This report has been updated with #1320.
The Journal of the American Medical Association published a study that showed that women who take estrogen and progesterone after the menopause are at increased risk for heart attacks and strokes. Two weeks later it reported another study showing the same thing, that estrogen and progesterone together do not prevent heart attacks and strokes in older women, and may even increase a woman's risk for heart attacks and strokes. A multi-million dollar, government-supported study on the effects of estrogen and progesterone was stopped because the authors feel that their own study shows that estrogen and progesterone may increase risk for heart attacks and strokes in older women.
These three studies show how important it is to do multi million-dollar studies involving thousands of people, rather than smaller studies that can give conflicting results. Most studies done over the last 50 years have shown that estrogen prevents heart attacks in older women, but none involved as many women and followed these women to see how they respond to estrogen over the years.
Should a woman take estrogen? These studies show that the combination of estrogen and progesterone increases an older woman‘s risk for heart attacks and strokes. They do not show that estrogen alone increases risk. The reason doctors give progesterone with estrogen is to prevent uterine cancer. Estrogen stimulates the uterus to grown. Progesterone stops the stimulation. Women who are given only estrogen have uteri that are stimulated all the time, which can lead to uncontrolled growth, which is cancer. So, no woman who has a uterus should be given estrogen without progesterone also.
The studies were done on older women, not younger women. We do not have any evidence that estrogen increases breast cancer risk in younger women. Another study showed that birth control pills do not increase risk for breast cancer. The only benefit that has been shown consistently for estrogen is that it prevents hot flushes better than anything else we have. With the exception of last week's study, almost all other studies show that estrogen also strengthens bones and helps to prevent fractures of the hips and spine. Since postmenopausal estrogen has been shown to prevent hot flushes and bone fractures; increases risk for breast cancer; and may increase risk for heart attacks and strokes, all women should be evaluated for osteoporosis at the menopause. Those who are at high risk for osteoporosis can take drugs such as Fosamax, Actonel, Didronel, or Miacalcin. If they have severe osteoporosis, they may also consider taking estrogen.
So far, the data show that estrogen does not increase breast cancer risk for the first three years a post-menopausal woman takes it, so it may be all right for a woman to take estrogen for three years. If a woman has terrible hot flushes, she should try a diet loaded with phytoestrogens found in seeds: beans, nuts, whole grains and other seeds such as flax seeds, and other vegetables such as yams. If that doesn't work, she may want to discus with her doctor whether she needs estrogen for her comfort. A woman who suffers from a dry vagina can take estrogen cream three times a week for few months, take Viagra before making love, or use lubricants.
JAMA, July 3 and July 17, 2002
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