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ACOG News Headlines

Tuesday, November 21, 2017 3:55:53 PM
When Disaster Strikes, Planning and Collaboration are Essential
Due to the lack of data regarding the safety and efficacy of vaginal seeding, the American College of Obstetricians and Gynecologists (ACOG) does not encourage or recommend it outside of the context of institutional review board-approved research, according to new guidance issued today. 


Tuesday, November 14, 2017 8:24:09 AM
First National Multi-state Collaborative Launched on Treating Maternal Opioid Use Disorder
ACOG has launched the first national multi-state collaborative to develop strategies for scalable programs to provide care and treatment for maternal opioid use disorder, which has surpassed hemorrhage and hypertension as the leading cause of maternal mortality in many states across the country.


Tuesday, October 24, 2017 1:51:48 PM
ACOG Releases New Guidance Aimed at Making VBAC Available to More Women
Vaginal birth after cesarean delivery (VBAC) should be attempted at maternal care facilities that typically manage uncomplicated births if they are capable of performing emergency deliveries, according to updated guidance from the American College of Obstetricians and Gynecologists (ACOG). 


Tuesday, October 24, 2017 1:43:04 PM
Vaginal Seeding Not Recommended for Infants
Due to the lack of data regarding the safety and efficacy of vaginal seeding, the American College of Obstetricians and Gynecologists (ACOG) does not encourage or recommend it outside of the context of institutional review board-approved research, according to new guidance issued today. 


Tuesday, October 24, 2017 1:41:15 PM
LARC and Reproductive Choice
The American College of Obstetricians and Gynecologists (ACOG) today issued an updated Practice Bulletin, “Long-Acting Reversible Contraception: Implants and Intrauterine Devices,” outlining new key data on the safety of long-acting reversible contraception (LARC), the most effective, reversible contraceptive methods available.


Monday, September 25, 2017 8:27:28 AM
ACOG Expands Recommendations to Treat Postpartum Hemorrhage
While maternal mortality rates due to postpartum hemorrhage have decreased in the last four decades it still accounts for more than 10 percent of pregnancy-related deaths. Postpartum hemorrhage is excessive bleeding (1,000 mL or greater) within the first 24 hours after birth but can occur up to 12 weeks postpartum. While there can be several causes, uterine atony, or when the uterus fails to contract after delivery, accounts for 70-80 percent of cases and should usually be considered first. 


Wednesday, August 23, 2017 10:55:53 AM
Discussions and Counseling About Obesity Should Begin in Adolescence
Adolescents affected by obesity face serious short-term and long-term physical and mental health complications that are often otherwise uncommon in their age group, including cardiovascular disease, diabetes, non-fatty alcoholic fatty liver disease and breathing complications.


Wednesday, July 26, 2017 3:50:44 PM
Medication-assisted Treatment Remains the Recommended Therapy for Pregnant Women

“Concern about medication-assisted treatment must be weighed against the negative effects of ongoing misuse of opioids, which can be much more detrimental to mom and baby,” said lead Committee Opinion author, Maria Mascola, M.D.


Wednesday, July 26, 2017 3:35:18 PM
Ob-Gyns Should Include Contraceptive Counseling in Every Visit with Adolescents

By the 12th grade, more than half of young women report having had sex. In an effort to provide anticipatory guidance, discussions about contraception, sexually transmitted disease prevention, and other sexual health issues should begin before a girl has become sexually active, ideally during the first reproductive health visit between ages 13-15. However, regardless of a patient’s age or previous sexual activity, contraceptive counseling should be a routine part of every visit.


Thursday, June 22, 2017 3:23:24 PM
ACOG Revises Breast Cancer Screening Guidance: Ob-Gyns Promote Shared Decision Making

Today, The American College of Obstetricians and Gynecologists (ACOG) released its updated breast cancer screening guidance for average-risk women. ACOG’s revised guidelines continue to underscore the importance of screening mammography and its role in early detection of breast cancer and consequent reduction in mortality. Among the changes, however, is an emphasis on patient–provider shared decision making to help women make informed, individualized decisions about when to start screening, the frequency of screening and when to end screening. 


Thursday, June 22, 2017 2:46:14 PM
Ob-Gyn Awareness of Sex Workers’ Health Risks During Routine Visits is Essential

New guidance from The American College of Obstetricians and Gynecologists was released today recommending ob-gyns screen all patients for sex work in a nonjudgmental manner during sexual history-taking. The goal of increasing recognition of this population is to increase their access to preventive care.


Friday, May 26, 2017 8:46:25 AM
ACOG Congratulates Dr. Tedros Adhanom Ghebreyesus as the new Director-General of WHO
The American College of Obstetricians and Gynecologists (ACOG) extends sincere congratulations to Dr. Tedros Adhanom Ghebreyesus as he steps into the role of Director-General of the World Health Organization (WHO).


Tuesday, May 23, 2017 3:55:20 PM
Ob-Gyns Play Key Role in Diagnosing and Treating a Common Condition in Female Athletes

Ob-gyns have an important role to play in the health of female athletes, according to the latest guidance released from The American College of Obstetricians and Gynecologists (ACOG). Menstruation is a key vital sign, as well as an important factor in recognizing a medical condition observed in physically active girls and women known as the female athlete triad.


Monday, May 8, 2017 10:31:31 AM
Haywood L. Brown, M.D., Becomes 68th President of The American College of Obstetricians and Gynecologists

Today, Haywood L. Brown, M.D., of Durham, North Carolina, became the 68th president of The American College of Obstetricians and Gynecologists (ACOG), based in Washington, D.C. In assuming this role, Brown also became the president of The American Congress of Obstetricians and Gynecologists.


Saturday, May 6, 2017 8:00:36 AM
Largest Gathering of Women's Health Providers Meet in San Diego for ACOG's 2017 Annual Meeting
Nearly 5,000 attendees are expected to participate in the 2017 Annual Clinical and Scientific Meeting held by The American College of Obstetricians and Gynecologists (ACOG), marking the 65th meeting for the association which ends on May 9. This year’s theme, “Next Generation of Health Care,” will focus on how to prepare ob-gyns to meet the challenges ahead.


Friday, May 5, 2017 1:57:23 PM
Research Awards Announced for ACOG 2017 Annual Meeting
The American College of Obstetricians and Gynecologists (ACOG) is pleased to announce the 2017 Annual Clinical and Scientific Meeting research award winners, who were selected from among more than 700 outstanding original research papers and posters to be presented at this year’s event.


Tuesday, March 14, 2017 7:56:52 AM
Ob-Gyns Tell Congress: Don’t Turn Back the Clock on Women’s Health

Six hundred ob-gyns are in Washington, D.C., today to meet with their members of Congress and deliver a firm message: Don’t turn back the clock on women’s health. Members of The American Congress of Obstetricians and Gynecologists (ACOG), the nation’s largest professional membership organization for women’s health care physicians, are urging a NO vote on the American Health Care Act (AHCA). Last week, ACOG outlined concerns with how the AHCA will affect women’s access to health care coverage, and yesterday the Congressional Budget Office issued a report confirming many of those concerns —estimating 14 million fewer Americans will have health care coverage in 2018 and 24 million by 2026. We cannot afford the devastating effect this will have on the health and well-being of all Americans, especially women and families. 


Thursday, March 2, 2017 1:53:54 PM
Bipartisan Legislation to Prevent Maternal Deaths

The American Congress of Obstetricians and Gynecologists (ACOG) and the Preeclampsia Foundation announce their endorsement of bipartisan legislation introduced today that will strengthen state efforts to prevent maternal deaths by addressing the devastating and costly health consequences that threaten the lives of moms and babies across the country. 

 


Monday, February 27, 2017 11:03:21 AM
ACOG Recommends Offering Additional Carrier Screening to All Women, Regardless of Ethnicity or Family History

In recognition of how critical genetic testing is in preparing for and managing a successful pregnancy, The American College of Obstetricians and Gynecologists (ACOG) has expanded guidelines on carrier screening in two new Committee Opinions released today. In the past, ACOG recommended carrier screening—genetic testing that determines whether an asymptomatic person has a genetic mutation or abnormalities associated with a particular disorder that may be passed on to children—based primarily on ethnicity. The focus was on specific ethnic populations with known increased risk for particular disorders. ACOG’s two new Committee Opinions go beyond previous guidance to broaden who should be screened and for which genetic disorders.

 


Thursday, February 2, 2017 2:47:38 PM
Presidents of Five Medical Organizations Representing 500,000 Physicians and Medical Students Meet with U.S. Senators With One Message: Protect Patients’ Access to Health Care

In meetings with Republican and Democratic senators, the presidents of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Congress of Obstetricians and Gynecologists and the American Osteopathic Association laid out five recommendations for any legislation that would make changes to our current health care system.


Women's Health News Headlines

Friday, December 15, 2017 10:00:00 AM
Breast cancer: These gene variations may shorten young women's survival
New research finds that young women with early-onset breast cancer possess variations in a specific gene that might affect their survival.


Wednesday, December 13, 2017 7:00:00 AM
What you should know about tubular breasts
Learn about tubular breasts, a condition where the breasts appear irregularly shaped. Included is detail on risk factors and possible treatment options.


Monday, December 11, 2017 10:00:00 AM
Cervical ectropion: What you need to know
Cervical ectropion is a condition where cells from inside the cervix form a red, inflamed patch on the outside the cervix. Learn more.


Monday, December 11, 2017 9:00:00 AM
Breast cancer treatment: Can Brussels sprouts, soy reduce side effects?
Researchers have found that soy and cruciferous vegetables, such as Brussels sprouts, could reduce the long-term side effects of breast cancer treatment.


