F acts About

Menopausal hormone therapy once seemed the answer for many of the conditions

women face as they age. It was thought that hormone therapy could ward off heart 

disease, osteoporosis, and cancer, while improving women’s quality of life.

But beginning in July 2002, findings emerged from clinical trials that showed this was not

so. In fact, long-term use of hormone therapy poses serious risks and may increase the risk

of heart attack and stroke.This fact sheet discusses those findings and gives an overview of

such topics as menopause, hormone therapy, and alternative treatments for the symptoms

of menopause and the various health risks that come in its wake. It also provides a list of

sources you can contact for more information.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Heart, Lung, and Blood Institute

Menopausal

Hormone 

Therapy
Menopause and Hormone

Therapy

As you age, significant internal

changes take place that affect your

production of the two female 

hormones, estrogen and progesterone.The hormones, which are

important in regulating the menstrual cycle and having a successful 

pregnancy, are produced by the

ovaries, two small oval-shaped

organs found on either side of 

the uterus.

During the years just before

menopause, known as perimenopause, your ovaries begin 

to shrink. Levels of estrogen 

and progesterone fluctuate as 

your ovaries try to keep up 

hormone production.You can 

have irregular menstrual cycles,

along with unpredictable episodes

of heavy bleeding during a period.

Perimenopause usually lasts 

several years.

Eventually, your periods stop.

Menopause marks the time 

of your last menstrual period.

It is not considered the last until

you have been period-free for 

1 year without being ill, pregnant,

breast-feeding, or using certain

medicines, all of which also can

cause menstrual cycles to cease.

There should be no bleeding,

even spotting, during that year.

Natural menopause usually happens sometime between the ages

of 45 and 54.

You also can undergo menopause

as the result of surgery.A surgical

procedure, called a hysterectomy,

removes the uterus.This surgery

puts an end to your menstrual

cycle but does not affect

menopause, which still occurs 

naturally.

You go through menopause

immediately if both of your

ovaries are also removed 

at surgery.Whether you go

through menopause naturally 

2

Box 1

Estrogen pills:

Brand Generic

Premarin conjugated equine 

estrogens

Cenestin synthethic conjugated 

estrogens

Estratab esterified estrogens

Menest esterified estrogens

Ortho-Est estropipate (piperazine 

estrone sulfate)

Ogen estropipate (piperazine 

estrone sulfate)

Estrace micronized 17-betaestradiol

Estinyl ethinyl estradiol

Progestin pills:

Brand Generic

Cycrin medroxyprogesterone 

acetate

Provera medroxyprogesterone 

acetate

Aygestin norethindrone acetate

Norlutate norethindrone acetate

Prometrium progesterone USP 

(in peanut oil)

Estrogen-plus-progestin pills:

Brand Generic

Premphase conjugated equine 

estrogens and 

medroxyprogesterone 

acetate

Prempro conjugated equine 

estrogens and 

medroxyprogesterone 

acetate

Femhrt ethinylestradiol and 

norethindrone acetate

Activella 17-beta-estradiol and 

norethindrone acetate

Ortho-Prefest 17-beta-estradiol and 

norgestimate

Examples of Oral Estrogen and Estrogen/Progestin Products
or surgically, symptoms can result

as your body adjusts to the drop 

in estrogen levels.These symptoms

vary greatly—one woman may 

go through menopause with few

symptoms, while another has 

difficulty. Symptoms may last for 

several months or years, or persist.

The most common symptoms are

hot flashes or flushes, night sweats,

and sleep disturbances. (A hot flash

is a feeling of heat in your face

and over the surface of your body,

which may cause the skin to

appear flushed or red as blood 

vessels expand. It can be followed

by sweating and shivering. Hot

flashes that occur during sleep are

called night sweats.) But the drop

in estrogen also can contribute to

changes in the vaginal and urinary

tracts, which can cause painful

intercourse and urinary infections.

To relieve the symptoms of

menopause, doctors may prescribe

hormone therapy.This can involve

the use of either estrogen alone 

or with another hormone called

progesterone, or progestin in its

synthetic form (See Box 1.). The

two hormones normally help to

regulate a woman’s menstrual cycle.

Progestin is added to estrogen to

prevent the overgrowth (or hyperplasia) of cells in the lining of the

uterus. This overgrowth can lead 

to uterine cancer. If you haven’t

had a hysterectomy, you’ll receive

estrogen plus progesterone or 

a progestin; if you have had a 

hysterectomy, you’ll receive only

estrogen. Hormones may be taken

daily (continuous use) or on only

certain days of the month (cyclic

use). (See Box 3.)

They also can be taken in several

ways, including orally, through 

a patch on the skin, as a cream 

or gel, or with an IUD (intrauterine device) or vaginal ring (See

Box 2.). How the therapy is taken

can depend on its purpose. For

instance, a vaginal estrogen ring 

or cream can ease vaginal dryness,

urinary leakage, or vaginal or urinary infections, but does not

relieve hot flashes.

Hormone therapy may cause side

effects, such as bleeding, bloating,

breast tenderness or enlargement,

headaches, mood changes, and

nausea. Further, side effects vary 

by how the hormone is taken. For

instance, a patch may cause irritation at the site where it’s applied.

There also are nonhormonal

approaches to easing the symptoms of menopause. Box 4 offers 

a list of some of these alternatives.

