Kathy Martin & JoAnn Manson’s excellent review The Patient with Menopause Symptoms stresses the importance of not initiating oral hormone therapy OHT many years after menopause; and the grave doubts about continuing Wyeth HT (premarin +- progestin) long after age 60yrears ie for much more than 12 – 15years. .
But while they emphasise the benefits of progesterone over synthetic progestins; and of starting HT for menopause symptoms early rather than late (the timing hypothesis), and the numerous greater risks of oral estrogen therapy OET (versus parenteral estrogen replacement ERT), they do not point out the latter risks in their abstract,
the far fewer benefits of oral ET (pop-a-pill convenience; marginally better HDL/LDL ) – ie two benefits;
physiological parenteral ERT : less adverse effects than OET :.- ie at least a dozen extra benefits parenterally versus orally:..
risk of OET on SHBG; triglyceride; CRP; fibrinogen; factor VII; PAI1; testosterone, uterus; endometrium; breast density; collagen dissolution );
and thus greater risk of OET (compared to parenteral ERT) overall for :
fluid retention, hypertension, deep vein thrombosis, coronary artery and cerebrovascular thrombosis, dysrhythmia, heart failure (Mercuro 1999; Regitz-Zagrosek 2007); biliary disease, libido, depression, adiposity, and thus urinary incontinence, insulin-glucose intolerance, breast cancer ; and skeletal muscle frailty.
This Harvard review thus bypasses the prime reasons for not extrapolating the uniquely valuable WHI Womens’ Health Initiative -notwithstandng it was misguidedly planned, gave overhasty initial wrong statistics, and caused foolish sometimes hysterical generalizations (“a thalidomide disaster“).
The WHI was not about menopause – it tested mostly elderly obese “asymptomatic” but already high-risk Caucasian women on oral HT with xenohormones- premarin, provera – when xenohormones have for good reason no longer been used in any other branch of endocrinology.
Why should older women be treated any differently for the commonest acquired endocrine deficiency of all, that affects 100% of womankind? Especially when postgonadopausal men (and women) have already for over a decade been advised to use solely physiological parenteral human HRT?
What the WHI was about was assessing the benefits of appropriate medium term convenience sex hormone therapy . As in all other endocrinology -restoring physiological hormone balance – the aging woman (and man) requires appropriate balanced HRT (preferably parenteral testosterone +- ERT+- progesterone) started early and permanently for permanent multisystem protection against CVD; cancers; fractures; arthritis; depression; urinary incontinence; loss of sexuality; dementia; and thus against premature devastating disability and death.
The small under-sixties cohort of the WHI actually confirmed these multiple benefits for up to almost ten years for solo oral premarin- but ten years is not long term since women can now live the second (and potentially the best) half of their lives – up to sixty years- post menopause.
And it is common cause that many benefits of HRT eg on bone, skin, sexuality etc are lost as soon as HRT stops.
So it is never too late to start and never too long to continue appropriate HRT under supervision.
See other recent reviews of appropriate HRT .