given to women fairly liberally with the false expectation that it would protect them from getting heart disease. Then, in 2002, the results from the Women’s Health Initiative trial were released, and everything changed. The results, which are still being dissected and reanalyzed today, demonstrated that HRT does not protect women from getting cardiovascular disease. In fact, there is an attributable excess risk per 10,000 person-years of 7 more cardiovascular events, 8 more strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers (JAMA. 2002 Jul 17;288(3):321-33). As a result, the FDA requires that all estrogen-containing prescription therapies carry an added warning of the new associated risks. These risks have made doctors and patients fearful of HRT, and this has resulted in a backlash: women are being denied access to a treatment that they could benefit from.
Yes there are risks associated with HRT; however, these risks do not mean that there is no role for these medicines. Scientific evidence proves that HRT effectively helps such conditions as hot flashes, vaginal dryness, night sweats and bone loss. A recent review determined a 75 percent reduction in the frequency and an 87 percent reduction in severity of hot flashes. Benefits can lead to improved sleep, sexual relations and quality of life.
Many factors will be part of a woman’s decision to use HRT. A clinician should consider a women’s age, her risks, her preferences, all available treatment options and cost when determining if HRT is appropriate. HRT is not an option if the patient has a personal history of blood clots in the legs or lungs, breast cancer or a high risk of stroke or heart disease. In this case, other non-hormonal remedies to treat the symptoms should be offered.
So talk to your doctor! Only after examining and understanding your own situation, and after a thorough consultation with your clinician discussing the risks, benefits and alternatives, can you make the best treatment choice.