Facts About Menopausal Hormone Therapy

3

Box 2

Estrogen products:

Type Brand Generic

Vaginal Cream Estrace micronized 17-beta-estradiol

Ortho Dienestrol dienestrol

Ogen estropipate (piperazine estrone sulfate)

Premarin conjugated equine estrogens

Vaginal Tablet Vagifem estradiol hemihydrate

Vaginal Ring Estring micronized 17-beta-estradiol

Femring estradiol acetate

Skin Patch Alora micronized 17-beta-estradiol

Climara micronized 17-beta-estradiol

Esclim micronized 17-beta-estradiol

Estraderm micronized 17-beta-estradiol

Vivelle micronized 17-beta-estradiol

Vivelle-Dot micronized 17-beta-estradiol

Skin Gel Estrogel estradiol gel

Skin Cream Estrasorb estradiol topical emulsion

Progestin products:

Vaginal Gel Crinone progesterone

IUD Mirena levonorgestrel

Estrogen plus progestin products:

Skin Patch Combipatch 17-beta-estradiol and norethindrone 

acetate

Ortho-Prefest 17-beta-estradiol and norgestimate

Examples of Gels, Creams, Patches, and Other

Hormone Products

Box 3

Cyclic or sequential

■ Estrogen every day

■ Progesterone or progestin added 

for 10–14 days out of every 

4 weeks

Continuous-combined

■ Estrogen and progestin daily 

without a break

Hormone Therapy

Schedules
4

Box 4

You may want to consider alternatives to hormone therapy 

to ease menopausal symptoms. The list below includes 

some locally applied hormone products, which might 

not carry the same risks as those that deliver medication

throughout the body.

Be aware that some of these remedies are regulated by the

Federal Government as dietary supplements, and as such do

not undergo premarket approval and may not have data showing them to be safe and effective (See Box 5.). Talk with your

doctor or other health care provider about the best treatment

for you for each symptom.

Positive moves you can make to feel better are related to

adopting a healthy lifestyle—don’t smoke, eat a variety of

foods low in saturated fat, trans fat, and cholesterol and moderate in total fat. Include grains, especially whole grains and a

variety of dark green leafy vegetables, deeply colored fruit, and

dry beans and peas in your eating plan. Also, maintain a

healthy weight, and be physically active for at least 30 minutes

most days of the week, preferably daily. Alternatives include:

For Postmenopausal Conditions:

Osteoporosis

■ See Box 13 for lifestyle behaviors to protect bone density.

■ Designer estrogen raloxifene (Evista), which preserves bone

density and prevents fractures (although not hip fractures).

■ Bisphosphonates Actonel or Fosamax, which preserve

bone density, prevent fractures, and can reverse bone loss

■ Teraparatide (parathyroid hormone), which may reverse

bone loss

■ Calcitonin (a nasal spray or injectable), used to treat women

who have osteoporosis, which may prevent some fractures

(This drug is not approved for preventing osteoporosis.).

■ Note: Phytoestrogens (see hot flashes) have not been shown

to prevent osteoporosis or reduce the risk of fractures.

Heart disease

■ Lifestyle behaviors, including:

■ Following a healthy eating plan that includes a variety of

foods low in saturated fat, trans fat, cholesterol and

moderate in total fat, and rich in fruits and vegetables

■ Choosing and preparing foods with less salt

■ Not smoking

■ Maintaining a healthy weight

■ Being physically active

■ Preventing and controlling high blood pressure

■ Preventing and controlling high blood cholesterol

■ Managing diabetes

■ Taking prescribed medication to control heart disease

For Menopausal Symptoms:

Hot flashes

■ Lifestyle changes. These include dressing and eating 

to avoid being too warm, sleeping in a cool room, and

reducing stress. Avoid spicy foods and caffeine. Try deep

breathing and stress reduction techniques, including meditation and other relaxation methods.

■ Phytoestrogens. Soybeans and some soy-based 

foods contain phytoestrogens, which are estrogen-like

compounds. Soy phytoestrogens can be consumed

through foods or supplements. Soy food products include

tofu, tempeh, soy milk, and soy nuts. Other plant sources 

of phytoestrogens include such botanicals such as black

cohosh, wild yam, dong quai, red clover, and valerian root.

However, there is no solid evidence that the phytoestrogens

in soybeans, soy-based foods, other plant sources, or

dietary supplements really do relieve hot flashes. Further,

the risks of taking the more concentrated forms of soy 

phytoestrogens, such as pills and powders, are not known.

Dietary supplements with phytoestrogens do not have 

to meet the same quality standards as do drugs. Little is

known about the safety or efficacy of these products. 

■ Antidepressants, such as Effexor, Paxil, and Prozac. 

These medications have been proved moderately effective

in clinical trials.

Vaginal dryness

■ Vaginal lubricants and moisturizers (available over the

counter).

■ Products that release estrogen locally (such as vaginal

creams, a vaginal suppository, called Vagifem, and a plastic

ring, called an Estring)—these are used for more severe

dryness. The ring, which must be changed every 3 months,

contains a low dose of estrogen and may not protect

against osteoporosis. 

Mood swings

■ Lifestyle behaviors, including getting enough sleep and

being physically active

■ Relaxation exercises

■ Antidepressant or anti-anxiety drugs

Insomnia

■ Over-the-counter sleep aids

■ Milk products, such as a glass of milk or cup of yogurt—

choose low-fat or fat-free varieties—consumed at bedtime

■ Do physical activity in the morning or early afternoon—

exercising later in the day may increase wakefulness

■ Hot shower or bath immediately before going to bed

Memory problems

■ Mental exercises

■ Lifestyle behaviors, especially getting enough sleep and

being physically active

Alternatives to Hormone Therapy To Help Prevent

Postmenopausal Conditions and Relieve Menopausal Symptoms
Postmenopausal Use

Menopause may cause other

changes that produce no symptoms yet affect your health. For

instance, after menopause, women’s

rate of bone loss increases.The

increased rate can lead to osteoporosis, which may in turn increase

the risk of bone fractures.The risk

of heart disease increases with age,

but is not clearly tied to the

menopause.

Through the years, studies were

finding evidence that estrogen

might help with some of these

postmenopausal health risks—

especially heart disease and 

osteoporosis.With more than 

40 million American women over

age 50, the promise seemed great.

Although many women think 

it is a “man’s disease,” heart disease

is the leading killer of American

women.Women typically develop

it about 10 years later than men.

