Hrt In Older Women: Is It Ever Too Late
Short periods of hormone replacement therapy are often used to treat vasomotor symptoms around the time of the menopause, but long-term adherence to therapy is low. However, there is accumulating evidence to support the initiation or re-initiation of HRT as a later intervention for a variety of progressive conditions associated with menopause and aging. If the risk-benefit ratio is in favor of HRT, various strategies can be used to improve acceptance and minimize side effects, with the goal of improving the quality, if not the quantity, of life.
If a risk-benefit analysis favors hormone replacement therapy, it may be appropriate and acceptable to initiate systemic or local HRT in some older women to improve the quality of their lives.
Introduction
Intuitively, prevention is preferable to the treatment of established disease. However, universal therapy for prevention of disease may not be practical, affordable, or acceptable. Many of the health consequences of menopause and aging can be modified by hormone replacement therapy , using either estrogen alone or estrogen plus a progestin. In recent years, standard teaching suggested that HRT should be continued throughout the menopausal years to confer maximal relief of vasomotor symptoms, optimal effects on bone, lipids, and the urogenital tract, and the possibility of protection from cardiovascular disease, cerebrovascular disease, colon cancer, and neurodegenerative disorders such as Alzheimers disease.
Vasomotor symptoms
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However, the age of medical consent defined by WPATH is still too old, as far as Dr Telfer is concerned. She says “Sixteen was a convenient age, but a totally arbitrary age in terms of other aspects of medical care”, and that there is no “actual medical or physical argument for choosing that particular number”.
The authors of the guidelines instead believe that case-by-case assessment and individualised treatment that does not abide by chronological age is the most responsible practice. Dr Telfer says that a young person’s capacity to understand medical decisions is best assessed by getting to know them and speaking to their family.
Fifteen-year-old Isabelle, a transgender girl and one of Dr Telfer’s patients at RCH, began stage 2 earlier this year and is relieved that she did not have to wait another year: “I think I started at a good time for me personally since I was 11 I’ve been wanting it, so any time feels a bit late, but I think when I took it was the healthiest time.”
Isabelle, a transgender girl and patient at Royal Children’s Hospital Melbourne.
Mental health is also affected when a trans adolescent is forced to start puberty at 16, the age they are permitted to begin stage 2 treatment.
“If you’re suppressing puberty at a young age and then waiting five years while your peers go through puberty, there are consequences,” Dr Telfer said.
Seventeen-year-old Freya is a transgender girl and a patient at RHC. She says the current rules are unfair to trans teens.
Early Versus Delayed Treatment
For men who need hormone therapy, such as men whose PSA levels are rising after surgery or radiation or men with advanced prostate cancer who dont yet have symptoms, its not always clear when it is best to start hormone treatment. Some doctors think that hormone therapy works better if its started as soon as possible, even if a man feels well and is not having any symptoms. Some studies have shown that hormone treatment may slow the disease down and perhaps even help men live longer.
But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the side effects of hormone therapy and the chance that the cancer could become resistant to therapy sooner, treatment shouldnt be started until a man has symptoms from the cancer. This issue is being studied.
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What Questions Remain In This Area Of Research
The WHI trials were landmark studies that have transformed our understanding of the health effects of MHT. Its important to note that women who were enrolled in the WHI trials were, on average, 63 years old, although about 5,000 of them were under age 60, so the results of the study may also apply to younger women. In addition, the WHI trials tested single-dose strengths of one estrogen-only medication and one estrogen-plus-progestin medication .
Follow-up studies have expanded and refined the original findings of these two trials. But many questions remain to be answered:
- Are different forms of hormones, lower doses, different hormones, or different methods of administration safer or more effective than those tested in the WHI trials?
- Are the risks and benefits of MHT different for younger women than for those studied in the WHI trials?
- Is there an optimal age at which to initiate MHT or an optimal duration of therapy that maximizes benefits and minimizes risks?
Are There Alternatives For Women Who Choose Not To Take Menopausal Hormone Therapy
Women who are concerned about the changes that occur naturally with the decline in hormone production that occurs during menopause can make changes in their lifestyle and diet to reduce the risk of certain health effects. For example, eating foods that are rich in calcium and vitamin D or taking dietary supplements containing these nutrients may help to prevent osteoporosis. FDA-approved drugs such as alendronate , raloxifene , and risedronate have been shown in randomized trials to prevent bone loss.
Medications approved by the FDA for treating depression and seizures may help to relieve menopausal symptoms such as hot flashes . Drugs that have been shown in randomized clinical trials to be effective in treating hot flashes include venlafaxine , desvenlafaxine , paroxetine , fluoxetine , citalopram , gabapentin , and pregabalin .