Sunday, December 10, 2017 1:00:00 AM
How does menopause affect sex drive?
Menopause can cause physical and emotional changes that impact a woman’s life, including her sex life. Learn about how to increase libido after menopause.


Friday, December 8, 2017 9:00:00 AM
Under the mistletoe: Tips for a happy sex life over the holidays
The holidays can be a stressful time for couples, with very few chances to share intimate moments. Here is our guide to a happy sex life this Christmas.


Tuesday, December 5, 2017 1:00:00 AM
Endometrial cancer: Drug-loaded nanoparticles destroy tumor cells
Researchers reveal how nanoparticles filled with two anti-cancer drugs targeted and killed tumor cells in mice with aggressive endometrial cancer.


Sunday, December 3, 2017 4:00:00 AM
What you need to know about menopause and pregnancy
In this article, we look at the links between menopause and pregnancy. Included is detail on whether you can get pregnant during menopause.


Saturday, December 2, 2017 1:00:00 AM
What you should know about non-hormonal birth control
A look at non-hormonal birth control, contraception that does not rely on hormones. Included is detail on barrier methods and permanent solutions.


Friday, December 1, 2017 10:00:00 AM
How to lose weight by having sex
Looking to burn off a few pounds before the peak holiday season? Find out how sex can help you lose weight by burning calories and staving off hunger.


Friday, December 1, 2017 1:00:00 AM
What's the secret to younger-looking skin? Study sheds light
Women who look much younger than their age have specific gene expression patterns, researchers reveal. The results could be used to combat skin aging.


Wednesday, November 29, 2017 9:00:00 AM
IBS: Five facts you need to know
Irritable bowel syndrome affects over a tenth of the population globally, but many go undiagnosed. Nobody knows what causes it, however. Find out more.


Saturday, November 25, 2017 1:00:00 AM
Exercise alone does not achieve weight loss
Exercise alone is unlikely to help you shift the pounds, a new study finds. Instead, physical activity should be combined with a healthful diet.


Friday, November 24, 2017 1:00:00 AM
Is there a link between menopause and an underactive thyroid?
In this article, we examine whether there is a link between menopause and an underactive thyroid, and how the two may affect each other.


Thursday, November 23, 2017 4:00:00 AM
What to know about monophasic birth control
Learn about the monophasic birth control pill, a form of contraception. This article examines its uses, benefits, and possible side effects.


Saturday, November 18, 2017 4:00:00 AM
Do you gain weight with a birth control implant?
A look at birth control implants and weight gain. Included is information on the causes of weight gain and other birth control implant side effects.


Friday, November 17, 2017 10:00:00 AM
What are the best birth control pills for PCOS
A look at some of the best birth control pills for PCOS. Included is detail on how birth control can affect PCOS and the best non-pill options.


Thursday, November 16, 2017 3:00:00 AM
Obesity: Five surprising facts
Obesity rates are on the rise. But did you know that weight gain tends to sneak up, and that our diet influences our children's genes?


Wednesday, November 15, 2017 9:00:00 AM
Trauma may lead to weight gain in women
A new study strengthens the link between stress and weight gain, after finding that bad life experiences may raise the risk of obesity in women.


Monday, November 13, 2017 4:00:00 AM
What birth control methods take the shortest and longest time to work?
A look at how long it takes for birth control to work. Included is information on a variety of methods, and the duration it takes for them to be effective.


Wednesday, November 8, 2017 8:00:00 AM
Brisk walking may help older women live longer
A study of physical activity in older women tied brisk walking or similar exercise to a 60–70 percent lower risk of early death, compared with inactivity.


Tuesday, November 7, 2017 9:00:00 AM
Life hacks: Dealing with postpartum depression
The weeks and months after giving birth can be emotional and stressful. Here are some ways to cope if your baby blues become postpartum depression.


Tuesday, November 7, 2017 9:00:00 AM
Why am I cold when nobody else is?
As winter begins to set in, it's time to get those hats and gloves ready. But not everyone feels the cold the same way, scientists say.


Wednesday, November 1, 2017 8:00:00 AM
Teen moms at risk of heart disease
Recent research found that teenage first-time mothers have a significantly greater long-term risk of cardiovascular disease than older moms.


Tuesday, October 31, 2017 7:00:00 AM
Letter from the Editor: Know thyself
The ancient Greeks urged "know thyself." In this month's letter, Managing Editor Marie Ellis unmasks what that means — for our editors and our readers.


Articles on Women's Health

No Scientific Evidence Supporting Effectiveness or Safety of Compounded Bioidentical Hormone Therapy

Washington, DC -- There is no scientific evidence to support claims of increased efficacy or safety for individualized estrogen or progesterone regimens prepared by compounding pharmacies, according to a new Committee Opinion released today by The American College of Obstetricians and Gynecologists (ACOG). Furthermore, hormone therapy does not belong to a class of drugs with an indication for individualized dosing. ACOG's opinion also points out that salivary hormone level testing used by proponents to 'tailor' this therapy isn't meaningful because salivary hormone levels vary within each woman depending on her diet, the time of day, the specific hormone being tested, and other variables.

Compounded "bioidentical hormones" are plant-derived hormones that are prepared, mixed, assembled, packaged, and labeled as a drug by a pharmacist. These preparations can be custom made for patients according to a physician's specifications. "Bioidentical hormones" refer to hormones that are biochemically similar or identical to those produced by the ovaries or body.

According to ACOG, most compounded products, including bioidentical hormones, have not undergone rigorous clinical testing for either safety or efficacy. Also, there are concerns regarding the purity, potency, and quality of compounded products. In 2001, the FDA analyzed a variety of 29 product samples from 12 compounding pharmacies and found that 34% of them failed one or more standard quality tests. Additionally, 9 of the 10 failing products failed assay or potency tests, with all containing less of the active ingredient than expected. In contrast, the testing failure rate for FDA-approved drug therapies is less than 2%.

The FDA requires manufacturers of FDA-approved products that contain estrogen and progestogen to include a black box warning that reflects the findings of the Women's Health Initiative. However, compounded products, including bioidentical hormones, are not approved by the FDA and therefore, compounding pharmacies are exempt from including warnings and contraindications required by the FDA in class labeling for hormone therapy.

Given the lack of well-designed and well-conducted clinical trials of these compounded hormones, ACOG recommends that all of them should be considered to have the same safety issues as those hormone products that are approved by the FDA and may also have additional risks unique to the compounding process.

Committee Opinion #322, "Compounded Bioidentical Hormones," is published in the November 2005 issue of Obstetrics & Gynecology.

The American College of Obstetricians and Gynecologists is the national medical organization representing over 49,000 members who provide health care for women.

Frequently Asked Questions About Hormone Therapy

New Recommendations based on ACOG's Task Force Report on Hormone Therapy

If you're a woman navigating the transition through menopause, it may seem as though these are the best of times and the worst of times. On the bright side, solid research is finally providing long-awaited answers to crucial women's health questions that researchers and women have been asking for years. Some of that research has led to a broader range of treatment options for the management of menopausal symptoms and some of the long-term health risks associated with menopause, such as osteoporosis.

On the down side, sometimes the long-awaited answers aren't what anyone expected, as was the case with the Women's Health Initiative (WHI), which made headlines in 2002 and again in 2004 when two arms of the federally funded study were halted prematurely after finding that hormone therapy (estrogen and progestin, or HT) and estrogen alone (ET) did not protect against heart disease, as was once believed.

Even before the WHI study results were announced, The American College of Obstetricians and Gynecologists (ACOG) in early 2002 had created a task force of 21 national experts to look at questions surrounding the use of HT and ET. The Task Force met over the next two years to evaluate all of the studies to date, including new research published since the WHI results were released, and to develop guidelines for the appropriate use of hormone therapies based on the most current research.

One of the most significant achievements of the Task Force was to put into perspective - for both doctors and patients - the results of the WHI and their relevance to the way hormones are prescribed in the management of menopause. Indeed, as important as the WHI was in advancing our knowledge about the use of hormones for the prevention of chronic illness and in clarifying some of the risks of hormones, it's important to keep in mind that the WHI was designed to investigate whether or not HT or ET could prevent disease - not whether they relieve menopausal symptoms. In fact, most of the women in the WHI were 10 years older than women who use hormones to relieve menopausal symptoms, and most of the WHI study participants had no menopausal symptoms while they were enrolled in the study. So although the WHI clearly showed that hormones should not be used for disease prevention, they are still appropriate as a treatment for the relief of menopausal symptoms. As with all medications, the decision to use HT or ET is a personal one based on a review of the individual woman's health needs.

What does this mean for you? Essentially, HT and ET can still play a role in the treatment of menopause, provided you use the medications for appropriate reasons and after weighing the benefits and risks.

To help you evaluate the benefits and risks, here are answers to some of the most frequently asked questions about HT and ET, based on ACOG's new Hormone Therapy report.

Background: Hormone Therapy Then and Now

If you're not already familiar with ET, it is a form of drug therapy in which you're given estrogen to supplement the estrogen your body makes much less of after menopause. If you haven't had a hysterectomy and therefore still have your uterus, you should also be given a progesterone-like agent (synthetic forms are called progestins) to help reduce the risk of uterine cancer, which is referred to as hormone therapy, or HT. Sometimes, androgens (male reproductive hormones) may be prescribed, either alone or in combination with estrogen (and progestin, if needed) for certain women who are having problems with sexual desire -- although studies are still ongoing as to whether androgens are effective for treating women's sexual libido.