Furthermore, women are more

prone to osteoporosis than men.

Menopause is a time of increased

bone loss. Bone is living tissue.

Old bone is continuously being

broken down and new bone

formed in its place.With

menopause, bone loss is greater

and, if not enough new bone is

made, the result can be weakened

bones and osteoporosis, which

increases the risk of breaks. One 

of every two women over age 50

will have an osteoporosis-related

fracture during her life.

Many scientists believed these

increased health risks were linked

to the postmenopausal drop in

estrogen produced by the ovaries

and that replacing estrogen would

help protect against the diseases.

Facts About Menopausal Hormone Therapy

5

Box 5

If you use dietary supplements to try to

ease hot flashes and other menopausal

symptoms, be aware that these products

do not require U.S. Food and Drug

Administration (FDA) review or approval

prior to their marketing. Because they are

considered “dietary supplements,” they

are covered by less stringent regulations

than those involving prescription drugs.

Manufacturers are responsible for establishing that they are safe and efficacious.

They can be sold without the review or

approval of the FDA. Thus, the quality of

these products is not often known. It is

important to tell your health care provider

that you are taking such remedies.

The products sold over the counter as dietary supplements may be in pill or

capsule form or as fortified items, such as candy bars. The possible effects 

of the products are not known. Some of the substances they contain are being

studied. For example, soy contains phytoestrogens, which are being studied 

to see if they have the same risks and benefits as estrogen.

Some of this research is being supported by the Office of Dietary Supplements,

the National Center for Complementary and Alternative Medicine, the National

Institute on Aging, and other units of the NIH.

Until more is known about these substances, you should use them with 

caution. Also, as noted, tell your health care provider if you take a dietary 

supplement or if you increase your intake of dietary phytoestrogens. There

may be dangerous side effects. An increase in the level of estrogens in your

body could interfere with other prescription medications you are taking or even

cause an overdose.

About Dietary Supplements
Early Findings

Early studies seemed to support

hormone therapy’s ability to 

protect women against the 

diseases that tend to occur after

menopause. For instance, research

showed that the treatment does

prevent osteoporosis. However,

other findings lacked evidence 

or were unclear. No large clinical

trials had proved that hormone

therapy prevents heart disease 

or fractures.Answers also were

needed about other possible effects

of long-term use of hormones,

especially on such conditions as

breast and colorectal cancers.

Further, prior research on

menopausal hormone therapy’s

effect on heart disease had

involved mainly observational

studies, which can indicate possible

relationships between behaviors or

treatments and disease, but cannot

establish a cause-and-effect tie.

(See Box 6 for more about types

of studies.)

There were some clinical trials,

considered the “gold standard”

in establishing a cause-and-effect

connection between a behavior 

or treatment and a disease, but

most looked at the therapy’s effects

on the risk factors or predictors 

of various diseases.

6

Box 6

Medical researchers conduct many types of studies. The reason is that the

studies yield different kinds of information. Together, the studies help scientists understand health and disease, and how to educate people so they can

lead healthier lives.

Three main types are: observational studies, clinical trials, and community 

prevention studies. Each type is discussed briefly below:

■ Observational studies follow women’s medical and lifestyle practices

but do not intervene. Such studies can turn up possible relationships

between various factors and health or illness. Those factors include

population traits, ethnicity, genetic attributes, and behaviors. For

instance, researchers can track women who do and do not take

menopausal hormone therapy. The results may show that the hormone

users have fewer heart attacks. But the results cannot conclude that

hormone therapy reduces heart disease risk. Other factors may have

played a part. For instance, compared with women who do not use hormone therapy, those who do are often healthier, have a higher education

level, better access to medical care, and are more willing to follow a prescribed therapy.

■ Clinical trials control and compare specific medical interventions, such

as the use of menopausal hormone therapy. Women on an intervention

are compared with those who do not receive the treatment. Researchers

try to control all of the experimental conditions so that any difference

between the two groups can be tied to the intervention.

The most rigorous of these investigations is the randomized, controlled,

double-blinded clinical trial. Women are randomly assigned to the study

groups and, in a drug trial for instance, neither the women nor the

researchers typically know who is receiving an active drug or a placebo.

Further, on average women in the two groups are similar in age, education, health, and other factors that may affect the results upon entering

the trial. These trials are considered to be the “gold standard”

studies because they yield the

most reliable information.

Clinical trials are often done to test

a possible relationship uncovered

in an observational study. The trials help establish a causal link

between a treatment and a specific

medical outcome, such as fewer

heart attacks.

■ Community prevention studies

explore ways to encourage people 

to adopt healthier behaviors.

What We Learn From Different Types of Studies
Two important clinical trials 

were the “Postmenopausal

Estrogen/Progestin Interventions

Trial” (PEPI) and the “Heart and

Estrogen-Progestin Replacement

Study” (HERS).

PEPI looked at the effect of 

estrogen-alone and combination

therapies on key heart disease risk

factors and bone mass. It found

generally positive results, including

a reduction by both types of therapy of “bad” LDL cholesterol and

an increase of “good” HDL 

cholesterol. (LDL, or low density

lipoprotein, carries cholesterol to

tissues, while HDL, or high density

lipoprotein, carries it away,aiding

in its removal from the body.) 

HERS tested whether estrogen

plus progestin would prevent 

a second heart attack or other

coronary event. It found no

reduction in risk from such 

hormone therapy over 4 years.

In fact, the therapy increased

women’s risk for a heart attack

during the first year of hormone

use.The risk declined thereafter.

HERS also found that the therapy

caused an increase in blood clots

in the legs and lungs.The “HERS

Follow-Up Study,” which tracked

the participants for about 3 more

years, found no lasting decrease in

heart disease from estrogen-plusprogestin therapy.

The Women’s Health

Initiative

In 1991, the National Heart,

Lung, and Blood Institute

(NHLBI) and other units of 

the National Institutes of Health

(NIH) launched the Women’s

Health Initiative (WHI), one of

the largest studies of its kind ever

undertaken in the United States.

