Hormone-replacement therapy — yes or no in your 50s, 60s, 70s?

Birth control pills — yes or no in your teens, 20s, 30s, 40s?

In 2002, the abrupt end to a study on post-menopausal women undergoing hormone-replacement therapy, including Hawai'i women, made front-page headlines around the world. The conclusion? HRT can be hazardous to your health, increasing the risk of heart disease and breast cancer.

However, more recently, researchers have added a footnote to that advice: HRT doesn't affect women in their 50s, in the midst of menopause and immediately post-menopause, in the same way it affects women who are a decade and more older.

Meanwhile, birth control pills remain effective and safe — for the most part, that is, unless your personal medical history indicates otherwise.

Confused yet? Join the crowd; even healthcare providers disagree in some cases.

Each choice requires the weighing of potential benefits and complications.

RETHINKING HORMONES

When the $600 million Women's Health Initiative was launched more than a decade ago, it was supposed to solve the dilemma of what to do at menopause and beyond, and nail down whether or not hormone-replacement therapy — HRT — really was the magic bullet many expected it to be to extend youth and well-being.

When early results in 2002 showed just the opposite — a combination of estrogen and progestin in HRT increased the risk of heart disease, breast cancer, strokes, blood clots and memory loss — the news was a staggering blow to the prevailing belief system and the pharmaceutical industry.

By the millions, women tossed out their hormones and went hunting for more natural antidotes to fight the difficulties of hot flashes, mood swings and night sweats. Some found alternatives in herbal products from naturopathic physicians or health food stores (see accompanying story), while others continued to flirt with short-term hormone use to control menopausal symptoms.

Now, a recent analysis of data from a companion study examining the use of estrogen in women with hysterectomies has sparked a reconsideration.

The analysis shows that the risk of heart attacks may actually be lower — and certainly not higher — in women taking estrogen from age 50 to 59, even though a slightly increased risk of stroke and blood clots remains.

As a result, doctors like J. David Curb are now saying it appears safer to take hormones for short-term use to reduce unpleasant symptoms. Replacement hormones are typically used to reduce complications of menopause, including hot flashes.

"People are a little more comfortable that women who have just started menopause can start hormone replacement for symptom relief in the short-term," says Curb. Curb is principal investigator for the Women's Health Initiative study site in Hawai'i — one of 40 research sites nationwide that participate in the monitoring of women's health issues, including hormone-replacement therapy.

NEW DATA REVEALED

"The controversy that has been out there is, 'Would the results have been different if these were younger women starting hormones at menopause, rather than 15 years later?' " says reproductive endocrinologist Dr. Bruce Kessel. "There is now data coming out that sort of supports that hypothesis."

Kessel is an associate professor in the Department of Obstetrics and Gynecology and Women's Health at the University of Hawai'i medical school, and past president of the North American Menopause Society.

As Kessel points out, many women in the Women's Health Initiative were many years past menopause, with the average age being 63.

He also says that even with the larger, older group of women studied, the increased risk based on HRT use is "small" — translating to eight additional breast cancers per 10,000 women.

But Curb, a professor of geriatric medicine at the University of Hawai'i, which headquartered the Hawai'i study segment, reiterates the study's headline-making findings: Risks rise for replacement hormones taken over time.

"The risks are there, and they're serious," he says. "There's no significant benefit to a woman of any age (after menopause) taking hormones for any length of time. If you look at the overall picture, there's not a real benefit."

Hawaiian singer Nalani Olds discovered those risks herself. After joining the study in her 50s because she wanted to help future generations of women, Olds quit her combination hormones before the study ended.

"I had two scares of possible breast cancer, so I stopped on my own," she says.

Though the lumps weren't malignant, the concerns were enough. "I just decided that was it," says Olds. "I had never had lumps before. So the day I walked out of having the biopsy, I threw the pills away."

Candace Hemmy made a contrasting choice. She knows what the studies have said about hormones and their potential risks. She's also intimately familiar with their benefits, and has chosen to use HRT.

