STORY BY

Nora K. Shire

A woman lives half her life deprived of hormones, putting her at risk for osteoporosis, heart disease and dementia.

Hormone replacement therapy (HRT), which has been the answer to many menopausal symptoms, is now being linked to dementia. What does this most recent report mean for women?

“We have to be very careful in jumping to conclusions because this study looked at one estrogen preparation, Prempro, and at one particular dosage,” observes geriatrics specialist Dr. Robert S. Tan of the University of Texas Medical School at Houston. “The message is that we are not clear of the relationship between HRT and the brain, and there are other data to consider.”

Landmark study finds dementia risk

The Women’s Health Initiative (WHI) Memory Study, part of a larger hormone therapy trial, was designed to determine the effects of hormone therapy on the development and progression of dementia symptoms in post-menopausal women. The study hypothesized that the development of symptoms associated with dementia will be delayed in women who are on hormone therapy as opposed to a placebo.

HRT risks

Of the 40 WHI Clinical Centers nationwide, 39 participated with 4,532 women ages 65-79 being analyzed. The study participants were on Prempro for an average of four years.

The study results appeared in May 2003 in the Journal of the American Medical Association and reported a heightened risk of dementia. The study also found that the therapy offered no protection against the development of mild cognitive impairment, a form of cognitive decline less severe than dementia.

Old question, new answer

Tan, an associate professor of geriatrics and gerontology in the Department of Family Practice and Community Medicine at the UT Medical School at Houston and medical director of the Garden Terrace Alzheimer’s Center, is no stranger to this question of HRT and its link to dementia.

Several years ago, he and a colleague authored a report for Clinical Geriatrics on “Cognition and Estrogens in the Elderly Woman.” All the animal studies at that time were reflecting that estrogens had the ability to change cognition. “Early studies showed that there was a protection for the brain because estrogen interacted with nerve cells and increased transmission across the brain,” he explains.

Gambling with your age

Dr. Shahla Nader is wondering if some of the study subjects in the most recent report had mini-strokes so that the dementia has a vascular basis.

“My younger patients come in asking for hormones to help boost their memory and their concentration,” she says. “Based on my clinical experience, hormones work for the short term. The results of this study did surprise me a little because what I experience in my practice is not what this study says—except that most of my patients are under 65.” Nader is a professor in both the Departments of Obstetrics, Gynecology and Reproductive Science and Internal Medicine.

“I do not believe that this study is going to alter women’s decision to go on hormones in early menopause. That will be determined by their symptoms,” says Nader.

None of Nader’s patients have phoned since this news was announced, unlike last summer when most of her patients were calling after the Women’s Health Initiative stopped a portion of the study because Prempro, (combined estrogen and progestin) slightly increased the risk of heart attack, breast cancer and stroke in women ages 50 – 79.

Placing bets

Many women decided to continue taking hormones because it was believed in part that HRT improved mental function by effecting nerve cells. There were studies on animals, tissue analysis, and women. “One of those studies involved 8,877 women, and it suggested that the increase in Alzheimer’s disease in older women may be due to estrogen deficiency,” says Tan.

This deprivation of hormones is one of Tan’s concerns. “Today, life expectancy on average for women is 77. If women begin menopause in their early 40s and live to expectancy, their bodies live for almost 40 years without hormones,” he explains. “This is why there are changes in bone health, cardiovascular health as well as the brain putting some women at higher risk for osteoporosis, heart disease and dementia.”

Alternatives to HRT, hedging your bet

So, what should women do about their long-term health while they wait for more studies and all this data to be examined?

• “There are some good medications approved for osteoporosis – Fosamax and Atenolol. They just affect bone,” Nader says.
• For hot flashes, there is a drug for high blood pressure, Clonidine, which comes in a patch. She says it is helping 50 percent of those who try it.
• Other possibilities are the SSRIs (serotonin re-uptake inhibitors) such as Effexor, Prozac, Paxil, and Zoloft.
• She also tells her patients about Black Cohosh, an herb, but she does not know what the long-term effects are.

Tan tells his patients to keep their cardiovascular risks low.

• Maintain and control blood pressure and diabetes, which can lead to a stroke, a contributing factor to Alzheimer’s.
• Starting in young adulthood, eat a good diet and exercise, which increases your blood circulation.

“One positive thing that has come out of this news is the need for doctors to talk to their patients more and explain medications and the side effects in detail,” says Tan. “Now, hopefully, they will talk about the pros and cons plus the risks and benefits as they prescribe a new drug.”

Last Updated: 6-30-2003

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