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Stanford Report, February 6, 2002

Hormone therapy appears to boost quality of life


Hormone therapy after menopause can be a blessing or a curse — it helps keep bones strong and may prevent heart disease, but it may also increase a woman's risk of breast cancer or side effects that lead to an overall lower quality of life.

A study by Stanford researchers now shows that women who have symptoms of menopause, such as hot flashes, are more likely to see improved quality of life from hormone therapy. In other words, they may be happier.

"We studied quality of life because it is really important to people," said Mark Hlatky, MD, professor of health research and policy and of cardiovascular medicine at the School of Medicine. "In fact, people are willing to risk shortening their life in order to improve quality of life."

Results from the study, called The Heart and Estrogen/Progestin Replace-ment Study appear in the Feb. 6 issue of The Journal of the American Medical Association.

When women go through menopause their ovaries stop producing estrogen. This loss of hormone can result in side effects that range from annoying to life-altering, such as hot flashes, mood swings, vaginal dryness, lowered libido and trouble sleeping.

Many women opt to replace lost estrogen through hormone replacement therapy — as much to reduce these symptoms as for achieving health benefits. However, contradictory reports about long-term effects have left women in a quandary about whether replacement therapy is right for them.

The study was intended to resolve questions both about heart disease and quality of life in women taking hormone therapy, which contains both estrogen and progesterone.

The study included 2,763 postmenopausal women who received either hormone therapy or a placebo. Hlatky and his group monitored four aspects of quality of life over the course of three years. These variables included physical activity, energy levels, mental health and depressive symptoms.

It turns out that estrogen has different effects in different women. Those women who had symptoms of estrogen loss such as hot flashes had improved mental health and less depression when they replaced their lost estrogen.

Those women who did not have symptoms had worse physical function and lower energy levels when taking hormone therapy. Previously, doctors prescribing hormone therapy had not anticipated an ill effect on women's health and energy — in short, their overall quality of life.

These results make sense, Hlatky said. Hormone therapy can reduce menopausal symptoms, but can also have side effects such as breast tenderness and abnormal bleeding.

"In women with symptoms from menopause the balance is tipped toward improvement," Hlatky said. "In women without symptoms from menopause the balance is tipped toward lower quality of life. The most likely explanation is that when you don't have any symptoms, it's hard to make you feel better."

In the heart disease portion of the research, which was published last year, the study found no difference on the risk of having a heart attack or dying of heart disease between women who were taking hormone therapy and those who were taking a placebo.

"That finding was a surprise to many people, because the conventional wisdom was that post-menopausal hormone therapy reduces heart disease risk," Hlatky said. "This and other well controlled studies found hormone therapy does not lower risk in women who have already developed coronary disease.

The jury is still out on the question of whether hormone therapy can prevent coronary disease from developing in the first place."

Hlatky points out that women in this trial do not necessarily reflect women in the general population. Study participants were an average age of 67 and had gone through menopause an average of 18 years before the trial began, which is older than many women considering hormone replacement for the first time. Furthermore, all the women in this trial had symptoms of coronary artery disease. "Our findings may not apply to younger women closer to menopause," Hlatky said.

Some aspects of this trial can help younger women make decisions about hormone replacement, Hlatky added. In particular, he points out that women who have symptoms are more likely to see a quality-of-life benefit from hormone therapy. He noted that each woman must discuss her risk of osteoporosis, heart disease, breast cancer and quality-of-life issues with her doctor before deciding.

"This study gives just one more piece of information," Hlatky said. "Women need to include this as one of many factors that they talk about with their doctor."

Other authors of the study include Derek Boothroyd of Stanford.

Despite new finding, hormone replacement therapy still considered promising (5/17/00)

Hormone replacement study yields surprising cardiac conclusion (8/26/98)