Hot Flashes and Hormones

Hormone therapy is an appropriate choice for some, but not all, women. On the benefit side, hormone therapy relieves hot flashes, night sweats and vaginal dryness, and it may improve sleep, mood and concentration. It also preserves bone density and protects against fractures. But there also are risks, including higher rates of breast cancer, stroke, blood clots in the legs and lungs and, for older women, coronary heart disease. What questions do you and your doctor need to answer to make an informed decision about hormone therapy? And if you choose hormone therapy, how can you minimize the risks? Here are the key elements of that conversation.

Do I have hot flashes or night sweats severe enough to disrupt my sleep, quality of life or ability to perform my usual activities?
Moderate to severe symptoms, which affect about one in five newly menopausal women, are the only compelling reason to take hormone therapy. If you're bothered by vaginal dryness only, consider low-dose vaginal estrogen rather than pills or patches.

Do I have a health profile for which the benefits of hormone therapy will likely outweigh the risks?
Mounting evidence indicates that a woman's age and time since menopause (on average at the age of 51 in the United States), along with her personal-health status, influence the risk-benefit balance. The best candidate for hormone therapy is a younger, recently menopausal woman—one whose final menstrual period occurred less than five years earlier—who isn't at high risk of heart disease, stroke or blood clots. An older woman many years past menopause and who is at higher risk of these cardiovascular conditions is not a good candidate. A woman who has had breast, uterine or ovarian cancer in the past, or who is at high risk of these cancers, should also avoid hormone therapy. [See the bio at the end of this piece for information about our book, which can help you estimate your risk of these health conditions.]

Am I open to the idea of using hormone therapy?
A woman who is reluctant to take hormones for any reason should never feel pressured by her doctor to do so. If you can answer "yes" to the three questions above, and you and your doctor determine that you're eligible to begin hormone therapy, you'll need to consider these issues:

What estrogen dose should I take?
To minimize risks, take the lowest dose needed to make your hot flashes or night sweats tolerable. Low-dose preparations often provide relief comparable to standard-dose preparations. (If taken as a pill, the standard daily dose is 0.625 milligrams of conjugated estrogens or 1 milligram of estradiol.) Start with one half of a standard dose and monitor your symptoms for one to three months. If you are not getting enough relief from your symptoms, work with your doctor to gradually adjust the dose upward until you do.

Should I use a progestogen?
If you haven't had a hysterectomy, you'll need to take a progestogen along with estrogen to prevent uterine cancer. Unfortunately, progestogen is the component of hormone therapy most strongly linked to an increased risk of breast cancer. Limiting progestogen exposure by taking it on a cyclic rather than a daily basis may be useful to minimize the excess breast-cancer risk. More research is needed on this issue.

Should I use bioidentical hormones?
Bioidentical hormones are an exact chemical match to the estrogen or progesterone that your body makes naturally. It's possible that bioidentical products provide a better benefit-risk balance than other hormone preparations, but—claims by proponents notwithstanding—scientists simply don't know whether this is so, because research on these medications is very limited. (To volunteer for a clinical trial on this subject, see keepstudy.org.)

Bioidenticals are available at conventional pharmacies in a range of set doses or at compounding pharmacies in individually prepared doses. (Blood or saliva tests are sometimes recommended to determine whether a woman has the "right balance" of hormones and whether to adjust her dose. However, there is little scientific research to support these tests.) Our advice to women wishing to use bioidenticals is to stick with commercial preparations, which are FDA-regulated, rather than custom-compounded ones, which are not. Studies indicate that some custom-compounded medications fall short of quality benchmarks. The advertised potency may not equal the actual potency, and contamination is possible.

Should I use estrogen pills or patches?
Many women find that popping an estrogen pill is more convenient, and less irritating to the skin, than wearing a patch. Estrogen pills are also better than patches at improving cholesterol levels. However, pills may be more likely to increase triglycerides, inflammation and blood clots. Being aware of these differences can help you and your doctor select the therapy that's best for you.

How long can I take hormone therapy?
Hormones are best used for only two to three years and generally no more than five years. Hot flashes and night sweats often peak in the first few years after the final menstrual period, and then taper off, so most women won't need hormone therapy for long-term relief. Moreover, the risk of breast cancer climbs with duration of hormone use, especially with estrogen plus progestogen. For all but a few women, the risks of long-term use outweigh the benefits. Who are the exceptions? If your ovaries were surgically removed before age 45 or if you are at very low risk of breast cancer and very high risk of fracture, it may be reasonable to stay on hormones for a few years beyond the time limits given above—provided that severe hot flashes or night sweats resurface when you try to stop therapy.

What if hormone therapy isn't right for me?
Hormone therapy is not the only way to cool hot flashes. Layered clothing, portable fans, exercise and paced respiration or other relaxation techniques can be very helpful, as can avoiding cigarettes, caffeine, alcohol and spicy foods. Soy, some botanicals, certain antidepressants and the antiseizure medication gabapentin may also be beneficial for some women. All women should try at least some of these strategies before considering hormone therapy.

Manson and Bassuk are affiliated with Harvard Medical School and Brigham and Women's Hospital. They are the authors of "Hot Flashes, Hormones & Your Health" (McGraw-Hill), which provides state-of-the-art information on hormone therapy and an easy-to-use flowchart for making the hormone-therapy decision. For more information, go tohealth.harvard.edu/NEWSWEEK.

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