Facts About Menopausal Hormone Therapy

7

Box 7

Estrogen Alone Estrogen Plus Progestin

Participants 10,739 16,608

Race

White 75% 84%

Black 15% 7%

Hispanic 6% 5%

Average age 64 63

50–59 31% 33%

60–69 45% 45%

70–79 24% 23%

Hormone use

Ever 35% 20%

At enrollment 13% 6%

BMI

Normal 21% 31%

Overweight 35% 35%

Obese 45% 34%

Smoking

Ever 38% 40%

At enrollment 10% 11%

Treated for high blood pressure

48% 36%

*Percentages are rounded

Altogether, the WHI involved about 161,000 healthy postmenopausal women.

Here’s the breakdown of participants in each study:

WHI In Profile*
8

Box 8

The two WHI studies’ findings should not be compared directly. Women in the estrogen-alone study began the trial with a higher

risk for cardiovascular disease than those in the estrogen-plus-progestin study. They were more likely to have such heart disease

risk factors as high blood pressure, high blood cholesterol, diabetes, and obesity.

Also, as you read the percentages below, bear in mind that the WHI involved healthy women, and only a small number of them

had either a negative or positive effect from either hormone therapy. The percentages given below describe what would happen to

a whole population—not to an individual woman. For example, breast cancer risk for the women in the WHI study taking estrogen

plus progestin increased less than a tenth of 1 percent each year. But if you apply that increased risk to a large group of women

over several years, the number of women affected becomes an important public health concern. About 6 million American women

take estrogen-plus-progestin therapy. That would translate into nearly 6,000 more breast cancer cases every year, and, 

if all of the women who took the therapy for 5 years, that could result in 30,000 more breast cancer cases.

Further, know that percentages aren’t fate. Whether expressing risks or benefits, they do not mean you will develop a disease. 

Many factors affect that likelihood, including your lifestyle and other environmental factors, heredity, and your personal medical history.

WHI Hormone Therapy Findings

Estrogen Plus Progestin

With 5.2 years of followup. For every 10,000 women each year,

estrogen plus progestin (combination therapy) use compared

with a placebo on average resulted in:

Increased risk for

Breast cancer

■ 26 percent increased risk—8 more cases (38 cases on

combination therapy and 30 on placebo)

Stroke

■ 41 percent increased risk—8 more cases (29 cases on

combination therapy and 21 on placebo)

Heart attack

■ 29 percent increased risk—7 more cases (37 cases on

combination therapy and 30 on placebo)

Blood clots (legs, lungs)

■ Doubled rates—18 more cases (34 cases on combination

therapy and 16 on placebo)

Increased benefits

Colorectal Cancer

■ 37 percent less risk—6 fewer cases (10 cases on combination therapy and 16 on placebo)

Fractures

■ 37 percent fewer hip fractures—5 fewer cases (10 on combination therapy and 15 on placebo

No difference

Deaths

Total cancer cases

Estrogen Alone

With 6.8 years of followup. For every 10,000 women each year,

estrogen-alone use compared with a placebo on average

resulted in:

Increased risk for

Stroke

■ 39 percent increase in strokes—12 more strokes (44 cases

in those on estrogen alone and 32 in those on placebo)

Venous thrombosis (blood clot, usually in a deep vein of legs)

■ About a 47 percent higher risk—6 more cases (21 cases in

those on estrogen alone and 15 in those on placebo.) An

increased risk of pulmonary embolism (blood clots in the

lungs) was not statistically significant. There were 13 cases

in those on estrogen alone and 10 in those on placebo.

No difference in risk (neither increased nor decreased) 

or of uncertain effect

Coronary heart disease

■ No significant difference—5 fewer cases (49 cases in those

on estrogen alone and 54 in those on placebo). During the

first 2 years of use, the risk was slightly increased for estrogen alone, but it appeared to diminish over time.

Colorectal/total cancer

■ No significant difference—1 more case for colorectal cancer

and 7 fewer cases for total cancer (for colorectal cancer, 17

cases with estrogen alone and 16 with placebo; for total

cancer, 103 cases in those on estrogen alone and 110 in

those on placebo.)

Deaths (all or specific cause)

■ No significant difference—3 more deaths (for all deaths, 81

in those on estrogen alone and 78 in those on placebo)

Breast cancer

■ Uncertain effect—7 fewer cases (26 cases in those on

estrogen alone and 33 in those on placebo). This finding

was not statistically significant.

Increased benefit

Bone fractures

■ 39 percent fewer hip fractures—6 fewer cases (11 cases in

those on estrogen alone and 17 cases in those on placebo)
It consists of a set of clinical trials,

an observational study, and a 

community prevention study,

which altogether involve 

more than 161,000 healthy 

postmenopausal women.

The observational study is looking

for predictors and biological 

markers for disease and is being

conducted at more than 40 centers

across the United States.The community prevention study, which

has ended, sought to find ways to

get women to adopt healthful

behaviors and was done with the

Federal Government’s Centers for

Disease Control and Prevention.

WHI’s three clinical trials, conducted at the same U.S. centers,

are designed to test the effects 

of menopausal hormone therapy,

diet modification, and calcium 

and vitamin D supplements on

heart disease, osteoporotic fractures, and breast and colorectal

cancer risk.

The hormone trials also were

checking whether the therapies’

possible benefits outweighed 

possible risks from breast cancer,

endometrial (or uterine) cancer,

and blood clots.The hormone

therapy trials have ended.

The menopausal hormone 

therapy clinical trial had two 

parts.The first involved 16,608

postmenopausal women with 

a uterus who took either estrogenplus-progestin therapy or a placebo.

(The added progestin protects

women against uterine cancer.)

The second involved 10,739

women who had had a hysterectomy and took estrogen alone or a

placebo. (A placebo is a substance

that looks like the real drug but

has no biologic effect.)

