“It’s unbearable! I’m having a dozen sweat-dripping hot flashes a day. I’m so irritable that I can barely be civil. And when I do manage to work up any enthusiasm for sex, which isn’t often, I’m dry and it hurts,” my friend Sadie lamented. “My doctor and I have tried everything else with no success, so now she’s recommending hormone therapy. She promises that taking estrogen will relieve my severe menopausal symptoms… but isn’t it dangerous?”

Like Sadie, a lot of midlife women are understandably worried that using menopausal hormone therapy (HT)—which consists of estrogen with or without progestin (a progesterone-like hormone)—would increase their risk for potentially deadly blood clots, stroke and breast cancer. But: Some experts feel that these dangers, while significant, have been emphasized more than is warranted. When I contacted Michelle P. Warren, MD, founder and medical director of the Center for Menopause, Hormonal Disorders and Women’s Health at Columbia University Medical Center, she told me, “The risks of HT have been overblown by the media—so now we have a generation of women who are suffering unnecessarily from intolerable menopausal symptoms because they are too scared to even consider taking hormones.”

Contrary to what is commonly believed, the most recent studies indicate that HT is less risky and more beneficial when taken around the time of menopause (not for many years or even decades afterward, as some women used to do). Evidence…

  • Current HT users were significantly less likely to die of coronary heart disease than women who had never used or had stopped using HT, according to a study published in Menopause in March 2011. This benefit was most pronounced among relatively younger, recently menopausal HT users and gradually diminished with advancing age.
  • Women who reported taking HT only at midlife (for varying amounts of time) but not in later life had a significantly decreased risk for dementia, a recent study in Annals of Neurology indicated. (However, dementia risk was increased in women who used HT later in life but not in midlife.)
  • In The Journal of the American Medical Association (JAMA), an analysis of data on postmenopausal women who took estrogen-only HT for about six years found that the increased risks for stroke and blood clots dissipated after hormone use was discontinued.
  • The JAMA study also showed that, among the estrogen-only HT users, there actually was a persistent reduction in breast cancer risk. (Note: Estrogen-only HT is limited to women who have had a hysterectomy because otherwise, the estrogen could increase uterine cancer risk. Combining estrogen with progestin avoids this problem for women with an intact uterus.)

The risks: This isn’t to say that the risks of HT are negligible, of course. For instance, in the JAMA study, women who had taken combined estrogen and progestin not only were more likely to get breast cancer, they also were more likely to die of the disease than women who had not used HT (though overall these risks were small).

Also, as Dr. Warren pointed out, the biggest risk with both types of HT (estrogen-only or estrogen-plus-progestin) is deep vein thrombosis, a blood clot that develops in a deep vein. If the clot breaks off and travels to the lungs, it can be fatal. Note: A new study found that oral contraceptives with the progestin drospirenone carry twice the risk for clots as those with a different progestin. Drospirenone also is in the HT brand Angeliq, so I asked Dr. Warren if the new study had influenced her recommendations on this HT product. It had not, she said, because a typical HT dose is only one-third to one-fourth as much as a contraceptive dose.

IS HT AN OPTION FOR YOU?

HT can be considered by women with moderate-to-severe menopausal symptoms—hot flashes, vaginal dryness, mood swings, anxiety and/or sleeplessness—that seriously interfere with the ability to function and that have not responded to other treatments.

According to Dr. Warren, having a family history of breast cancer need not disqualify you from taking HT because it does not boost risk that significantly. Also, you can consider HT even if you carry a breast cancer gene (as revealed by genetic testing), because the cancer risk associated with such genes is not affected by taking supplemental hormones. HT may be an option if you had uterine cancer, provided that the cancer had not spread and you had a hysterectomy.

Who should not use HT? Women with any of the following…

  • Only mild menopausal symptoms.
  • A personal history of breast cancer (since supplemental estrogen could hasten the growth of any cancer cells that might be present but have not yet been detected).
  • A personal history of invasive uterine cancer.
  • A personal history of a blood clot. (A family history of blood clots raises a red flag that there might be an undetected, hereditary blood-clotting disorder for which you should be evaluated before considering HT, Dr. Warren said.)

The ideal scenario with HT is to take the lowest effective dose for the least amount of time possible. In determining dosage, the goal is not to restore hormones to premenopausal levels, but rather to prevent the hormonal fluctuations that trigger menopausal symptoms. For this, some women need a higher dosage than others.

As for duration, some patients stay on HT for 10 years or more because their debilitating symptoms return with a vengeance when they try to halt treatment, Dr. Warren said. But most women who take HT continue for two to five years, then are successfully weaned off without experiencing a return of troublesome symptoms.