Estrogen comes in the form of pills, patches, gels, and emulsions, and, for women who have vaginal dryness, vaginal creams, tablets, and a flexible vaginal ring. For women with a uterus who also need progestin, there are progestin-only and combination (estrogen-progestin) pills and patches, as well as a vaginal progesterone gel. Most formulations of estrogen also come in varying strengths, or dosages.

For more than 60 years, hormone therapy (HT) has been a mainstay in the treatment of menopausal symptoms, such as hot flashes and vaginal dryness. When, in the mid-1980s, estrogen was found to retard (or slow) bone loss in postmenopausal women, the FDA approved it for the treatment of osteoporosis.

At the same time, other observational studies suggested that HT might prevent heart disease - the groups of women in these studies who used estrogen had about half the number of heart attacks as those who didn't use estrogen. This research was buoyed by evidence that estrogen lowered levels of the 'bad' LDL cholesterol and raised levels of the 'good' HDL cholesterol in postmenopausal women. Lower cholesterol levels are associated with a reduced risk of heart disease. Other research had suggested that HT might help prevent the onset of Alzheimer's disease.

Even so, questions remained about HT, in spite of the fact that it is one of the most thoroughly studied drugs on the market today. Was the heart protection found among estrogen users due to the estrogen, or did those women simply take better care of their health than other women enrolled in those studies? Would adding progestin to estrogen, necessary for reducing the known risk of uterine cancer, cancel out estrogen's heart protection? What about an increased risk of breast cancer?

Because so many questions about HT and ET remained unanswered, in 1993 the National Institutes of Health decided to look for definitive answers. The result was a randomized controlled study involving a total of 161,809 women nationwide known as the Women's Health Initiative. The main thrust of the WHI was to determine the exact degree to which hormone therapies presumably protected the heart, and to investigate the degree to which some of the known and potential risks of hormone therapies, such as breast cancer and blood clots, cancelled out any benefits. The WHI also explored whether hormone therapies prevented fractures, colon cancer and dementia, including Alzheimer's disease. Still other parts of the study looked at the effects of HT and ET on quality of life and cognitive function, energy levels, sleep and sex.

The main reason the study results carried so much weight had to do with the way the study was designed and carried out. First, the sheer number of study participants was huge. Many of the earlier studies on HT and ET involved small groups of women. Having large numbers of women participating in the study increases the accuracy of the statistics on which the researchers base their conclusions.

Second, the study was designed to take place over a number of years. Many of the questions researchers had about HT and ET - particularly their role in the prevention of heart disease and osteoporosis - involved the use of hormones over many years' time.

Finally, the study was designed to compare women using HT with those taking a placebo, or inactive tablet. Neither the researchers nor the study participants knew for sure until after the study was over which women were taking HT and which were taking a placebo. This type of study design gives the most definitive and objective results - in essence, by comparing apples to apples. In effect, one of the things the WHI did best was to clarify some of the risks involved with the use of hormone therapy.

What the WHI Found

One part of the WHI, an 8-year trial involving some 16,608 healthy women with a uterus, was designed to explore whether hormone therapy (estrogen and progestin) protected against heart disease and osteoporosis. But when researchers analyzed the data they had collected after only 5.2 years, they concluded that the risks for the study group on combined HT outweighed the benefits. Moreover, the risks, although small, were outside of the safety standards set for the study, which led to early termination of the study. Risks included a small but significant increased risk of breast cancer (38 women out of 10,000 women per year compared to 30 women taking placebo), heart attacks (37 women out of 10,000 women per year compared to 30 women taking placebo), strokes (29 women out of 10,000 women per year compared to 21 women taking placebo) and blood clots (34 women out of 10,000 women per year compared to 16 women taking placebo) for the group of women on HT.

To be sure, HT offered health benefits as well. HT users had a lower risk of spine and hip fractures. In the HT group, there was a 24 percent reduction in total fractures, and a 34 percent reduction in hip fractures. On average, per year, there were 10 cases of hip fracture per 10,000 women on HT compared to 15 per 10,000 women on placebo.

The WHI also reported a reduced risk of colon cancer among HT users, which was down by 37 percent (or 10 cases of colorectal cancer per 10,000 women per year on HT compared to 16 cases per 10,000 women per year on placebo). But given the risks for breast cancer and cardiovascular problems shown in the study, the risks of using HT for prevention of heart disease outweighed these benefits for most women.

Another part of the WHI, involving 11,000 healthy postmenopausal women who were using estrogen alone, continued for two more years after the estrogen-progestin part of the study was halted. But early in 2004, that arm of the study was halted as well. Researchers discovered that ET did not prevent cardiovascular disease and appeared to increase the risk of stroke at about the same rate as HT did. That is, women using ET had about 12 more strokes per year for every 10,000 women than did those who took a placebo (44 on ET vs. 32 on placebo). ET also increased the risk of blood clots (21 on ET vs. 15 on placebo).

The good news: ET did not appear to increase or decrease a woman's risk of breast cancer during the seven years the women took it. And the women on ET had a lower risk of hip fractures.

Although ET appears to pose fewer risks to women than HT, the researchers decided to halt the study a year early because after seven years of follow up, the results were unlikely to change in the one year remaining in the ET study to answer the primary question: is ET effective in reducing heart disease in women? There was also concern that the increased risk of stroke was no longer acceptable in healthy women participating in a research study on a drug that's supposed to prevent disease.

YOUR QUESTIONS

I'm confused. Do the findings of the WHI mean that menopausal women should never take hormones because the drugs are too dangerous?

No. Remember: The WHI was designed to determine whether HT and ET were effective in preventing illnesses such as cardiovascular disease and osteoporosis, and not their usefulness in the treatment of menopausal symptoms. What's more, all medications have side effects, and the WHI helped to clarify and quantify what some of those side effects were for hormone therapy.

In fact, for as much good information as the WHI provided about HT and ET, many physicians and researchers believe many more questions about hormone therapy have yet to be answered. For instance, do the results of the WHI study, which involved the use of a certain formulation of estrogen and progestin taken together daily, apply to the numerous other brands of estrogen and progestin on the market? What about lower doses of estrogen and progestin? Do estrogen-containing skin patches, vaginal creams and the new vaginal ring carry the same risks? Equally important are questions about the safety and effectiveness of over-the-counter products, which are not stringently regulated by the U.S. Food and Drug Administration (FDA) and, more often than not, have not been as rigorously tested for safety and effectiveness as prescription medications.

It does mean, however, that when considering hormones for relief of menopausal symptoms, you and your physician must carefully evaluate the benefits and risks of HT or ET as they apply to you as an individual.

So how do I weigh the risks?

First, it's important to distinguish between individual risk and public health risk. In the WHI trial, the size of the health risks for each individual woman was actually quite small. For instance, a woman's risk of developing breast cancer while using combination HT was 8 per 10,000 women taking HT per year - in other words, less than one tenth of one percent a year, according to the study authors. (There's a caveat, however: Although the increase was small, it was cumulative over time. In other words, the longer a woman stayed on HT, the more her risk for breast cancer increased, at a higher rate than would normally occur with advancing age.)

The National Institutes of Health stopped the study both in fairness to the group of women on HT and because the researchers were looking at the increased risks for an entire population of women over time. While the rate of increased breast cancer risk may not sound huge - only 8 additional cases of breast cancer diagnosed per 10,000 women per year in the HT group - the numbers become unacceptably large when you factor in the millions of women who take the drug over many years' time.

You may decide that the relief you get from your symptoms with HT may be well worth the slight individual risks. The decision is yours to make, as long as you have discussed the risks and benefits with your doctor.

Do the risks apply to other forms of hormone therapy, such as the skin patch?

The women in the hormone therapy arm of the WHI study used a combination form of HT containing .625 milligrams of conjugated equine estrogens and 2.5 milligrams of medroxyprogesterone acetate (brand name Prempro®) in the form of a daily pill. For now, experts advise doctors and patients to assume that all formulations carry the same risks as those reported in the WHI. But in fact, until more research is conducted, it's impossible to say whether other formulations or types of hormones will carry the same risks.

Some of that research is already under way. In August 2003, for instance, the Million Women Study, a large observational survey investigating the link between hormone use and breast cancer, confirmed the results of the WHI but also looked at which kinds of HT are associated with the greatest risk. In that study, women taking combinations of estrogen and progestin had four times as many breast cancers as those using estrogen alone. The study found that for every 10,000 women taking estrogen for 10 years, there would be five extra breast cancers; for those using combined HT, there would be 19. The results were similar for estrogen and progestin combinations in pills and patches, when taken daily or in cycles, and at higher and lower doses. The researchers also found that the increased risk falls to that of nonusers five years after HT is stopped.

In another small study, French researchers found that women who took estrogen pills were more likely to develop blood clots in the legs than those who used an estrogen patch. One reason may be that pills are broken down in the liver, where proteins involved in the formation of blood clots are activated. The estrogen in skin patches is released directly into the bloodstream, bypassing the liver completely.

Your best bet, regardless of the type or dosage of HT you use, is simply to be aware of the increased risks found in the WHI trial and, until we know more about your particular regimen, to factor those risks into your decision.

Is it safe to take hormones for the treatment of hot flashes and night sweats?

If you have hot flashes, night sweats, sleep disruptions or other symptoms, the Task Force found that HT and ET still are the most effective therapies, reducing hot flashes by up to 90 percent. In fact, for severe hot flashes, nothing works better. Numerous studies have shown that, in addition to oral estrogens, transdermal estrogen patches effectively alleviate hot flashes.

