Ask the Pharmacist

Q: I heard this week that it is now okay for women to take prescription hormone-type drugs to help with their menopausal symptoms. This seems like a complete reversal from the previous recommendations. What’s behind this change?

A: The use of estrogen, with or without progesterone (with progesterone for those with an intact uterus, without for the rest), in the treatment of menopause, is in many ways emblematic of society’s views on many issues; wildly embraced at one time, then suddenly completely shunned until eventually, we settle on a nuanced middle ground.

Back in the 1980s, when some of us “mature” pharmacists were in school (no, we did not write on chalk slates at the time, although cursive writing was still a thing), there was a professor who suggested that so great were the wide-ranging benefits of estrogen that a case could be made for automatically putting every female on it when they reached the age of peri-menopause.

While the prescribing of hormone replacement therapy (HRT) fortunately never reached these lofty heights, it was widely prescribed until 2002 upon which time the initial findings of a large study, called the Women’s Health Initiative (WHI), was released. The trial, which enrolled more than 27,000 women, was designed to see if HRT could help prevent chronic diseases in women, aged 50-79. 

However, instead of finding new benefits to HRT, the study was halted early as researchers learned that the opposite held true. Participants on HRT had more cases of blood clots, heart disease, stroke and, most damming of all, breast cancer, compared to those on a placebo. It is important to note that there were also a few positives found in that those on HRT had fewer hip fractures and there was also a decline in colorectal cancer.

This study was considered of such good quality that almost immediately, the prescribing of HRT virtually stopped, and alternative treatments for hot flashes and the other hallmark symptoms of menopause were subsequently pursued.

Which brings us to where we are today. While HRT is still used, we dispense the oral form of it a couple of times per week at most, as opposed to multiple times per day, back in the day. Women with hot flashes now try to combat their symptoms with a variety of treatments that range from natural products containing natural estrogens (such as soy) or other ingredients, or rely on prescription drugs that were originally designed for other purposes such as venlafaxine (an anti-depressant by classification) and clonidine (originally used to treat high blood pressure).

The reality is that while these do work for some women, their effectiveness falls far short of what prescription estrogens achieved, leaving many to go through a prolonged period feeling worn out and in a constant fog at a time in their life when they should be at their peak. Perhaps they are well-advanced in their career or maybe they are now kid-free for the first time in decades.

This week, a new study published in the Canadian Medical Association Journal (CMAJ), contains a recommendation that, once again, may well change the frequency with which HRT is prescribed. The CMAJ, one of Canada’s most-respected journals, has made the recommendation that HRT should be the first treatment offered to women under the age of 60 or who are less than 10 years past menopause and suffering from the symptoms of menopause. 

The study suggests that the WHI study exaggerated the dangers of HRT, particularly when it comes to its use in younger women. This new study was, in essence, a compilation of every other study on HRT that was published in medical journals up until April of 2022. This comprehensive analysis allowed the researchers to focus on the differences between women under the age of 60 (or who are less than 10 years past menopause which is medically defined as the point in time that is one year after a woman’s last period, although its symptoms can begin well before this time and last for up to a decade) and those who are over 60, and compared how they fared on HRT.

For instance, new evidence suggests that women who start HRT before 60/within 10 years of menopause may, in fact, see a possible reduction in coronary artery disease rather than the increase seen in the older cohort. The risk of breast cancer also appears to be lower in the younger age group as well.

Multiple studies found that the benefits of receiving effective relief from such menopausal symptoms as hot flashes, night sweats, mood swings, vaginal dryness and brain fog, far outweigh the risks in this age group. For some women, symptoms such as these and others, can be as debilitating as those suffered by people dealing with an auto-immune disorder.

Just because it’s a natural part of aging, does not make it mild or less disruptive to their lives for the many who go through it. Added to this symptom relief are the improvements that women see in their lipid levels, bone density and a possible reduction in their risk of being diagnosed with diabetes.

This recommendation falls in line with other recent endorsements of HRT in this age group, from such respected medical groups as the Society of Obstetricians and Gynecologists of Canada and the North American Menopause Society. Not all major health organizations are ready to endorse HRT.  The Canadian Cancer Society, for one, still does not, however it has stated it is reassessing that stance.

Note that HRT is not recommended for those women who are at particular risk for its major side effects, regardless of their age. Thus, any woman who has a personal history or is already at an increased risk of breast, ovarian or cervical cancer, blood clots, heart disease, liver disease, uncontrolled high blood pressure or stroke, should not use HRT, no matter how severe her symptoms may be. 

As always, when it comes to drug therapy, the dose used in those who can take HRT should be the lowest effective dose and for the shortest period of time.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/