African-American Women, Menopause, and Hormone Therapy - The Facts

Menopause is a natural change in a women's life and this seems very clear to African American women. The Study of Women's Health Across the Nation (SWAN) found that African-American women view menopause more positively than white or Asian women. Although this is good news the bad news is, as a result, African American women may be less likely to discuss menopause related symptoms with their doctor. African American women should discuss their menopausal symptoms with their doctor- there is so much to know and so much has changed over the years for treating menopause especially the use of Hormone Therapy (HT).

The Women's Health Initiative and Hormone Therapy

The Women's Health Initiative (WHI), a 15-year study involving over 161,000 women that focuses on strategies for preventing heart disease, breast and colorectal cancer and fracture in postmenopausal women, has made some strong clinically valid claims about hormone therapy. Results from the WHI Trial found that Hormone Therapy (HT) which has long been the medical treatment of choice for managing menopausal symptoms could be harmful for women. The facts from the WHI study are very clear, HT is not for everyone. HT is linked to stroke, breast cancer and heart disease for some women. To empower women to make the right choices about HT and management of menopausal symptoms it is critical to understand what menopause is, it's symptoms, and treatment that can be used safely based on one's personal health history and risk status.

What is Menopause?

Menopause (also called the "change of life") is a normal part of a woman's aging. Menopause marks the time period when women are no longer able to conceive children. For some women the time it begins is usually at age 47, with the final menstrual period usually around age 51. However, some women experience it earlier. Menopause occurs over a period of time because the levels of a hormone called estrogen, which is produced by the ovaries, begin slowly decrease. Menopause is typically completed when a woman has not had a period for 12 months in a row.

Menopause will occur immediately, for example, if a woman has both ovaries removed (sometimes done as part of a hysterectomy). This is called "surgical" menopause. Another way women might enter menopause is if her ovaries are damaged by cancer treatment.

What are the Symptoms of Menopause?

The symptoms of menopause include:

• Hot flashes
• Night sweats, or perspiring excessively,
• Sleep difficulties
• Vaginal dryness.

Treating Menopause

Menopause is a natural process for women as they age and treating it is unique for each woman affected. Treatment can begin with a healthier lifestyle that includes, eating a healthy diet and exercising. Some women may not need any special treatment for menopause. But some women may have menopause symptoms that need treatment. Several treatments are available so it is best to talk about the treatments with your doctor so you can choose what's best for you. There is no one treatment that is good for all women. Sometimes menopause symptoms go away over time without treatment. Some women may consider alternative treatments or hormone therapy (HT). If a woman is considering HT it must be used properly, under the supervision of a doctor. Hormone therapy is the only therapy that is approved by the government for treating more difficult hot flashes and vaginal dryness. However, according to the WHI, hormone therapy should not be taken to prevent heart disease. These products are approved therapies for relief from moderate to severe hot flashes and symptoms. The Food and Drug Administration (FDA) recommends that hormone therapy be used at the lowest doses for the shortest duration needed to achieve treatment goals. Postmenopausal women who use or are considering using hormone therapy should discuss the possible benefits and risks to them with their physicians.

Estrogen-alone and Breast Cancer

Long-term use of hormone therapy (10 years or more) has been associated with a more than 50% increase in breast cancer risk among black women, states, Lynn Rosenberg, Sc.D., of the Slone Epidemiology Center at Boston University. Dr. Rosenberg reported in the Archives of Internal Medicine that previous studies included mainly white women, and few examined hormone use and breast cancer risk in black women specifically. The study included more than 23,000 black women ages 40 or older enrolled in the Black Women's Health Study, which started in 1995. Data on hormone use, breast cancer risk factors, and the occurrence of breast cancer were collected via questionnaires administered every two years through 2003.

Results of the Women's Health Initiative, reported in the Journal of the American Medical Association in 2004, indicated an 81% increase in breast cancer risk for women on long-term estrogen combined with progestin. The study found no increased risk associated with estrogen alone. Other studies, most notably the Million Women Study, which presented results in The Lancet in 2003, found an elevated breast cancer risk associated with estrogen alone as well.

Prior to the release of the latest findings, hormone therapy had been the common treatment in the United States for treating menopausal symptoms. It was believed that hormone therapy relieved hot flashes and vaginal dryness and prevented many postmenopausal conditions, such as osteoporosis and heart disease. However, in July 2002, the Women's Health released a report that hormone replacement therapy actually caused more health risks than benefits for women in the clinical trial. As a result doctors stopped routine prescriptions for HT treatment.

What Options Exist for Women?

There are safer options for treating heart disease, osteoporosis, and the symptoms of menopause. The options include:

• Follow a heart-healthy lifestyle- Women's risks of heart disease increase with age which can be right at the time menopause has begun. So follow a heart healthy lifestyle which includes not smoking, eating a variety of foods low in saturated fat and cholesterol, limiting salt and alcohol intake, maintaining a healthy weight, and being physically active. Sometimes, drugs also are needed to control high blood pressure, high blood cholesterol, or diabetes. For those who already have heart disease, adhere to your medications, maintain a healthier lifestyle and maintain your doctor appointments
• Keep your bones strong- The risk of osteoporosis increases as women get older. To help prevent osteoporosis, include calcium and vitamin D in your diet and make sure you get some exposure to sunlight to help the body make vitamin D. Also, do weight-bearing exercises. Osteoporosis is treated by stopping bone loss which women can indeed do through lifestyle changes and sometimes medication.
• Talk to Your Doctor about Alternatives Therapies for Treating Menopausal Symptoms- Alternative therapies can include botanical products that contain or act like estrogens. Examples of botanicals are soy and herbs, such as black cohosh. According to the WHI, research has stated conflicting results on the safety and effectiveness of botanical products. Lifestyle changes can offer some relief from hot flashes and other menopausal symptoms, especially those that are mildly to moderately bad. For instance, dress to avoid being too warm; reduce stress; avoid spicy foods, alcohol, and caffeine; get enough sleep; and be physically active.

Empowerment Points

Each woman should discuss her risk-benefit concern with her physician to make the best decision prior to starting HT. Every woman taking HT needs to routinely reevaluate her prescription with her physician and decide, based on individual risk factors and symptoms, to continue therapy or consider alternative treatments.

Resources:

"HRT Cancer Risk Holds True for Black Women", By Jeff Minerd, MedPage Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
April 11, 2006

Boston University School of Medicine, Black Women's Health Study: http://www.bu.edu/bwhs/

Mayo Health Clinic: www.mayoclinic.com

Women's Health Initiative: www.whi.org

Reviewer:
David P. Pryor, MD, MPH