For the majority of women, hot flashes dissipate on their own within an average of four years. If you have mild to moderate hot flashes, a number of lifestyle changes can help you cope, such as wearing layers of light clothing, setting the thermostat to a lower temperature and avoiding spicy foods and caffeinated beverages and alcohol, which may help reduce the severity of hot flashes. Relaxation exercises or biofeedback may also help control temperature fluctuations.

If those or other measures don't work or if symptoms are severe and you have no family or personal history of blood clots, premature cardiovascular disease, or breast cancer, talk to your doctor about using hormones. If you do use estrogen alone or with progestin for relief of hot flashes, the Task Force recommends that you use the lowest effective dose for the shortest possible time. Be sure to reassess your need for hormones with your doctor at least on an annual basis.

Can hormone therapy improve my sex life?

It depends. If the chief complaint is painful intercourse as a result of vaginal dryness, then the answer may be yes. When estrogen levels fall after menopause, vaginal lubrication is diminished and vaginal tissues may become dry and irritated, especially during and right after intercourse. Vaginal estrogen creams, the vaginal estrogen ring, and even low doses of estrogen in the form of pills or patches can help relieve vaginal dryness and improve lubrication. It doesn't take much estrogen to do this, either, so the risks associated with the use of hormone therapy can be minimized. Still, many women find that over-the-counter vaginal lubricants and moisturizers work just as well.

Although vaginal dryness is one of the most common contributors to a decline in sexual activity after menopause, it is by no means the only one. In fact, sexual problems are complex issues that may stem from any number of physical, emotional and social factors. In a woman, physical changes, including a decline in estrogen and testosterone (yes, even women produce small amounts of this 'male' hormone) can contribute to the problem, as can emotional conflict, certain drugs, and depression.

Sometimes, the discomforts of menopause, such as hot flashes, night sweats, sleep problems, and irritability, can contribute to sexual problems. But so far, there's little evidence to support the use of systemic hormone therapy (pills, patches) to improve sexual libido.

Some research has suggested that women who have had their ovaries surgically removed may benefit from high dose transdermal androgen in addition to estrogen. But androgen can raise harmful blood lipids, which may increase a woman's risk of heart disease.

The Task Force concluded that, at this time, there are too few studies in the scientific literature to say that the use of estrogen or androgen improves sex drive in postmenopausal women.

What about urinary incontinence?

There's no evidence to support treating urinary incontinence with estrogen. In fact, some studies suggest that hormone therapy may actually contribute to a worsening of symptoms in some women.

Can hormone therapy lift depression?

The majority of women do not develop depression during menopause, although some studies do suggest that perimenopausal women may be somewhat more susceptible to depressive symptoms during this biologically tumultuous time.

Before beginning any medication for depression, you should undergo a thorough physical evaluation, including a check for thyroid problems, which can often mimic depressive symptoms. Although a couple of small studies have found estrogen to have antidepressive effects in perimenopausal women, the Task Force recommends trying antidepressant medications first. Selective serotonin re-uptake inhibitors (SSRIs), such as Prozac®, Paxil® and Effexor®, have the added benefit of helping to relieve hot flashes. If you don't want to or can't take antidepressants, talk with your doctor about trying estrogen for mild to moderate depression, particularly if you also suffer from hot flashes or other symptoms of menopause. Short-term use of HT or ET may facilitate the action of antidepressants in some women.

I'm at high risk for osteoporosis. Can I continue on HT?

If you are also taking HT for treatment of menopausal symptoms, it may be appropriate. If you are taking HT solely for the prevention of osteoporosis, consider stopping it, because there are other medications that can help prevent osteoporosis and fractures that appear to carry lower risks for conditions such as breast cancer.

Other preventive drug therapies include the family of drugs known as bisphosphonates, which can reduce the breakdown of bone. Still other options are the selective estrogen receptor modulators, or SERMs, which are a new class of synthetic estrogens that act like estrogen in certain parts of the body (such as the bone) while leaving other body tissues unaffected. Studies have shown that some SERMs may actually protect against breast cancer.

Some women with heartburn or ulcer problems may be unable to take bisphosphonates, and each of the medications discussed here has its own side effects. Although these medications appear to have a different ratio of benefits to risks compared to HT, it's not clear yet whether they're better. Studies are continuing to investigate the effects of these drugs.

To protect their bones, all peri- and postmenopausal women should be sure to consume 1,200 to 1,500 milligrams of calcium per day, a multi-vitamin containing vitamin D, and engage in regular weight-bearing exercise such as walking.

So, if I'm taking HT just to protect against heart disease, should I stop?

Yes. The WHI did not show any benefit to the heart. Lifestyle changes can help prevent heart disease - particularly regular exercise, smoking cessation and weight control. And, for certain women at high risk for heart disease, other medications have been shown to be effective. Medications such as statins can help reduce high cholesterol levels, and hypertension medications can help reduce high blood pressure. You'll want to discuss with your doctor the specific type of medication that may be right for you, along with any risks and side effects associated with those drugs.

Does hormone therapy prevent Alzheimer's disease and other types of dementia?

The ACOG Task Force on Hormone Therapy found no evidence that hormone therapy prevents cognitive decline in older women. Nor does it appear to improve cognition in women who already have Alzheimer's disease or other forms of dementia. However, more research needs to be conducted to determine whether the age at which a woman begins taking hormones has any bearing on the issue.

Is it true that women who take hormones gain weight?

No. The Task Force found no evidence that using hormones leads to weight gain. The cause is more likely to be associated with your diet and activity level than with hormone therapy.

The weight gain that occurs during this time in a woman's life appears to be related to aging, not menopause or HT. In one three-year study involving 485 women ranging in age from 42 to 50, researchers found the women gained an average of about 5 pounds. This weight gain occurred even among women who did not experience menopause during the study period.

As you grow older, your body's metabolism (the rate at which you burn calories) declines. When combined with a lower activity level, the result is added pounds. What's more, when you gain weight in the middle and later years, it's more likely to accumulate around your abdomen, rather than the hips and thighs. Abdominal weight is associated with a greater risk of heart disease, high blood pressure and diabetes.

The good news is that you can help stave off so-called middle-aged spread with a sensible low-fat diet and plenty of physical activity (a minimum of 30 minutes of activity, such as brisk walking, on most days of the week).

I have Type 2 diabetes. Will hormone therapy interfere with my ability to control my blood sugar?

No. According to the Task Force, long-term control of blood sugar in women with Type 2 diabetes doesn't appear to be adversely affected by hormone therapy. In fact, women who use HT have been found to have a lower risk of Type 2 diabetes than women who don't take hormones.

If you have diabetes and choose to use hormone therapy to relieve hot flashes and other symptoms, you need to be aware of the slightly increased risk of heart disease and stroke associated with its use, since you already face an elevated risk of cardiovascular disease by virtue of having diabetes.

Does hormone therapy increase the risk of developing ovarian cancer?

The Task Force concluded that hormone therapy doesn't appear to increase the risk of developing ovarian cancer. Although a few observational studies suggest the risk may be increased after 10 years of use, other studies found no such association.

Since the WHI found that hormone therapy reduces the risk of colon cancer, should I take hormones to prevent colon cancer?

No. Although a number of studies have associated hormone therapy use with a decreased risk of colon cancer, the Task Force does not recommend its use to prevent colon cancer.

How does my family health history factor into my decision?

Since many chronic conditions, such as heart disease and certain cancers, appear to have hereditary links, it's crucial that you and your doctor factor any potential hereditary health problems into your decision to use hormones. If you have a family or personal history of heart disease, stroke, blood clots, or breast cancer, you'll need to carefully consider those risk factors when making a decision to use HT. If, on the other hand, you have a family history of osteoporosis or colon cancer along with severe menopausal symptoms, HT or ET may provide added protection while you use it for short-term relief of your symptoms. But hormones should not be taken just for these benefits.

Is a woman ever too young or too old to use hormones?

Unfortunately, there are no good studies to answer this question definitively. If you're perimenopausal (you're still menstruating) and are experiencing mood swings, insomnia, and even hot flashes, you may find temporary relief with low-dose oral contraceptives or a low-dose estrogen patch, as long as you don't smoke. Risks appear to be relatively low, possibly because your body is still producing its own estrogen and progestin. (Cigarette smoking greatly increases the cardiovascular risks among cigarette smokers who are over 35 and who use birth control pills or hormone therapy.)

After menopause (when you haven't had a period for at least 12 months), ET or HT can help extinguish hot flashes and relieve vaginal dryness. In fact, estrogen is the single most effective treatment for hot flashes. It's not understood why some women have mild menopausal symptoms for only a short time, while others have severe symptoms for years at a time. If you're in the latter group, just remember that your natural risks for conditions such as breast cancer and heart disease rise as you age. You'll want to keep that in mind as you assess the benefits and risks of HT for an older woman.

If you're past menopause and are no longer having hot flashes or other symptoms of menopause, the WHI clearly shows that there really aren't many good reasons to continue taking hormones. But there appear to be several convincing reasons (slightly increased risks of heart disease, stroke, blood clots and breast cancer) to stop.

If ET is safer than HT, why can't all women just use estrogen alone?

If you have a uterus, the added progestin protects against an increased risk of endometrial cancer that occurs when taking estrogen alone.

It's also not clear that progestin is the sole factor that affected breast cancer risk among the women in the WHI who took HT instead of ET. Women who used estrogen alone had had a hysterectomy. They also were more likely to have high blood pressure and be overweight than the women who took HT. Any one of those differences might also have affected the study outcome.

What other risks and side effects are associated with hormone therapy?

About 10 percent of all women who take HT experience breast tenderness, fluid retention and pelvic cramping. Those who take progestin along with estrogen occasionally may have periodic bleeding similar to menstruation.