"For me, personally, I just can't live without them," says the 61-year-old who gardens, lays patios, rides horses, paints houses and feels perfectly at ease in a two-piece bathing suit.

"I don't feel my age," she says. "I feel like I'm in my late 40s or early 50s. I've had a lot of trouble with hot flashes and they've never gone away, so you couldn't pay me enough money not to take hormones. There's not enough proof one way or another (about their dangers) and, for me, quality of life is a really big deal. I really don't intend to be old."

DIFFERENT EFFECTS

As the varying experience of local women who tried hormone therapy shows, there is no one-size-fits-all recommendation on HRT.

Kessel argues that physicians should give women actual numbers from the Women's Health Initiative study so they can properly evaluate their risks when considering hormones.

"The risk is smaller than how it was portrayed at the time this study came out," he says. "Everyone has to make a personal decision based on what risks they want to take."

Sandi Sumbry has done just that. The 62-year-old retired Department of Education special education teacher and administrator joined the WHI study at 53 and remained in the program for nine years as part of the estrogen-only study. These were some of the best years of her life, she says.

"I was a happy camper when I got onto the hormones," says Sumbry, who had a hysterectomy at 29 and had been in menopause ever since, feeling unhappy, battling weight, having problems with her memory and losing interest in a sexual life.

Now, despite doctors' recommendations that she dispense with hormones, Sumbry takes an over-the-counter estrogen medication called Extrofam that a medical professional recommended, and has continued her feeling of well-being, although she continues to struggle with short-term memory problems.

"I've lost close to 100 pounds," she says. "It's just like a weight has been lifted off me. It's a major turn-around."

REVIEW OPTIONS

Though hormone use plummeted since the first findings of the Women's Health Initiative were released five years ago, there are those who may still be wrestling with their choices.

Hawai'i study coordinator Josephine Nicolo, who has followed the 265 Hawai'i women in the hormone study since it began, is especially concerned about those who haven't been following the information — or are confused by it.

"I'm now more concerned with women out there who don't know what the results are," she says.

Physicians suggest that any woman, of any age, who is pondering the use of hormones for any reason, consult with her doctor.

That includes the decision on whether or not to use hormone-replacement therapy to manage uncomfortable hot flashes, or whether or not to use low-dose estrogen and progestin birth control pills, or the higher-dose estrogen birth control patch, or birth control pills that virtually eliminate menstruation altogether.

Only in this one-on-one discussion can appropriate decisions be made, weighing individual risk, family health profile, and personal lifestyle.

If heart disease, breast cancer or blood clots run in a woman's family, for instance, hormones are not recommended.

Estrogen is particularly worrisome if a woman is a smoker.

"Birth control pills in younger women are very safe," says Kessel. "In healthy women, we're using birth control pills all the way up to menopause. But in women over the age of 35 who smoke cigarettes or have hypertension, there are increased risks of heart attack, strokes and blood clots in the legs."

Even if a younger woman has no risk factors, University of Hawai'i student medical center physician Dr. Jennifer Frank recommends birth control pills with the lowest dosage of estrogen — 20 micrograms. Since the birth control pill was first approved in the 1960s, estrogen dosage has dropped from around 80 micrograms in the earliest pills, to 50 micrograms and now 20, she notes.

That's also true if a woman takes birth control pills for a reason other than contraception, she says. "People take them for different reasons, whether it's contraception or controlling heavy periods, or for (easing) migraines."

Frank has patients in her private practice that have been on the pill 20 or more years, and says there appears to be no reason to simply stop unless there are new health issues.

"Generally, if you're on birth control pills, you're seeing your physician every year, so you should be discussing it," she says. "And there may be new information. That's one advantage of seeing your physician at least annually — to go over 'Do you still want to be on this?' 'Are you still taking it?' and 'Is it safe to be on this?' "

Even though she believes estrogen has benefits for her, Sumbry does just that.

"I'll give it a year," she says of the over-the-counter medication she takes. "And then I'll go talk to her again."

Reach Beverly Creamer at bcreamer@honoluluadvertiser.com.