Estrogen alternatives: Understanding your options

Like your own internal messenger service, hormones trigger growth, menstruation, lactation and a host of other normal bodily functions. For women suffering the short-term effects of menopause (hot flashes, headache, insomnia), there is no better illustration of the havoc hormones can wreak than when they go awry. Those uncomfortable symptoms are caused by the decrease in estrogen production that marks the onset of menopause. In addition to those transitional symptoms, menopause also has some long-term effects, such as increased risk for heart disease and osteoporosis, thinning vaginal tissues and weakened pelvic floor muscles.

For years, women have relied on hormone replacement therapy (HRT) to help offset those changes. But taken unopposed (without progesterone), estrogen can produce some unwanted side effects, such as an increased risk for uterine cancer and blood clots. And some studies suggest estrogen therapy can increase a woman’s chance of developing breast cancer, although many experts say the link is not at all clear. To this day, the estrogen–breast cancer connection continues to be a subject for debate.

Unanswered questions about HRT coupled with side effects, such as vaginal bleeding, breast tenderness and swelling, are enough to make some women think twice about the therapy. But today women have some new alternatives to HRT.

New options Known as SERMs (selective estrogen replacement modulators) or “designer estrogens,” these synthetic hormones seem to promise many of the long-term benefits of traditional HRT without some of the risks. Raloxifene (brand name Evista) and tamoxifen are two types currently available. Somehow, SERMs are able to mimic the beneficial effects of estrogen on the heart and the bones without stimulating estrogen receptors on the breast and, in the case of raloxifene, on the uterine lining. They also don’t cause the breast tenderness and vaginal bleeding sometimes triggered by HRT.

However, like estrogen, both raloxifene and tamoxifen are associated with an increased tendency to form blood clots, and tamoxifen also has been linked to an increased risk for endometrial cancer (cancer of the uterine lining).

Here’s a closer look at how these designer estrogens work in a woman’s body.

Breast tissue. Both raloxifene and tamoxifen have been shown to decrease the risk of breast cancer. This is good news for women who have already had breast cancer and want to reduce the chance for recurrence but still protect their hearts and bones. It also may spell good news for women at high risk for breast cancer, such as those with close family members who have had the disease. In fact, tamoxifen has recently been approved by the FDA for use as a breast cancer-prevention drug.

Bones. In a recent study, raloxifene was shown to increase bone density by 2 percent in postmenopausal women who took the drug for two years—a bit less than with HRT or with alendronate (brand name Fosamax), a nonhormonal drug. And in another study, women who took tamoxifen had fewer fractures of the hip, wrist and spine than those taking a placebo.

The heart. In general, the risk for heart disease is reduced when you lower your LDL (“bad” cholesterol) and triglycerides and raise your HDL (“good” cholesterol). Studies have shown that raloxifene lowers both total and LDL cholesterol without increasing triglycerides. On the other hand, it does nothing to raise HDL cholesterol—something that HRT can accomplish. Although lowering LDL cholesterol in itself is thought to be beneficial, the jury is still out on SERMs’ overall cardioprotective effects. None of the SERM studies have been going on long enough to determine how they will affect heart disease over a period of years or decades.

It may be a few years before we have answers to our questions about SERMs as well as estrogen. Critical information may come from the government-sponsored Women’s Health Initiative, a study of 160,000 women across the country. Until the results are released sometime over the next decade, your best bet is to discuss postmenopausal therapy with your healthcare provider.

(Hot) flash!

Don’t look to SERMs to provide relief from menopausal symptoms, such as hot flashes and irritability. In fact, the designer estrogens may even intensify hot flashes. If you’re looking for short-term relief, traditional HRT may be your best bet. Discuss alternatives with your healthcare provider.