Some women who are prone to migraine headaches find they develop more headaches when using hormones, but others have fewer headaches when taking hormones.

Another long-term complication is a slightly increased risk of gallbladder problems. If you experience any problems, talk to your ob/gyn. Often, the form of HT or the dosage of your medication can be changed to alleviate any side effects.

What else is available for relief from hot flashes if I can't or don't want to take hormones?

Other medications that have been found to help relieve hot flashes are a class of antidepressant medications known as selective-serotonin re-uptake inhibitors, or SSRIs (Prozacâ, Paxilâ, Effexorâ).

What about alternative therapies, such as black cohosh or phytoestrogens?

The Task Force found that few nutritional supplements have been rigorously studied and tested for safety and effectiveness. Ongoing research should help shed some light on the subject, but the results from these studies are still a number of years away. Here's a roundup of some of the more common over-the-counter remedies that are frequently recommended for the treatment of menopause, and what researchers now know about them.

Soy Foods, Beverages and Supplements. Soybeans are made up of two primary components, soy protein and isoflavones, plant chemicals that have estrogen-like properties. The isoflavones genistein and diadzein in soy are thought to be responsible for relieving menopause symptoms, such as hot flashes. But the effectiveness of soy foods and supplements on hot flashes and other menopause symptoms isn't clear. In one or two studies, soy protein supplements were found to reduce the incidence of hot flashes by up to 45 percent. Other reports, however, have found that soy was no more effective than a placebo.

Soy protein in foods does lower blood cholesterol levels and, theoretically, may reduce the risk of heart disease. However, some research suggests that when isoflavones are removed from soy protein and ingested alone, as they are in soy supplements, they may not be effective for reducing cholesterol. Ongoing research should help shed some light on the subject.

Soy's effect on bone loss is unclear, too. Women who take soy protein supplements while they are experiencing menopause and still having menstrual periods on their own appear to lose bone mass while taking soy supplements. But there may be a role for soy products in preventing further bone loss after menopause. Current studies are not entirely consistent. For this reason, soy is not recommended to help prevent bone loss.

As for safety, more research is needed before scientists know for sure whether the plant estrogens in soy are safer than prescription estrogens. But one recent study suggested that the use of soy supplements for up to five years may possibly increase a woman's risk of endometrial cancer, just as estrogen does in women with a uterus who don't also take progestin. In a 2004 randomized, placebo-controlled study involving 376 postmenopausal women, those who took soy phytoestrogen for up to five years had an increased rate of endometrial hyperplasia - an overgrowth of cells in the uterine lining.

Black Cohosh. This plant, also known as snakeroot, "squaw" root and bugbane, has been used for centuries in the treatment of women's reproductive disorders, although no one knows exactly how - or even if - it works. For the past 40 years, black cohosh has been prescribed in Germany where it is regulated and used by women for hot flashes, depression, and sleep disturbances common during perimenopause.

Because no large, controlled studies of black cohosh have yet been conducted, no recommended doses have been established, nor have specific claims been allowed regarding the herb's effectiveness. Black cohosh does not appear to have any effect on bone density or cardiovascular health. Some researchers recommend that you limit its use to six months.

Topical Progesterone, Testosterone and other 'Natural' Hormones. These topical creams are sold in health food stores and via the Internet as an alternative to synthetic forms of progesterone (progestins) and testosterone (also known as androgen), amid claims that these products can build bone, increase sexual desire, prevent endometrial and breast cancer, and substitute for hormone therapy.

At this point, no formal studies have been conducted to determine the safety and/or effectiveness of these products. Many so-called 'natural' progesterone creams do not contain substances that the human body can use as progesterone. These products are often derived from wild yam extracts and contain a substance, diosgenin, that only plants can metabolize into active progesterone. Other such products contain these plant extracts plus chemically synthesized progesterone, which is added to the plant extract in the cream. It is not always possible for a woman to tell exactly how much progesterone is available to her body by using these creams. And there's no evidence to date that progesterone creams can prevent the over-stimulation of the uterine lining by estrogen or reduce the risk of endometrial cancer. There's even less information about the safety and effectiveness of testosterone creams, which have been studied only in men.

The bottom line: The Task Force's review of studies to date has found no evidence that treatment with alternative therapies, such as wild yam extract, black cohosh, or dietary phytoestrogen supplements derived from red clover extracts has any significant effect on hot flashes.

If you decide to use alternative therapies, be sure to tell your physician. Some treatments have the potential to cause drug interactions with other medications you are using. Your doctor may recommend that you be monitored more closely for safety's sake while using alternative or complementary therapies. Remember, too, that dietary supplements, including herbal products, are not as strictly regulated by the federal government as are prescription and over-the-counter drugs. As a result, potency may vary from product to product, or even from batch to batch of the same product. Bear in mind that just because alternative therapies are referred to as 'natural' remedies doesn't mean they're without risks or side effects. For this reason, you should take the same care when using alternative supplements or products as you would when using any over-the-counter or prescription medication. Be sure to inform your physician that you are using these therapies, as well as any prescription medications, during medical visits.

I've been taking hormones to treat hot flashes for the past two years. How long is "too long?"

Again, there are no good studies to tell us precisely what constitutes safe short-term use. In the past, hormone therapy of five years or less was believed to be associated with little or no risk. However, the WHI study found an increase in the incidence of blood clots and stroke during the first year of use, and a rise in the diagnosis of breast cancer after 4 years, suggesting that even the first four years of use may not be risk-free. The estrogen-only arm did not show an increased risk for breast cancer after nearly seven years, but did find similar small increases in blood clots and stroke after just one or two years' use.

Keep in mind that the risks are low. If you don't already have a hereditary risk of blood clots, strokes, heart disease or breast cancer, you and your doctor may decide that the slightly elevated risks associated with the use of hormone therapy are perfectly acceptable to you when you factor in the relief you get from hot flashes. Again, you'll also want to reassess on an annual basis whether you still need relief for hot flashes.

What do I do when I'm ready to stop taking hormones?

So far, there aren't many good studies to guide you. You and your physician will have to discuss whether it's better for you to go "cold turkey" and simply stop taking hormones one day, or whether you might benefit from a more gradual approach.

Not all women can comfortably quit using hormone therapy. Some women experience heavy vaginal bleeding for several days after they stop taking hormones. Hot flashes and other menopausal symptoms may return, too, especially if you stop abruptly. A recent survey of patients from the Northern California Kaiser Permanente group suggests that one in four women who stopped using hormone therapy following the publication of the WHI results have re-initiated therapy because of persistent bothersome symptoms.

If you experience any of these problems, talk with your doctor about how you might taper off the dosage over time.

If I stop taking hormone therapy, will the elevated risks associated with its use go down?

There's no evidence to suggest that the slightly increased risks associated with using hormones - blood clots, strokes, heart attacks and breast cancer - remain elevated after you stop taking hormones. In fact, observational studies suggest that these risks do decline after you stop taking hormones. WHI researchers are monitoring their study participants to answer this question definitively.

Making a Decision

Only you, working together with your physician, can decide whether the benefits of using HT for relief of menopause symptoms are worth the small risks that have been identified. Start with a thorough medical evaluation to assess your current health status. You'll also want to learn as much as you can about the options available to you. This way, the choices you make will be informed ones, tailored to your individual needs.

If you do choose HT, the Task Force recommends that you use the smallest effective dose for the shortest time you can, and that you see your doctor at least once a year to discuss whether you are ready to stop, and what new information may be available that might influence your decision to stop or continue using hormones. Of course, you'll want to continue to get regular breast cancer screenings, including annual physician breast exams and periodic mammograms (which ACOG recommends every one to two years during your forties, and annually thereafter).

As with most issues concerning your health, the decision to use hormones is a very personal one that rests with you. Just make sure it's a well-informed one with which you feel comfortable.

An Important Note: Research Continues, Recommendations May Change

ACOG's statements here are for general information purposes and should not be construed as medical advice. Before making a decision about HT, consult with your physician for individualized advice that takes into account your personal needs and your medical and family history.

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The American College of Obstetricians and Gynecologists is the national medical organization representing over 47,000 members who provide health care for women.

Copyright © October 2004, The American College of Obstetricians and Gynecologists, 409 12th Street, SW, Washington, DC 20024-2188
ACOG Issues State-of-the-Art Guide to Hormone Therapy

Experts Expand Prior Post-WHI Advice on Estrogen

Herbal Remedies Don't Relieve Hot Flashes;
Too Soon to Know if Testosterone Enhances Libido


Washington, DC -- The American College of Obstetricians and Gynecologists (ACOG) today announced the most comprehensive, evidence-based clinical recommendations to date on hormone therapy (HT). ACOG's Hormone Therapy report, written by a task force of 21 national experts, "is an exhaustive, one-stop guide for doctors and their menopausal patients reviewing the risks, benefits, and continuing questions about hormone therapy," says ACOG President Vivian M. Dickerson, MD.

In addition to reaffirming most of the recommendations it issued after the landmark 2002 Women's Health Initiative study -- e.g., that combined HT (estrogen plus progestin) is effective treatment for menopausal symptoms but should not be taken to prevent certain diseases -- ACOG tempers some of its earlier advice regarding the length of time and reasons women might take hormone therapy. ACOG's encyclopedic report also "catalogues what medical science knows so far about the effect of reproductive hormones on everything from sex life to mental health, cancer to weight gain," adds Isaac Schiff, MD, chair of the ACOG Task Force on Hormone Therapy.

