When my 55-year-old sister told me vaginal estrogen cream had really helped her with vaginal dryness and painful intercourse, I was surprised that estrogen was something new to her. I asked her if her doctor had talked to her about hormone replacement therapy (HRT) at the time of her hysterectomy 10 years earlier. Either he had not, or she had not heard him.
Let me say that while vaginal estrogen cream treatment for vaginal dryness works, it is not hormone replacement therapy, it is a topical treatment only. It does not affect blood levels of hormones and does not treat hot flashes nor prevent bone deterioration (osteoporosis). HRT does relieve vaginal dryness, as well as offers all of the benefits of treatment of hot flashes, prevention of osteoporosis, and more.
All perimenopausal and menopausal patients need to be informed of HRT. It is very positive for women. Many doctors, including some OB/GYN specialists, are not well informed about the risks vs. benefits of HRT and do not recommend it for their patients. Much of this confusion or uncertainty on the part of physicians is due to data from the Women’s Health Initiative Study of 2002 that seemed to indicate an increased risk of:
- Heart attack
- Stroke
- Blood clots
- Breast cancer
Further analysis of the results later refuted these findings, but the damage was already done. Out of fear patients took themselves off their hormones, or their physicians stopped their prescriptions. The reversal of the negative findings of the study did not generate the media attention of the initial findings of the increased risk.
The radical difference in interpretation turned out to be due to timing. If women are placed on HRT within two years (some say five) of menopause the above side effects are not noted, and there is actually a decreased risk of all but blood clots and breast cancer, and those increased risks are very small.
- 1/1000 risk per annum for breast cancer, a very small increase in risk
- 2 x the normal minimal risk (16/10,000 person-years to 32/10,000) for blood clots, probably not this high in otherwise healthy nonsmokers, again, a very small increase in risk
Now, let me tell you about the benefits of HRT.
- Relief from painful intercourse from vaginal dryness
- Maintenance of bone health
- Quality of life issues
- Enhance sexual desire
- Better sleep
- Mood improvement
- Improved cognitive function
- Decrease risk of Alzheimer’s disease
- Fewer urinary tract symptoms of urgency and frequency
I can’t emphasize the bone health benefit enough, over the long run, HRT is invaluable in maintaining mobility and preserving independence with aging by preventing hip, vertebral body, and wrist fractures.
There are patients who can not take HRT because of other health problems.
- Undiagnosed abnormal vaginal bleeding
- Venous thromboembolic disease(blood clots)
- Not due to and not within 2 years of a precipitating event, such as surgery or fracture
- Heart attack within 2 years, or active angina
- Breast cancer (relative contraindication, see below)
- Active liver disease
- Uncontrolled high blood pressure
However, even these patients can use vaginal estrogen for the treatment of vaginal dryness because locally applied or topically applied estrogen is not systemically absorbed in sufficient quantities to affect the above health problems.
What about those breast cancer families? There are families who generation after generation have members affected by breast cancer. Females of these families benefit from genetic testing for the breast cancer genes BRCA 1 and 2. HRT is more complicated in those women who test positive and generalizations can not be made about their risk/benefit ratio.
As far as breast cancer and hormone replacement theory, recent studies have reported that there is no increased risk of recurrent breast cancer for those treated for early-stage estrogen receptor positive cancers with the use of HRT.
Back to my sister and her appreciation of vaginal estrogen treatment for vaginal dryness and painful intercourse, it works. Would I recommend that she use HRT in place of or in addition to vaginal topical hormone treatment? Yes.
The take-home message is that hormone replacement therapy is safe and effective for the vast majority of women. It eliminates the menopausal symptoms of vaginal dryness, hot flashes, and night sweats. Although HRT is not important for bone health at menopause, it could be very important at age 85 if you have not taken it and are disabled from osteoporosis and its effects. The safety of HRT is a matter of timing, if you begin within two years of the last menstrual period, the risks are dramatically reduced. Breast cancer does not automatically eliminate the use of HRT.
References
Søren Cold MD et al., Systemic or vaginal hormone therapy after breast cancer: a Danish observational cohort study, Journal of the National Cancer Institute, volume 114, issue 10, October2022, pp.1347-1354