The estrogen-plus-progestin trial

used 0.625 milligrams of conjugated

equine estrogens taken daily plus

2.5 milligrams of medroxyprogesterone acetate (PremproTM) taken

daily.The estrogen-alone trial used

0.625 milligrams of conjugated

equine estrogens (PremarinTM)

taken daily.

Prempro and Premarin were 

chosen for two key reasons: They

contain the most commonly prescribed forms of estrogen-alone and

combined therapies in the United

States, and, in several observational

studies, these drugs appeared to

benefit women’s health.

Women in the trials were aged 

50 to 79—their average age at 

enrollment was about 64 for both

trials (See Box 7 for a profile of 

the participants.). They enrolled 

in the studies between 1993 and

1998.Their health was carefully

monitored by an independent

panel, called the Data and Safety

Monitoring Board (DSMB).

Both hormone studies were to

have continued until 2005, but

were stopped early. The estrogenplus-protestin study was halted in 

Facts About Menopausal Hormone Therapy

9
July 2002, and the estrogen-alone

study at the end of February 2004.

Women in both trials are now in 

a followup phase, due to last until

2007. During the followup, their

health will be closely monitored.

See Boxes 8 and 9.

Effects on Disease and Death

Briefly, the combination therapy

study was stopped because of an

increased risk of breast cancer and

because, overall, risks from use of

the hormones outnumbered the

benefits.“Outnumbered” means

that more women had adverse

effects from the therapy than 

benefited from it. For breast 

cancer, the risk was greatest among

women who had used estrogen

plus progestin before entering the

study, indicating that the therapy

may have a cumulative effect.

The combination therapy also

increased the risk for heart attack,

stroke, and blood clots. For heart

attack, the risk was particularly

high in the first year of hormone

use and continued for several years

thereafter. Unlike HERS, which

involved women with heart 

disease, there was an overall

increased risk from the hormone

therapy over the 5.6 years of the

trial.The risk for blood clots was

greatest during the first 2 years of

hormone use—four times higher

than that of placebo users. By the

end of the study, the risk for blood

clots had decreased to two times

greater—or 18 more women with

blood clots each year for every

10,000 women.

Estrogen plus progestin also

reduced the risk for hip and other

fractures, and colorectal cancer.

The reduction in colorectal cancer

risk appeared after 3 years of 

hormone use and became more

marked thereafter. However,

the number of cases of colorectal

cancer was relatively small,

and more research is needed 

to confirm the finding.

The estrogen-alone study was

stopped after almost 7 years

because the hormone therapy

increased the risk of stroke and 

10

Box 9

The data sound scary—and confusing. Estrogen plus progestin

increases stroke risk by 41 percent—and decreases the risk for

hip fractures by 34 percent? Which is more important? 

The bad news, or the good?

Either way, the percentages sound big. So it’s good to take 

a moment and check out what they’re really saying.

There are two main ways to express risk—“relative risk” and

“absolute risk.” Relative risk estimates percent increase or

decrease in a health event occurring in one group compared 

to another group. Absolute risk estimates the number of health

events among individuals in a group, and gives a better sense

of personal or individual risk.

The risk to an individual can be low, but in a large population

the number of health events can be great. 

For example, the WHI study found that, among 10,000 women

taking estrogen plus progestin for one year, there will be 8 more

cases of breast cancer among the hormone users than if they

had not taken the therapy. So, the absolute risk to the individual is relatively low. 

But, the risk of taking hormones to the overall population was

substantial. If you count up all the added cases of breast 

cancer, heart attacks, strokes, and blood clots in the lungs and

subtract the fewer cases of colorectal cancer and hip fractures,

you’d still get about 100 extra harmful events among the

10,000 hormone users after 5.2 years—the period the study

ran. Multiply that by 10 years and millions of women taking

hormones and the number of cases of adverse effects grows.

Remember too that reports of

increased risks do not

mean you will develop

breast cancer or

another condition 

if you have been

using the hormone

therapy. Your personal and family

medical history,

along with your 

lifestyle and other 

influences, play a big 

role in your chance 

of developing 

a disease.

What Do the Data Really Mean?
did not reduce the risk of coronary heart disease. It also increased

the risk for venous thrombosis

(blood clots deep in a vein, usually

in the leg).There also was a 

trend towards increased risk for

pulmonary embolism (blood clots

in the lungs), but it was not statistically significant (See Box 10 

for explanation of statistical significance.).The therapy had no 

significant effect on the risk of

heart disease or colorectal cancer.

Its effect on breast cancer was

uncertain.Although the risk for

breast cancer for those on estrogen

alone appeared to be lower, this

finding was not statistically significant (see Box 10). Estrogen alone

reduced the risk for hip and other

fractures.The reduction began

early in the study and persisted

throughout the followup period.

Neither estrogen plus progestin

nor estrogen alone affected the

risk of death.

Effects On Mental Functions 

An ancillary study of the hormone

trials, the WHI Memory Study

(WHIMS), included women age

65 and older. It found that women

taking estrogen plus progestin had

twice the rate of dementia, including Alzheimer’s disease, as those on

the placebo. The combination

therapy also did not protect

women against mild cognitive

impairment, which is a less severe

loss of mental abilities such as 

having trouble paying attention

and remembering.

Estrogen alone also increased the

risk of mild cognitive impairment

plus dementia, though the number

of cases of dementia alone was too

small to be statistically significant.

Facts About Menopausal Hormone Therapy

11

Box 10

Sometimes, studies report results that are not “statistically significant.” For

instance, in the WHI, estrogen alone caused fewer cases of breast cancer, but

the finding was not statistically significant. How can that be?

Significance with statistics refers 

to the likelihood that a finding is

probably true—and probably not

due to chance. With breast cancer,

the result could be due to factors

other than hormone therapy, such

as genetics or environmental 

exposures. The difference in breast 

cancer cases between the estrogenalone and placebo groups was 

not large enough to rule out

other factors.