Among the findings released today in a special supplement to the October issue of ACOG's Obstetrics & Gynecology journal:

    Jury Still Out on Sex Drive - There have been too few studies to prove that taking estrogen or the male hormone testosterone -- either orally or topically -- can improve a woman's sexual libido (sex drive). However, there is ample evidence that estrogen given topically or orally can improve the quality of a woman's sex life, by relieving vaginal dryness and related symptoms that make sexual intercourse uncomfortable for many menopausal women.
    SSRIs Relieve Hot Flashes; Herbal Remedies Do Not - The category of anti-depressants known as selective serotonin reuptake inhibitors (SSRIs) can be effective alternatives to HT for the relief of menopausal vasomotor symptoms like hot flashes. As for herbal remedies, the Task Force concludes: "Treatment with wild yam extract, black cohosh, or dietary phytoestrogen supplements derived from the isoflavone red clover has no significant effects on vasomotor symptoms."
    Estrogen May have Anti-Depressive Effects - Estrogen appears to have mood- elevating effects in some perimenopausal women, who may be more vulnerable to depression than pre- or post-menopausal women. Due to its risks, estrogen should not be a first-choice treatment for depression, but it may be appropriate therapy under certain circumstances.

Beyond the WHI

ACOG experts say the report puts the 2002 Women's Health Initiative (WHI) study in the context of the wide range of research studies that came before and after it. "The WHI was a huge milestone in our understanding of the risks and benefits of hormone therapy," says Dr. Dickerson. "Though significant, it's only an early step in the continuing quest to understand how women's hormones affect their health."

Over two years ago, WHI study authors announced not only that the risks of combined HT outweighed its benefits when used to prevent certain diseases, but that it could actually increase the risk of certain conditions it was previously believed to prevent, such as a heart attack. Dr. Schiff believes that ACOG's Task Force, which was created prior to the 2002 WHI announcement by past ACOG president Charles B. Hammond, MD, has had the benefit of reviewing multiple studies over several years and can now look at the big picture.

"When the WHI came out, the pendulum of popular opinion on hormones swung wildly, from a mistaken belief that estrogen was the panacea for a variety of ills, to the frightened belief that it was now anathema even for conditions like hot flashes," says Dr. Schiff.

"Approximately 65% of women on HT stopped therapy after the WHI," notes Dr. Schiff. "Two years later, reports suggest that about 1 in 4 women who stopped HT went back on it because it still offers the best relief for menopausal symptoms. So we're moving back to an appropriate balance -- accepting that HT has risks, but recognizing that it can be appropriate for conditions like hot flashes so long as women are informed about the risks and weigh their decision with their doctor."

Adds Deborah M. Smith, MD, an advisor to ACOG's Managing Menopause consumer magazine, "From the WHI we also learned more about what we don't know. For example, the average age of women in the WHI study was 63. ACOG would like to see more research that answers key questions. Are the effects of hormones different for the more typical menopausal patient at the average age of 51, or for younger women who have undergone surgical or premature menopause? Are hormones more dangerous or beneficial at one time of life than another and, if so, why?"

ACOG's Hormone Therapy report includes 15 chapters examining available studies on hormone therapy and its relation to over 20 health conditions. These include sexual dysfunction, depression, cognition and dementia, coronary heart disease, breast and gynecologic cancers, osteoporosis, weight and insulin resistance, skin, stroke, gall bladder conditions, and genitourinary tract changes. The following are some report highlights:

Use of HT: Some Confirming, Some Loosening of Post-WHI Recommendations

In Hormone Therapy, ACOG reaffirms many of its earlier recommendations issued in the months immediately following the 2002 WHI announcement on combined HT, and the 2004 WHI announcement on estrogen-alone (ET) therapy. This includes advice that:

    Combined hormone therapy should not be used for prevention of diseases such as cardiovascular disease, due to the small but significant increased risk of conditions such as breast cancer, heart attack, stroke, and blood clots;
    Estrogen-alone therapy, used for women who have had a hysterectomy, should also not be used for prevention of diseases, due to increased risks of blood clots and stroke. Although ET carries fewer risks than combined HT, women with a uterus should not use estrogen alone due to their increased risk of uterine cancer;
    Hormone therapies are appropriate for the relief of vasomotor symptoms, so long as a woman has weighed the risks and benefits with her doctor; and
    Women on combined HT or ET should take the smallest effective dose for the shortest possible time and annually review the decision to take hormones.

The Task Force also softens some recommendations on the duration and need for hormone treatment, noting that although women should use HT for the shortest possible time, about 10% of menopausal women will continue to have vasomotor symptoms beyond the average four years it takes such symptoms to resolve. "It is inappropriate to withhold HT from persistently symptomatic women who prefer to continue HT or who do not derive relief from currently available alternatives," concludes the report.

"The report also says it is appropriate to treat women who feel better on hormone therapy or who feel it improves sexuality," says Dr. Schiff.

Although the report notes that hormone therapies should not be used solely for disease prevention, there are instances where disease prevention is appropriate as a secondary benefit for women who are already taking hormones for vasomotor symptoms. This includes its use to prevent osteoporosis, or to treat depression under certain limited circumstances for women with mild to moderate depression.

Alternatives to HT: What Does and Doesn't Work

Other Medications

The report affirms that to date estrogen is the most effective treatment for symptoms like hot flashes or night sweats, and that nasal sprays or transdermal (patch) hormone treatments provide comparable results to hormones taken orally. The report also catalogues the range and quality of research studies on alternative treatments for women who cannot or do not wish to take hormones.

"So far, research that includes randomized, double-blind studies shows that SSRI anti-depressants appear to be effective in reducing or relieving hot flashes," notes Dr. Schiff. "This is probably not surprising, given that certain types of serotonin receptors in the brain are believed to play a role in causing hot flashes."

Another agent that showed relief in a small, randomized, double-blind, placebo-controlled trial is an anticonvulsant medication known as gabapentin. "The reasons why it improves hot flashes are not yet understood," he adds.

Herbal Alternatives

"There has been a lack of published reports on most alternative medicine treatments," says Dr. Schiff. "The few studies done so far show disappointing results about the effectiveness of botanical treatments."

Studies on wild yam showed little difference in results between this method and placebo, and there was a high withdrawal rate of study participants due to unrelieved symptoms.

Soy contains isoflavones, one of the types of plant-based estrogens or phytoestrogens. The report notes, "A few very limited studies have suggested that soy helps with vasomotor symptoms in the short-term (less than 2 years), while other studies show little difference between soy beverages or extracts and placebo."

A study of two dietary phytoestrogen supplements derived from red clover showed no clinical effects on hot flashes or other symptoms.

Although black cohosh is a botanical treatment widely used in Europe for menopausal symptoms, "its benefits have been evaluated primarily in small short-term studies using since-invalidated measures," notes Dr. Schiff. The few randomized, controlled trials on black cohosh showed no significant reduction in hot flashes.

The report also cautions that since soy and dietary isoflavones appear to affect estrogen receptors, they may not be safe for women with estrogen-dependent cancers such as breast cancer.

Sexual Function: Too Few Studies on Female Sexual Libido, but Several Options for Relieving Vaginal Discomfort

"After years of publicity about Viagra and other products to improve male sexual performance, we still know pitifully little about what hormones or other products might enhance female sexual functioning," notes Dr. Dickerson.

Sexual response and function in women are complex, adds Dr. Dickerson, and include biologic, physiologic, and social factors. A National Health and Social Life Survey of 1,749 women ages 18-59 years found that 43% of respondents reported sexual dysfunction.

Sexual Libido

"Despite some claims about the benefits of certain hormone creams for sexual libido, it's still too early to know whether reproductive hormones like testosterone or estrogen, applied either topically or orally, can improve women's sex drive," says Dr. Dickerson. "There just haven't been enough studies on these or other therapies," she notes.

The report observes that the use of oral estrogen to improve sexual desire is supported by only one short-term, randomized, placebo-controlled trial. The same is true for the use of testosterone added to estrogen therapy. The most noteworthy improvements to sexual function were seen in studies involving women who have had an oophorectomy (ovary removal, or surgical menopause). These women are much more likely than women who have had a hysterectomy to report adverse changes in their libido and orgasmic response. Significant improvements in sexual desire were seen in these women when transdermal testosterone was added to ET, but only at high doses (300 micrograms).

"It's still premature to say what does or doesn't work in improving women's sexual libido, but researchers are learning more all the time," says Dr. Dickerson. Just this month, for example, the US Food and Drug Administration granted priority review to an investigational female testosterone patch for the treatment of low sexual desire in women who have undergone oophorectomy.

Relief of Vaginal Pain

"What we do know," adds Dr. Dickerson, "is that there are ample studies showing that even very low doses of estrogen can relieve vaginal dryness, which has been associated not only with painful intercourse, but with a decrease in sexual desire. The good news," she says, "is that there are several methods for relieving vaginal dryness with estrogen, including pills, vaginal creams or rings."

Heart Health and Weight: Lifestyle and Other Factors, Not Estrogen, Make the Difference

"One of the most notable results of the WHI was its confirmation that higher-evidence studies give us more reliable results," says Dr. Smith. "Nowhere was that more apparent than in our understanding of estrogen and heart disease."

The WHI was the largest randomized, double-blind, placebo-controlled study on hormone therapy to date, meaning that neither the health providers nor the patients in the study knew whether the patients were taking hormones or placebo. Prior to that study, smaller observational studies suggested that HT protected against heart disease by elevating the levels of so-called good cholesterol (HDL) and reducing so-called bad cholesterol (LDL) that can be a factor in heart disease.

"Now we know that at least two things were going on," says Dr. Smith. "First, there was probably 'user bias' in those earlier studies, meaning that the women on HT were already healthier than the women not taking hormones. Second, medical experts may have overestimated the effect of cholesterol in heart health, and been unaware of other factors in heart disease that we still don't understand."

