Hormone replacement therapy has been a controversial issue for a lot of women over the last decade. Many have rejected any type of hormone therapy since a large, federally funded study found hormone replacement therapy could increase a woman’s risks for heart disease and strokes.

Now, a new study out of Yale School of Medicine suggests anywhere from 18,000 to 91,000 women in their 50s who had hysterectomies may have died prematurely in the last decade because they did not take estrogen-only hormone replacement therapy.



A bit of background

Before 2002, it was standard practice for gynecologists to recommend estrogen therapy to women with hysterectomies. More than 90% of those patients used it to treat symptoms such as hot flashes and to prevent osteoporosis and other diseases related to menopausal hormone deficiency. But according to the Yale study, only about 10% of these women use estrogen therapy today.

The data analyzed for this study comes from the large Women’s Health Initiative trial. That study was designed to confirm the hypotheses that hormone replacement therapy not only provides relief for menopause symptoms, but also helps protect women from heart disease, osteoporosis and dementia. The WHI first looked at the benefit of taking two hormones - estrogen and progestin, and then examined the benefits of taking estrogen alone.

The first part of the study was stopped in 2002, when early results suggested the combined estrogen-progestin therapy was actually increasing the risk of heart disease, stroke, breast cancer and dementia. Researchers saw a sharp decline in overall hormone use afterward as women heeded their doctors' warnings and stopped taking all post-menopausal hormones, whether they had had a hysterectomy or not.

In 2005 and 2012, the U.S. Preventive Services Task Force recommended against using the combined therapy or estrogen alone to prevent chronic conditions in postmenopausal women, which may have deterred more women from asking their doctors about these therapies - or stopped doctors from offering it in the first place.

The study

In this new study, published Thursday in the American Journal of Public Health, researchers looked at data from the second portion of the WHI trial, which looked at estrogen-only therapy.

According to the Yale researchers, the increased risks discovered in the first part of the WHI study only applied to women who had not had a hysterectomy and were taking pills that combined estrogen and progestin. They say the dangers did not apply to women without a uterus who used estrogen-only therapy - but few understood the difference.

"Sadly, the media, women, and health care providers did not appreciate the difference between the two kinds of hormone therapy," said Dr. Philip Sarrel, lead author of the study and emeritus professor in the departments of obstetrics, gynecology & reproductive sciences and psychiatry, at Yale. "As a result, the use of all forms of FDA-approved menopausal hormone therapy declined precipitously."

The study noted that results from the second part of the WHI study were very different.

A series of papers published by the WHI between 2004 and 2012 showed that estrogen-only therapy had mostly positive health outcomes; they said women who received estrogen, compared to those who received a placebo, had fewer deaths each year for 10 years and were less likely to develop breast cancer and heart disease.

Each year, the death rate among those not taking estrogen was 13 more per 10,000 women. Most of those deaths were due to heart disease. This doesn't need to happen, the study authors say.

The takeaway

"Women need to know that estrogen replacement is an important part of therapy, especially for women who are in their 50s and have had a hysterectomy and their ovaries removed," says Dr. Holly Thacker, director of the Cleveland Clinic Center for Specialized Women’s Health.

She says it’s time for women who have had hysterectomies to "stop being fearful of estrogen.” She points to other recent studies that show starting estrogen therapy shortly after menopause is key to reaping the benefits of the drugs.

Because each woman's health issues are different, experts recommend that women talk to their physicians about estrogen and other hormone replacement therapy before they make a decision on whether to take it.

"Estrogen avoidance has resulted in a real cost in women's lives every year for the last 10 years — and the deaths continue," said Sarrel. "We hope this article will stir an overdue debate and raise consciousness about the health benefits of estrogen-only therapy for women in their 50s with no uterus."