Philip Sarrel, MD, Professor Emeritus of Obstetrics, Gynecology, and Reproductive Sciences; Professor Emeritus of Psychiatry
In 2002, The Women's Health Initiative Study (WHI) first reported adverse findings in women aged 50 to 79 who received hormone therapy (HT) in the form of estrogen combined with a progestogen. The women studied had experienced natural menopause. The effect of the initial WHI reports was a marked decline in all menopausal hormone therapies including estrogen-only (ET), a treatment for women who had a surgical menopause.
Prior to 2002, more than 50 years of basic research and clinical studies indicated ET was safe and effective for controlling symptoms and reducing disease risks in women who had a surgical menopause. More than 90% of women were prescribed ET after surgery.
In 2004, WHI investigators reported that women receiving ET after hysterectomy did not show the adverse effects of the hormones used by naturally menopausal women.1 Women who initiated ET between age 50 and 59 showed beneficial effects with only rare occurrences of adverse effects. For example, the women taking estrogen-only therapy did not show the increased risk for breast cancer that was reported in 2002. Nevertheless, a marked decline in the use of ET continued and the positive findings were largely ignored. By 2004, estrogen had become a dirty word.
Now, 16 years later, and after many reports of the safety and efficacy of ET, the WHI investigators are reporting that long-term follow-up of the women who initiated ET between age 50 and 59 shows significant protection from at least 5 major diseases: CHD, breast and colorectal cancer, hip fracture, and stroke. Since 2011, WHI reports also show decreased mortality from CHD, breast cancer, hip fracture, and dementia in women age 50 to 59. Yes, you read that correctly, breast cancer risk and mortality were significantly reduced by the use of ET.2
These findings are underscored in a new WHI publication in Menopause: The Journal of the North American Menopause Society, June 2020. The article highlights the excess medical expenditures incurred in women because they didn’t take estrogen after hysterectomy. The estimate is in the many hundreds of millions of dollars. Of greater concern are the lives shortened, diseases suffered, and symptoms impairing quality of life due to not taking ET. For more than a decade, these problems could have been avoided if women and their healthcare practitioners better understood and appreciated the importance of estrogen in preserving women’s health.
An accompanying Editorial, “Adding up the healthcare costs when estrogen therapy is avoided after hysterectomy” recognizes the significance of the WHI paper in describing estrogen as disease prevention and life-saving. The Editorial expands the WHI medical expenditure estimates by including women who were excluded in the WHI study: women who have estrogen-deficiency symptoms such as hot flashes and women age 50 and younger who experience premature menopause or a hysterectomy and/or removal of their ovaries. In addition to the disease conditions listed in the WHI paper, the Editorial also lists other conditions - diabetes, Alzheimer’s Disease, Parkinson’s Disease, and severe psychiatric depression- found to be increased following hysterectomy and/or removal of the ovaries in women under age 50 who did not use ET. Not to be overlooked are sexual dysfunctions including pain with intercourse, a condition easily and readily treated with replacement estrogen.4
The POINT is: estrogen therapy is highly beneficial and very safe for the women who need it most- surgically-menopausal women age 60 and younger who are having symptoms of estrogen deficiency.
1. Women's Health Initiative, WHI Extension Study 2005-2010, https://www.whi.org/about/SitePages/WHI%20Extension%202005-2010.aspx
2. Women's Health Initiative, WHI Extension Study 2010-2020, https://www.whi.org/about/SitePages/WHI%20Extension%202010-2020.aspx
3. Women's Health Initiative, WHI Findings, https://www.whi.org/about/SitePages/WHI%20Findings.aspx
4. National Library of Medicine, Adding Up the Healthcare Costs When Estrogen Therapy is Avoided After Hysterectomy, https://pubmed.ncbi.nlm.nih.gov/32217889/