"Where does that leave us today?" questions Dr. Smith. "Since the average age of WHI participants was 63, ACOG believes that more research is needed to determine whether hormones taken in perimenopause or early in menopause have a different effect on heart health. But very importantly, we know that lifestyle factors -- such as eating a healthy diet, not smoking, and getting plenty of exercise -- are the biggest contributors to heart disease prevention."

"Finally," notes Dr. Smith, "the Task Force reminds us that it's not hormone therapy, but the normal process of aging that accounts for the average weight gain of women during middle age." She points to what the report calls the "single biggest modifier for weight gain: physical activity."

"No matter how many studies are conducted about weight, we can't avoid the inevitable," concludes Dr. Smith. "If we want to lose, we've got to move."

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Editor's Note: ACOG's Hormone Therapy report is published as a special supplement to the October issue of Obstetrics & Gynecology. As of Friday, October 1, 2004, consumers can be referred to www.acog.org for a detailed update, entitled "Frequently Asked Questions About Hormone Therapy."

The American College of Obstetricians and Gynecologists is the national medical organization representing over 47,000 members who provide health care for women.
Questions and Answers on Hormone Therapy

In Response to the Women's Health Initiative Study Results on Estrogen and Progestin Hormone Therapy

Many women have questions about whether to use or continue using hormone therapy (HT) after the recent halting of the Women's Health Initiative (WHI) study on combined estrogen and progestin use in healthy postmenopausal women.

Experts from The American College of Obstetricians and Gynecologists (ACOG) have carefully reviewed the published study results. (To date, the complete WHI study data have not been released to outside organizations.) ACOG-member physicians have responded to questions from thousands of women around the country. Here ACOG addresses the most frequently asked questions about the published results of the WHI study and what they may mean for women facing decisions about HT.

We hope the following information is helpful. Since it is not a substitute for medical advice, ACOG urges each reader to consult her personal physician when deciding about HT.

Background on the WHI Study Results

The Women's Health Initiative is a long-term study sponsored by the National Institutes of Health (NIH) that is looking at ways to prevent heart disease, breast and colon cancer, and osteoporosis.

One part of that study followed 16,608 healthy women with a uterus, who were ages 50 to 79 when they entered the study, and who took either estrogen and progestin therapy (combined hormone therapy, or HT) or a placebo. The goal of this 8-year trial was to study the relationship between HT and its possible benefits for heart disease and hip fracture, as well as its possible risks for breast cancer, endometrial cancer, and blood clots. The trial was not intended to study the effect of HT on menopausal symptoms or on other conditions such as Alzheimer's disease.

On July 9, 2002, the NIH halted this trial after 5.2 years, concluding that the risks for the study group on combined HT outweighed the benefits. (The published report is in the July 17, 2002 issue of the Journal of the American Medical Association. Additional information on the WHI can be found at the website www.whi.org.) Risks included small but significant increased risks of breast cancer, coronary heart disease, stroke, and blood clots for the group of women on HT. Benefits of HT use included lower risks for hip fractures and colon cancer. There was no difference between the two groups in death rates. A separate WHI trial on the use of estrogen alone (ET) in women who have had a hysterectomy is continuing, because study officials have apparently not seen comparable risks in those women. The data and safety monitoring board of the WHI will continue to review data from this trial every six months.

The NIH is continuing to review a number of the statistics that were part of the WHI study, conducting what are known as subset analyses of the WHI data. So far, the NIH has issued its published JAMA report but has not released the underlying WHI data to outside organizations including ACOG. As the WHI data become available and as NIH announces the results of subset analyses, there may be further clarification of HT issues and further revisions to ACOG recommendations.


YOUR QUESTIONS

1. What are the specific risks uncovered by the WHI study?

While there was no difference in the death rates between the group on combined hormone therapy (HT) and the placebo group, there was a small but significant increased risk of certain diseases for the group of women on HT. NIH officials concluded these risks were significantly high enough to justify stopping the study for public health reasons. These risks can be summarized as follows.

Heart Disease - Unlike earlier observational studies that suggested the possibility of some protection against heart disease, this study showed a small but significant increased risk for events such as non-fatal heart attacks. The risk for heart disease was 29% higher for the group taking combined HT than for the group on placebo. While this percentage reflecting the increased risk for the group seems large, the annual increased risk for an individual woman was still relatively small. For example, on average during a year of the WHI study, there were 37 heart disease events (such as heart attacks) per 10,000 women in the HT group compared to 30 events per 10,000 women in the placebo group. Thus there were, on average, 7 more cases per 10,000 women per year in the HT group. The risk appeared in the first year of HT use.

Breast Cancer - The risk for invasive breast cancer was 26% higher in the group on HT. The annual increased risk for an individual woman was still relatively small. On average, per year there were 38 cases of breast cancer per 10,000 women on HT compared to 30 breast cancer cases per 10,000 women on placebo. Thus there were, on average, 8 additional cases of breast cancer per 10,000 women per year, in the HT group. The increase in breast cancer was apparent after 4 years of HT use, and the risk appears to be cumulative, increasing over time. While the risk for breast cancer was also increasing for the placebo group over time — because advancing age increases one's risk for breast cancer — the risk for the HT group appeared to increase at a higher rate than would normally occur with advancing age.

Stroke and Blood Clots - Stroke: There was a 41% increased risk for the group on HT. On average, per year there were 29 cases of stroke per 10,000 women on HT compared to 21 cases of stroke per 10,000 women on placebo (8 more cases per 10,000 women). The risk appeared in the second year of HT use and continued into year 5 of the study. Blood Clots: The group on HT had two-fold greater rates of blood clots than the group on placebo. On average, per year there were 34 cases of blood clots per 10,000 women on HT compared to 16 cases per 10,000 women on placebo (18 more cases per 10,000 women).

2. Weren't there benefits or protections to HT use as well?

Yes, but the study was stopped because these were not considered to be sufficiently strong enough to outweigh the increased risks for the group using HT. These were the benefits shown:

Colon Cancer - The risk of colon cancer was reduced by 37% in the HT group. On average, per year there were 10 cases of colorectal cancer per 10,000 women on HT compared to 16 cases of colorectal cancer per 10,000 women on placebo (6 fewer cases per 10,000 women). The benefit appeared after 3 years of use and became more significant over time.

Bone Fractures - The WHI study was the first of its kind to show a decreased risk of vertebral and other osteoporotic fractures with HT use. In the HT group, there was a 24% reduction in total fractures, and a 34% reduction in hip fractures. On average, per year there were 10 cases of hip fracture per 10,000 women on HT compared to 15 cases per 10,000 women on placebo (5 fewer cases per 10,000 women).

3. How do I apply these conflicting accounts of risk - whether "small" or "significant" — to my own situation? If a study was halted, isn't HT unsafe, period?

Knowing how to apply the risks uncovered by the WHI is complex for both patients and physicians. That's because there's a difference between the size of the risks found for the group of women using HT, which were large enough to warrant stopping the study, and the size of the risks for each individual woman using HT, which — though real and often increasing over time — were still quite small. A look at the breast cancer risk illustrates this difference, and some of the problems.

Risks for the Group on HT: The NIH stopped the study for public health reasons, both in fairness to the group of women on HT and because they were looking at the increased risks for an entire population of women using HT over time. While the rate of increased breast cancer risk described in Question 1 may not sound huge (8 additional cases of breast cancer per 10,000 women, on average per year, in the HT group), in a drug taken by millions of women over many years, this can result in a large number of women with breast cancer.

Risks for the Individual Woman on HT: Since the percentage of women in the WHI study who actually had adverse effects from HT use was small, the size of the risk for each individual woman on HT was also small. For example, with breast cancer, while the increased risk for the group on HT was 26%, an individual woman's increased risk for breast cancer with HT use was less than one tenth of one percent a year, according to study authors. There's one important caveat however. This small increase in individual risk appeared to be cumulative over time. The longer a woman stayed on HT, the more her risk for breast cancer increased, at a higher rate than would normally occur with advancing age.

What does this mean for a woman trying to make a decision about HT? The bottom line is that while HT is still an acceptable option for the treatment of menopausal symptoms in certain cases, the decision for a woman considering whether to use HT and for how long has become much more complex.
You will have to decide in consultation with your doctor whether the risks uncovered by the WHI are acceptable to you. This means reviewing with your doctor:

(1) why you want to be on HT;

(2) your personal benefits with HT use; and

(3) your increased risks with HT use, taking into account your individual and family history for conditions such as heart disease or breast cancer.

ACOG recognizes that many women are tired of the phrase "talk to your doctor," which has been in
constant use since the WHI report was published. But the phrase has never been more important. When it comes to HT, there is no one-size-fits-all answer, and decisions about HT will have to be made on a case-by-case (or woman-by-woman) basis.

The following chart may be helpful, which illustrates the differences in risks and benefits for the group on HT as compared to the placebo group.

 

 

4. I was taking HT for the reason that it could help prevent heart disease. Now the WHI says it doesn't. What happened?

HT is no longer recommended to prevent heart disease in healthy women (primary prevention) or to protect women with pre-existing heart disease (secondary prevention). The WHI tells us that not only does it not work, it may actually increase your risk of a heart attack or stroke.

Why did medicine once think otherwise? Earlier observational studies compared women who took HT with women who didn't. But these studies are not as sophisticated as the WHI study, which was "double-blinded" — that is, it compared patients on HT with a "control group" on placebo, with neither group knowing which pill they were taking. The earlier observational studies suggested that HT had a benefit in protecting the heart, since the women on HT had better cholesterol levels, and they appeared to have fewer heart attacks and strokes. In addition, these women may have been younger when they started HT than the women in the WHI study.

