Ask Dr. Roach: Always weigh the risks of HRT


DEAR DR. ROACH >> One has to wonder which is worse for longevity: living a life without sleep, the ticking time bomb of hormone replacement therapy (HRT), or prescription sleep meds?

I am a 71-year old woman who began having insomnia and sleep issues when I went through menopause in my mid-40s. Sleep has been a difficult struggle for over 30 years.  I’ve been through sleep studies, worked with psychologists, listened to sleep tapes and done meditation, as well as taken all sorts of prescriptions for sleep and depression (which I don’t have), melatonin, and even THC derivatives. The list goes on and on. (There is no TV in my bedroom, the mattress is good, and it’s quiet. I eat healthy and exercise regularly, but I’m about 20 pounds overweight.)

I’ve always felt that hormones (lack thereof) were at the root of this problem, but my primary doctor would not prescribe them due to cancer risk and doesn’t want me to taking HRT. But I finally went to a naturopath and was prescribed compounded morning estradiol (.5 mg) and evening progesterone (200 mg). They absolutely help with my sleep. I do not notice any other differences within the female-specific body parts. I have gone on and off HRT, and whenever I’m off, sleep difficulties occur again. They disappear when I go back on HRT.

I’ve read studies that discuss the similarities and dangers whether one takes compounded HRT or prescription strength HRT. I’ve tried not taking the compounded HRT for an extended time, and I am unable to sleep.

— K.C.

Dear K.C. >> The fact that your sleep disturbances reliably get better with treatment, and worse when treatment is stopped, is pretty strong evidence that the sleep disturbance is hormone-related, although I would still recommend women be considered for other sleep disturbance causes, such as restless legs and sleep apnea, which both may occur around menopause. It sounds like you’ve done that.

Treatment of menopausal symptoms with hormones is entirely reasonable, and I feel that many primary care doctors are so concerned about the potential harms of the treatment that they do not consider the whole woman. “The ticking time bomb” is not a fair description of HRT. It is absolutely true that HRT has risks: a roughly 20% increased risk of breast cancer among women taking both estrogen (the studies looked mostly at women taking equine estrogen, not the bioidentical estradiol) and a progestin (again, the studies mostly evaluated women taking medroxyprogesterone and newer formulations, such as natural micronized progesterone). Progestins definitely reduce the increased risk of endometrial cancer that occurs in women who have a uterus and take an estrogen.

Heart disease is probably a bigger concern. Women who start combination HRT in their 60s (or 10 or more years after menopause) are at increased risk for heart attack.

Both your individual breast cancer risk and your heart disease risk can be estimated with tools available to your doctor, and you can get a pretty fair idea of how much additional risk you are accepting if you choose HRT to treat your sleep disturbance. An average woman in her 60s might have about a 1% total increase in the combined risk of blood clot, heart disease and cancer, but some women will have higher or lower risks.

If the risk is unacceptably high, you can certainly work with a sleep medicine expert to find effective treatment.

Contact Dr. Roach

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