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The Cost Of Transitioning
Most of these treatments are still very expensive and often out of reach for people without the help of insurance. The cost of puberty blockers is approximately $1,200 per month for injections and can range from $4,500 to $18,000 for an implant. The least expensive form of estrogen, a pill, can cost anywhere between $4 to $30 a month, according to Simons, while testosterone can be anywhere between $20 to $200 a vial.
What were seeing in the clinic is that whether or not specific insurance plans cover medication or not is completely arbitrary, Simons said. It really cant be predicted very easily.
We almost always just expect a denial, she said.
Though it is not the only treatment, doctor-supervised medical transition is critically important to aid people in the treatment of gender dysphoria, Vincent Paolo Villano, the director of communications at the National Center for Transgender Equality, told FRONTLINE. Access to medical transition is often unobtainable due to cost and insurance discrimination.
Transgender people experience twice the rate of unemployment as non-transgender people, which means they often lack insurance to gain access to health care, period, Villano said. And even for trans people with insurance, health plans often outright ban coverage of transition-related care, forcing transgender people to pay outrageous out-of-pocket expenses for medically-necessary procedures that are covered without question for non-transgender people.
Hrt Does Not Cause Weight Gain
Weight gain at the menopause is related to age and lifestyle factors. An increase in body fat, especially around the abdomen, can occur during menopause because of hormonal changes, although exactly why this happens is not clear. Normal age-related decrease in muscle tissue, and a decrease in exercise levels, can also contribute to weight gain.
Most studies do not show a link between weight gain and HRT use. If a woman is prone to weight gain during her middle years, she will put on weight whether or not she uses HRT.
Some women may experience symptoms at the start of treatment, including bloating, fluid retention and breast fullness, which may be misinterpreted as weight gain. These symptoms usually disappear once the therapy doses are changed to suit the individual.
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Q: What Can I Expect At My Initial Visit
At your initial visit, well review your medical history with you, take your vital signs, go over the risks, benefits, and what to expect with gender-affirming hormone therapy, review the informed consent, and do some lab work. We also perform a brief physical exam we do not perform a genital exam unless you request one.
To note: its recommended that certain people who have had gender-affirming surgery have a pelvic exam yearly.
What Should You Do In Your 70s For Health
Just stay active and cut calories if needed, says Alice Lichtenstein, D.Sc., director of the Cardiovascular Nutrition Laboratory at the USDA Human Nutrition Research Center on Aging. The Not-So-Good News: In your 70s you may secrete less hydrochloric acid, which decreases the availability of vitamin B12, says Lichtenstein.
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Questions To Ask Your Doctor Or Nurse
- What is the aim of treatment?
- What type of hormone therapy are you recommending for me and why?
- How often will I have my injections or implants?
- How will my treatment be monitored?
- How long will it be before we know if the hormone therapy is working?
- What are the possible side effects, and how long will they last?
- What will happen if I decide to stop my treatment?
- Are there any clinical trials that I could take part in?
Hormone Therapy With Radiotherapy
You have this if:
- your cancer hasnt spread to other parts of the body but is at a high risk of coming back, eg the cancer has grown through the covering of your prostate
- you have a very high prostatic specific antigen level
- you have a high Gleason score
You might have hormone therapy before, during and after radiotherapy. Doctors usually recommend that you have the treatment for between 3 months and 3 years. How long depends on the risk of your cancer coming back and how many side effects you get.
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Reducing The Cancer Risks Of Hormone Therapy
If you and your doctor decide that MHT is the best way to treat symptoms or problems caused by menopause, keep in mind that it is medicine and like any other medicine its best to use it at the lowest dose needed for as short a time as possible. And just as you would if you were taking another type of medicine, you need to see your doctor regularly. Your doctor can see how well the treatment is working, monitor you for side effects, and let you know what other treatments are available for your symptoms.
All women should report any vaginal bleeding that happens after menopause to their doctors right away it may be a symptom of endometrial cancer. A woman who takes EPT does not have a higher risk of endometrial cancer, but she can still get it.
Women using vaginal cream, rings, or tablets containing only estrogen should talk to their doctors about follow-up and the possible need for progestin treatment.
For women who have had a hysterectomy , a progestin does not need to be a part of hormone therapy because theres no risk of endometrial cancer. Adding a progestin does raise the risk of breast cancer, so ET is a better option for women without a uterus.
Women should follow the American Cancer Society guidelines for cancer early detection, especially those for breast cancer. These guidelines can be found in Breast Cancer Early Detection.
Do I Need Hormone Replacement Therapy
The signs and symptoms of hormonal imbalance can vary between men and women and may be mild to severe. If the side effects of menopause or low T are negatively affecting your life, hormone replacement therapy may be right for you. Choosing to begin treatment is a personal decision and should be discussed with your medical providers.