Now, we are all benefiting from the effort in years past to increase the size and sophistication of research trials in women's health. The higher-quality WHI evidence suggests that these earlier studies probably had an inherent bias, meaning that the women taking HT already tended to be healthier than the women not taking HT. Also, there may be other, still-unknown factors that are affecting a woman's heart disease risk as much as, or more than, such known factors as cholesterol levels.

5. So, if I'm taking HT just to protect against heart disease, should I stop?

Yes. Lifestyle changes can help prevent heart disease — particularly regular exercise, smoking cessation, and weight control. And, for certain women at high risk for heart disease, other medications have been shown to be effective. Medications such as statins can help reduce high cholesterol levels, and hypertension medications can help reduce high blood pressure. You will want to discuss with your doctor the specific type that may be right for you.

6. I'm at high risk for osteoporosis. Can I continue on HT?

If you are taking HT solely for the prevention of osteoporosis consider stopping it, because there are other medications that can help prevent osteoporosis and fractures that appear to carry lower risks for conditions such as breast cancer or heart disease. If you are also taking HT for treatment of menopausal symptoms, it may be appropriate. (See Question 7.)

Other preventive drug therapies include the family of drugs known as bisphosphonates, which can reduce the breakdown of bone. Other options are the selective estrogen receptor modulators, or SERMS, which are a new class of synthetic estrogens that act like estrogen in certain parts of the body (such as the bones) while leaving other parts of the body unaffected.

Some women with heartburn or ulcer problems may be unable to take bisphosponates, and each of the medications discussed here will have its own side effects. Although these medications appear to have a better ratio of benefits to risks for you compared to HT, studies are continuing on the effects of these drugs, some of which have been in use for only a few years. Talk to your doctor about whether these medications would be appropriate for you. Weigh any benefits of continued HT use against your personal risks for cardiovascular disease and breast cancer.

For all women, lifestyle recommendations for healthy bones include a diet high in calcium (postmenopausal women should be taking 1,200 to 1,500 mg of calcium per day), a multi-vitamin containing Vitamin D, and regular weight-bearing exercise such as jogging or walking.

7. Where does this leave me if I want to take HT for menopausal symptoms such as hot flashes or sleep problems?

HT is highly effective in treating certain menopausal symptoms and may still be appropriate for you, depending on your circumstances. However, the small but real increased risks uncovered by the WHI study mean that this is now a more complicated decision.

You will have to evaluate, with your physician, the pros and cons of HT use in your individual circumstance. This includes weighing any benefits of continued HT use against your individual risks for conditions such as breast cancer, to decide whether taking HT is an acceptable or an unacceptable risk for you.

To date, HT is the most effective treatment for the relief of vasomotor symptoms such as hot flashes and sleep disturbances, which can affect both physical and mental health. It's also effective in treating genitourinary symptoms such as vaginal dryness, which can affect sexual pleasure.

The effects of these menopausal symptoms on the quality of a woman's life can be considerable, and the severity and duration of symptoms can vary widely from woman to woman. Some women experience few or very short-lived symptoms, while others experience severe symptoms over many years. Yet too often, women are made to feel guilty about how they respond to menopausal symptoms, which are often trivialized by such comments that women should simply be able to "put up with it." In fact, each woman will have her own physiological reaction to menopause, and each will have to make the decision that is right for her.

Some women may choose to manage their symptoms without any use of HT, either through lifestyle changes alone or with other therapies. Other women, particularly those with severe menopausal symptoms, may conclude that the benefits of short-term HT use are worth the small increased risks.
If you choose HT for relief of menopausal symptoms, ACOG recommends the following:

(1) Take HT for the shortest possible time that works for you, in the smallest effective dose;

(2) Have regular consultations with your physician - at least once a year - to review your reasons for taking HT and to see if you can successfully discontinue HT use; and

(3) Like all women, get regular breast cancer screenings, including annual physician breast exams and periodic mammograms (which ACOG recommends every one to two years during your forties, and annually thereafter).


8. If I've been on HT for more than 5 years for relief of menopausal symptoms, should I go off of it?

Try to discontinue HT use if you have been on it for this period of time, since the increased risk of breast cancer and other conditions rises over time. If you do experience a return of symptoms, ask your doctor about alternative therapies. (See Question 14.)

What if you discontinue HT after several years of use, but your menopausal symptoms come back and other therapies do not work for you? You can consider returning to HT so long as you understand the risks involved. There are some women who will do better on HT than on other therapies, and HT may be a reasonable option for them if they have weighed the pros and cons with their physician. If you do resume HT, do so at the lowest possible effective dose for you for the shortest possible time and, as discussed above, review with your physician at least annually whether you can successfully discontinue HT.

9. Am I safe then if I take HT for up to 4 years, since the increased risk for breast cancer appeared after that time?

We just don't know yet. There are no data from this or other studies to clearly establish what constitutes safe short-term use. Even the first 4 years of HT use may not be risk free. In the WHI study, there was an increase in the diagnosis of breast cancer after 4 years. It's possible that hormones are having some effect on the biology of breast cancer even in the first year of use.

It's also possible that as the NIH conducts and releases further analyses of different parts of the WHI data, we may get a better picture of certain factors (such as a participant's prior use of HT) to improve our understanding of why the increased breast cancer risk appeared when it did. Until we know more, if you do choose HT, use it for the shortest possible time that works for you and have an evaluation with your physician at least annually to see whether you still need it.

10. I'm not taking the Prempro pill studied by the WHI, but another form of hormones. Do any of these results apply to me?

It's true that this part of the WHI only studied a specific combined estrogen and progestin pill and thus findings can be reasonably applied only to this formulation (which was .625 mg/d continuous conjugated equine estrogen and 2.5 mg/d medroxyprogesterone acetate; brand name PremproTM). However, we cannot assume other hormone regimens or methods will be safer, without more conclusive data. Although future studies on lower hormone doses or different combinations may tell us more, for now all women taking all forms of HT should be aware of the increased risks found in the WHI trial.

11. I've had a hysterectomy and I'm taking estrogen alone. Is that still safe?

Another part of the WHI study that is examining the use of estrogen alone in women who have had a hysterectomy is continuing, because so far the same proportion of risks to benefits has not appeared in this group. Safety monitoring officials of the WHI will continue to review data from this part of the study every six months. However, complete results of this particular trial probably will not be known until the year 2005.

12. I haven't had a hysterectomy. Is it okay to switch to estrogen alone for the treatment of menopausal symptoms?

It is not recommended, since we know that women with a uterus who take only estrogen are at greater risk for endometrial cancer.

13. If I want to discontinue HT use, what's the best way to do so — "cold turkey" or gradually?

So far, there are no definitive studies to guide this process. You and your physician will have to discuss what method might work for you. Some women may tolerate "cold turkey," while others may require a more gradual approach. When stopping HT, some women experience heavy vaginal bleeding. If menopausal symptoms recur with the abrupt approach, a gradual approach should be considered.

14. If I stop HT and my menopausal symptoms return, what else can I try?

Some lifestyle modifications may help reduce symptoms such as hot flashes. These include quitting smoking; avoiding or reducing foods or substances that may trigger flashes, such as spicy foods, caffeine and alcohol; lowering stress levels; exercising regularly; and wearing loose clothing or dressing in layers, to peel off top layers during a hot flash.

There have been reports that some non-hormonal prescription medications may help relieve certain menopausal symptoms, although studies to date on these medications have been small and still lack long-term follow-up data. For example, for women experiencing vasomotor symptoms such as hot flashes and loss of sleep, the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs) may provide some relief. Clonidine, a type of anti-hypertension medication, may be helpful in some cases. Although these medications have been extensively studied and FDA approved for other uses, they have not yet been approved or marketed specifically for use in treating hot flashes. Talk to your physician about other possible medications for hot flashes.

For symptoms such as vaginal dryness, alternative delivery methods of estrogen alone — such as vaginal creams, vaginal tablets, or vaginal rings — are usually effective. Although the tablets and rings do not appreciably increase the estrogen levels in a woman's body, there are little data to assess the long-term safety of these three alternatives.

If you try other options and they do not relieve your symptoms, you can consider returning to HT, as long as you understand the risks and benefits.

15. What about natural or herbal remedies such as black cohosh, for relief of symptoms? I have a friend on black cohosh who swears it works.

Some of the herbal preparations sold over-the-counter contain phytoestrogens, weak forms of estrogen derived from plants. Unfortunately, most nutritional supplements have not undergone long-term tests for safety and effectiveness, so no one really knows for sure how helpful they are and whether or not they might have any risks. Ongoing research may help shed some light on the subject, but most study results are still a number of years away. If you do use herbal remedies, always inform your physician of this as well as of any medications you take.

An Important Note: Research Continues, Recommendations May Change

If you have additional questions you would like to ask ACOG about HT or other treatments for menopausal symptoms, email us at [email protected]og.org.

Research on HT and other therapies is continuing every day and medical recommendations may change. At present, the NIH is conducting further subset analyses of the WHI data. Despite requests to obtain them, the data have not yet been released to outside organizations. As these data become available, ACOG will update its recommendations accordingly.

Finally, remember that ACOG's statements here are for general informational purposes and should not be construed as medical advice. Before making a decision about HT, consult with your physician for individualized advice that takes into account your personal needs and your medical and family history.

ACOG is the national medical organization representing over 40,000 physicians who provide health care for women.

Copyright © August 2002, The American College of Obstetricians and Gynecologists, 409 12th Street, SW, Washington, DC 20024-2188