Some of the WHI findings are of

uncertain effect or not statistically

significant. They are intriguing 

findings that need more research.

Significant Statistics
Effects On Urinary Incontinence

The WHI has shown that estrogen

and estrogen combined with 

progestin increase the risk of

developing urinary incontinence

and worsen the symptoms of

incontinent women.

Effects On Quality Of Life

WHI also studied the effects 

of menopausal hormone therapy

on women’s quality of life, which

includes perceptions of general

health, energy, social functioning,

mental health, depression, and 

sexual satisfaction.There was no

improvement with estrogen plus

progestin. Slight improvements 

in women’s physical functioning,

body pain, and sleep disturbances

did occur after 1 year of hormone

use, but those effects were very

small.Among younger WHI 

participants (ages 50–54), there 

was a slight improvement in sleep.

Relief of hot flashes and night

sweats occurred in the majority 

of women who had these

symptoms when they 

started the study.

Results for the estrogen-alone

therapy are not yet available.

Putting It All Together

The WHI findings finally offer

women guidance about the use 

of menopausal hormone therapy.

They establish a causal link

between use of the therapies 

tested and their effects on diseases.

Further, the results apply broadly—

the studies found no important

differences in risk by prior health

status, age, or ethnicity.

As you read the information given

below, realize that most treatments

carry risks and benefits.Talk with

your doctor or other health care

provider and decide what’s best 

for your health and quality of life.

Begin by finding out your personal

risk profile for heart disease, stroke,

breast cancer, osteoporosis, colorectal cancer, and other conditions

(See Boxes 11, 12, 13, 15, 16, 17,

18, and 19.). Discuss quality of 

life issues and alternatives to

menopausal hormone therapy.

Box 20 will help you talk with

your health care provider.

Then weigh every factor carefully

and choose the best option for

your health and quality of life.

And keep the dialogue going—

your health status can change 

and so can your choice.

U.S. Food and Drug

Administration (FDA) 

Approved Use of Menopausal

Hormone Therapy 

■ Menopausal hormone therapy

products are effective for 

treating moderate-to-severe 

hot flashes and night sweats,

moderate-to-severe vaginal 

dryness, and prevention 

of osteoporosis associated 

12

Box 11

Main risk factors are:

■ High blood pressure

■ Cigarette smoking

■ Heart disease

■ Diabetes

■ Transient ischemic attacks (small

strokes lasting for only a few

minutes or hours)

■ Age

Other risk factors include:

■ Family history—stroke appears

to run in some families, whether

due to genetics and/or shared

lifestyle

■ Heavy consumption of alcoholic

beverages

■ High blood cholesterol

Risk Factors for Stroke
with menopause, but carry 

serious risks.Therefore, postmenopausal women who use or

are considering using estrogen

or estrogen with progestin treatments should discuss with their

health care providers whether

the benefits outweigh the risks.

■ If these products are prescribed

solely for vaginal symptoms,

health care providers are advised

to consider the use of topical

vaginal products (gel or cream

applied locally).

■ If menopausal hormone therapy

is used for osteoporosis, the risks

for osteoporosis must outweigh

the risk of estrogen or estrogen

with progestin. Health care

providers are encouraged 

to consider other treatments

before providing menopausal

hormone therapy for 

osteoporosis.

■ Menopausal hormone therapy

has never been approved for 

the prevention of cognitive 

disorders such as Alzheimer’s

disease or memory loss.

In fact, the WHI found 

that women treated with

menopausal hormone therapy 

have a greater risk of developing dementia.

■ Menopausal hormone therapy

should be used at the lowest

doses for the shortest duration

to reach treatment goals,

although it is not known at

what doses there may be less

risk of serious side effects.

Facts About Menopausal Hormone Therapy

13

Box 12

One of every eight American women will develop breast cancer in her lifetime.

The risk increases with age—and is greatest after age 60. Some factors

increase the risk for breast cancer. However, most women who develop breast

cancer do not have any risk factors.

Key factors that increase the risk of developing breast cancer are:

■ Personal history—if you’ve had it once, you’re more likely to develop 

breast cancer again.

■ Family history—if your mother, sister, or daughter had breast cancer, 

especially at an early age, you’re more likely to develop it.

■ Other breast changes (not including ordinary “lumpiness”)—such as atypical

hyperplasia (an irregular pattern of cell growth).

■ Genetic alterations—mutated forms of BRCA1 and BRCA2 genes, 

which are believed to be responsible for about half the cases of 

inherited breast cancer.

Other factors also may increase the risk of developing breast cancer.

These include:

■ Race—white women are more likely to develop it than African American 

or Asian women.

■ Estrogen exposure—risk is somewhat increased for those who 

began menstruation early (before age 12), had menopause late 

(after age 55), never had children, never breastfed, or took hormone 

therapy for long periods.

■ Late childbearing—having a first child after age 30.

■ Radiation therapy—if given to the chest more than 10 years ago, especially

in women younger than age 30.

■ Breast density—breasts with a high proportion of lobular and ductal tissue,

which is dense and prone to breast cancer. 

■ Obesity after menopause—the body makes some of its estrogen in fatty 

tissue and being obese means a woman has abnormally high body fat;

gaining weight after menopause increases the risk.

■ Physical inactivity—women who are physically inactive throughout life have

an increased risk, possibly because physical activity helps prevent obesity.

■ Alcoholic beverage consumption.

Breast Cancer Risk Factors
14

Box 13

More than eight million American women have osteoporosis—

and millions more have such low bone density that they’re 

likely to develop it.

Osteoporosis can happen at any age, but the risk increases as

you get older. The first noticeable sign of osteoporosis is often

losing height or breaking a bone easily. Other signs can be

changes in spine shape, prolonged severe pain in the middle 

of the back, and tooth loss.

Risk factors for osteoporosis include:

■ Age—risk increases as you grow older.