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The Health Risks And Benefits Of Hrt
In 1991, the U.S. National Institutes of Health launched the Women’s Health Initiative , a set of studies involving healthy post-menopausal women that was carried out in 40 U.S. centres. The WHI included a clinical trial to evaluate the risks and benefits of the two types of HRT and to see how they affected the incidence of heart disease, breast cancer, colorectal cancer and fractures in post-menopausal women. The trial was divided into two arms:
- One arm involved more than 16,000 post-menopausal women aged 50 to 79 who had not had a hysterectomy. They took pills daily that were either a combination of estrogen and progestin , or a placebo .
- The second arm involved more than 10,000 women who had received a hysterectomy and who took estrogen pills alone or a placebo.
In July 2002, after an average 5.2 years of regular follow-up, the NIH prematurely ended the combined HRT arm of the WHI trial. An independent monitoring board, which regularly reviewed the findings, concluded that there were more risks than benefits among the group using combined HRT, compared with the placebo group. The study found that changes in the incidence of disease per 10,000 women on combined HRT in one year were:
- Seven more cases of coronary heart disease
- Eight more cases of strokes
- Eighteen more cases and a twofold greater rate of total blood clots in the lungs and legs
- Eight more cases of invasive breast cancer
- Six fewer cases of colorectal cancer
- Five fewer cases of hip fractures
What Is Hormone Therapy
Hormone therapy slows or stops the growth of hormone-sensitive tumors by blocking the bodys ability to produce hormones or by interfering with effects of hormones on breast cancer cells. Tumors that are hormone insensitive do not have hormone receptors and do not respond to hormone therapy.
Hormone therapy for breast cancer should not be confused with menopausal hormone therapy treatment with estrogen alone or in combination with progesterone to help relieve symptoms of menopause. These two types of therapy produce opposite effects: hormone therapy for breast cancer blocks the growth of HR-positive breast cancer, whereas MHT can stimulate the growth of HR-positive breast cancer. For this reason, when a woman taking MHT is diagnosed with HR-positive breast cancer she is usually asked to stop that therapy.
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Types Of Studies Of Hormone Therapy And Cancer Risk
Different types of studies can be used to look at cancer risk from menopausal hormone therapy .
Randomized controlled trials: In this kind of study, a group of patients get the drug being studied , and another group gets a placebo . Results from this kind of study are powerful because which group a patient is in is based on chance. This helps assure that the groups are similar in all ways, such as risk for cancer, except for the drug thats being studied. This is the best way to see the effects of a drug. These types of studies can also be double-blinded, which means neither the people in the study nor their doctors know which group they are in. This lowers the chance that thoughts or opinions about treatment could affect the study results. Unfortunately, these kinds of studies are costly, which limits the number of people in the study, how long the study can continue, and the number of studies done.
A major drawback of observational studies is that the people getting the treatment being studied may have different cancer risk factors than the people who arent. Plus, the treatment can differ between the people being studied. This makes it less clear that the differences seen are only due to the drug being studied and not other factors.
When observational studies and randomized controlled trials have different results, most experts give more weight to the results of the randomized controlled trial.
Effects Of Testosterone And Estrogen
Many trans men seek maximum virilization, while others desire suppression of their natal secondary sex characteristics only. As a result, hormone therapy can be tailored to a patients transition goals, but must also take into account their medical comorbidities and the risks associated with hormone use.
The following changes are expected after estrogen is initiated: breast growth, increased body fat, slowed growth of body and facial hair, decreased testicular size and erectile function. The extent of these changes and the time interval for maximum change varies across patients and may take up to 18 to 24 months to occur. Use of anti-androgenic therapy as an adjunct helps to achieve maximum change.
Hormone therapy improves transgender patients quality of life . Longitudinal studies also show positive effects on sexual function and mood . There is biologic evidence that may explain this. Kranz et al. have looked at the acute and chronic effects of estrogen and testosterone on serotonin reuptake transporter binding in trans men and women. SERT expression has been shown to be reduced in individuals with major depression . Kranz et al. found that androgen treatment in transmen increased SERT binding in several places in the brain and anti-androgen and estrogen therapy led to decreases in regional SERT binding in trans women. These types of data are preliminary, but do point to the important role of hormone therapy in patients who suffer from gender dysphoria.
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When Transgender Kids Transition Medical Risks Are Both Known And Unknown
The last couple of years have seen burgeoning awareness in society of what it means to be transgender as an adult. But now doctors, like those at Ann and Robert H. Lurie Childrens Hospital of Chicago, are helping children who identify as transgender negotiate their journey into adulthood.
For earlier generations of transgender people, the only way to transition physically was through surgery or taking hormones as adults. However, new medical options are allowing transgender children to start the process of transitioning at younger ages.
But doctors tread carefully, navigating medical interventions that carry risks that are both known and unknown.