■ Being female—Women have less bone tissue than do men

and tend to experience a rapid loss of bone in the first few

years after menopause.

■ Body size—small, thin-boned women are at greatest risk.

■ Ethnicity—White and Asian women are at highest risk.

■ Having parents with a history of osteoporosis as well as

fractures in adulthood can place someone at increased risk

for osteoporosis.

■ Sex hormones—abnormal absence of menstrual periods

(amenorrhea) or menopause.

■ Anorexia.

■ Lifetime diet low in calcium and vitamin D.

■ Certain medications, such as glucocorticoids (prescribed

for various diseases, including arthritis, asthma, and lupus)

and some anticonvulsants.

■ Physical inactivity or extended bed rest.

■ Cigarette smoking.

■ Excessive use of alcoholic beverages.

If you think you’re at risk for osteoporosis or if you’re

menopausal or postmenopausal, you may want to ask your

doctor or other health care provider about having a DXA-scan

(dual-energy x-ray absorptiometry). It measures spine, hip, 

or total body bone mineral density, or how solid bones are. 

The results can show the presence and severity of osteoporosis,

or if you’re at risk of developing it or having fractures.

You can prevent osteoporosis. The key steps are to follow an

eating plan rich in calcium and vitamin D, and be sure to get

regular weight-bearing exercise. Although food sources are usually better absorbed, calcium and vitamin D intake can be taken

as supplements but check with your health care provider first.

Too much of either can cause problems. Recommended daily

intakes of calcium and vitamin D are given in Box 14. Good

food sources of calcium include canned fish with bones (such

as salmon and sardines), broccoli, dark green leafy vegetables,

(such as kale, turnip greens, and collards), dairy foods such as

nonfat or low-fat milk, calcium-fortified orange juice, soy-based

beverages with added calcium, and cereal with added calcium.

Vitamin D is made by the body—being in the sun 20 minutes 

a day helps most women make enough. But it’s also found 

in foods such as fatty fish (sardines, mackerel, and salmon), 

and cereal and milk fortified with Vitamin D. Thirty minutes 

of weight-bearing exercises such as walking, jogging, stair

climbing, weight training, tennis, and dancing, done three 

to four times a week can help prevent osteoporosis.

It’s also important not to smoke and to limit

how many alcoholic beverages you drink.

Too much alcohol (for women, more than

one alcoholic drink a day) can put you at risk

for developing osteoporosis. Smoking

increases bone loss by decreasing estrogen

production.

Osteoporosis is treated by stopping bone

loss with lifestyle changes and medication.

Hormone therapy has been used to prevent

and treat osteoporosis. But other drugs 

are available:

■ Raloxifene is a selective estrogen receptor modulator

(SERM), which preserves bone density and prevents 

fractures (although not hip fractures). Possible side effects

include hot flashes and blood clots.

■ Alendronate (brand name Fosamax) and risedronate (brand

name Actonel) are bisphosphonates, drugs that slow the

breakdown of bone, prevent fractures, and may increase

reverse bone loss. Side effects may include nausea, heartburn, and pain in the stomach.

■ Calcitonin is a naturally occurring nonsex hormone that

increases bone mass in the spine, and it may prevent some

fractures. It is used to treat women who have osteoporosis

and who are at least 5 years beyond menopause. The drug

is taken by injection or nasal spray. The injection may cause

an allergic reaction and has some unpleasant side effects,

including flushing of the face and hands, urinating often,

nausea, and skin rash. The nasal spray may cause a 

runny nose.

■ Teriparatid (parathyroid hormone), which may reverse 

bone loss.

Boning Up On Osteoporosis
Facts About Menopausal Hormone Therapy

15

Box 14

Age Vitamin D Calcium

19–50 200 IU* 1,000 mg** 

51–70 400 IU* 1,200 mg**

70+ 600 IU* 1,200 mg**

Note: International Units (IU)

* not to exceed 2,000 IU

**not to exceed 2,500 mg

Recommended Daily Intakes of Calcium 

and Vitamin D

Box 15

About 30,000 women a year die of colorectal cancer—it is the third-leading 

cause of cancer deaths for women after lung and breast cancers.

Factors that increase the risk of colorectal cancer include:

■ Age—risk increases after age 50.

■ Body Mass Index of 25 or greater (overweight and obesity).

■ Polyps—these are benign growths on the inner 

wall of the colon and rectum.

■ Personal medical history—having had

cancer of the ovary, uterus, or breast; also

having had colorectal cancer once

increases the chance of developing 

it again.

■ Family medical history—having

first-degree relatives (parents, 

siblings, or children) with colorectal 

cancer, especially at a young age; risk

increases even more if many family

members have had 

colorectal cancer.

■ Ulcerative colitis—

a condition in which 

the lining of the colon 

becomes inflamed.

Risk Factors for Colorectal Cancer

Box 16

There are various types of uterine

cancer. The most common is

endometrial cancer, which begins in

the uterine lining (endometrium). It is

often referred to as uterine cancer.

Key risk factors for uterine 

cancer are:

■ Age—usually occurs after age

50.

■ Endometrial hyperplasia—

an increase in cells in the lining

of the uterus.

■ Hormone therapy—using estrogen without progesterone.

■ Obesity and related conditions.

■ Tamoxifen—taken to prevent 

or treat breast cancer.

■ Race—White women are 

more likely than African

American women to develop

uterine cancer.

■ Colorectal cancer—those who

have an inherited form are at 

a higher risk of developing 

uterine cancer.

■ Factors that increased exposure

to estrogen—starting menstruation at an early age, not having

children, never breastfeeding, 

or entering menopause late.

Risk Factors for

Uterine Cancer
When Menopausal Hormone

Therapy Should Not Be Used

Findings from the WHI and

HERS have led to conclusions

about when menopausal hormone

therapy should not be used:

■ Menopausal hormone therapy

should not be used to prevent

heart disease. In fact, estrogen

plus progestin actually increases

the chance of a first heart

attack, as well as breast cancer.

Both forms of hormone therapy

increase the risk for blood clots.

■ Women with heart disease

should not use menopausal 

hormone therapy to prevent 

the risk of further heart disease.

Such use increases the risk of

blood clots. It also increases the

risk of heart attack in the first

year of therapy.

What Can You Do Instead?

Talk to your health care provider

about lifestyle changes and other

action steps that have proven to 

be safe and effective in helping 

to prevent heart disease and 

osteoporosis.Ways to prevent 

heart disease and stroke include

lifestyle changes and such drugs 

as cholesterol-lowering statins 

and blood pressure medications.

Lifestyle changes include: not

smoking, maintaining a healthy

weight, being physically active,

and managing diabetes. (See Box

21 to learn more about heart disease risk factors.)

Another key lifestyle change is to

follow a healthy eating plan that

has a variety of foods, including

grains, especially whole grains, and

dark green leafy vegetables, deeply

colored fruits, and dry beans and

peas. It should also be low in 

saturated fat, trans fat, and cholesterol, and moderate in total fat.

In addition, limiting how much

salt and other forms of sodium

you eat will help keep your blood

pressure at a healthy level.

Take action to prevent osteoporosis

and bone loss, including consuming enough calcium and vitamin

D (See Box 14.), being physically

active, especially with weightbearing exercises (such as walking,

jogging, playing tennis, and dancing), not smoking, and limiting

how many alcoholic beverages you

drink. Smoking and drinking

excessive amounts of alcohol

increase your risk of osteoporosis.

Talk with your health care

provider about what your personal

risks and benefits would be from

either estrogen-alone or estrogenplus-progestin therapy to prevent

osteoporosis. Consider whether

the risks of osteoporosis outweigh

the risks of hormone therapy.

Ask about alternate medications

that are considered safe and 

effective in preventing osteoporosis 

and fractures.These include 

oral biphosphonates, such as 

alendronate (or Fosamax) and 

risedronate (or Actonel), and 

selective estrogen receptor 

modulators (SERMs), such as

raloxifene (or Evista). SERMs 

are also known as designer 

estrogens.They are substances 

that have estrogen-like effects 

on some tissues and anti-estrogen

effects on others. For more on

osteoporosis, see Box 13.

16
General Advice for the

Postmenopausal Years

The postmenopausal years are 

a time when the risk for various

conditions rises. Be sure to protect

your health by having certain tests

(See Box 22 for details.):

■ Keep a regular schedule of

mammograms, and breast and

clinical exams.

■ Check your blood pressure 

at least every 2 years (more 

frequently if it is elevated).

■ Know your cholesterol 

levels—they should be tested 

at least once every 5 years

(more frequently if levels 

are elevated).

■ Test your fasting blood glucose

(sugar) level—this is a test to see

if you have diabetes or are likely

to develop it.Take it at least

every 3 years, beginning at age

45. If you have risk factors 

for diabetes, start the test 

at a younger age and take 

it more often.

■ Find out your bone mineral

density with a DXA-scan (dualenergy x-ray absorptiometry)—

results can show the presence

and severity of osteoporosis,

or if you’re at risk for developing it or having fractures.

■ Learn your body mass index

(BMI) and waist circumference—this will tell if you need

to lose weight. Check these

every 2 years or more often 

if your doctor recommends.

(See Box 23.)

Facts About Menopausal Hormone Therapy

17

Box 17

About 1 in 57 American women will develop ovarian cancer. Most will be over age 50, but younger women 

also can develop the disease.

Here are some factors that increase or decrease the risk of ovarian cancer:

Risk Factors for Ovarian Cancer

Increases risk

■ Age—risk increases as a woman ages.

■ Family history of ovarian cancer—higher risk if mother or

sister has had ovarian cancer; somewhat higher risk if other

relatives, such as grandmother, aunt, or cousin, have developed ovarian cancer.

■ Menopausal hormone therapy—may increase risk.

■ Fertility drugs.

■ Personal history of breast and/or colon cancer.

Decreases risk

■ Oral contraceptives—the longer the use, the lower the risk

may be, and the decrease may last after use has ended.

■ Childbearing and breast-feeding.

■ Tubal ligation (sterilization) or hysterectomy.

■ Surgery to remove one 

or ovaries to help prevent 

ovarian cancer, which is 

called a prophylactic 

oophorectomy.
18

Box 18

Early menopausal hormone therapy studies found inconsistent results about its effect on the risk of ovarian cancer: some

reported increased risk with estrogen use, while others reported no effect or even a protective one. Most of those studies

were relatively small and did not take into account the key ovarian cancer risk factors.

However, two large observational studies have indicated that long-term estrogen use may increase the risk of ovarian cancer.

It’s important to keep in mind that observational studies do not prove that a treatment causes a disease (See Box 6.). The evidence from these studies is cautionary, not definitive.

Here’s more on the studies:

■ One study followed 211,581 postmenopausal women

from 1982–1996. Of those, 44,260 had used estrogenonly hormone therapy; the rest did not use hormone therapy. None of the women had had a hysterectomy, ovarian surgery, or cancer. Those with 10 or more years of

estrogen use had an increased risk of dying from ovarian

cancer—and, while the risk decreased somewhat long

after use was stopped, it was still higher than that of

women who had never used estrogen-only therapy.

■ Another study followed 44,241 women from 1979–1998.

It found that estrogen-only therapy increased the risk of

ovarian cancer. Women who used estrogen-only for 10 

or more years had an 80 percent higher risk of ovarian

cancer than women who had never used the hormone

therapy; women who used estrogen-alone for 20 or more

years had a 220 percent higher risk than women who

had never used hormone therapy.

The study found no increased risk of ovarian cancer 

for users of estrogen plus progestin. However, few

women in the study had used the combination therapy

for more than 4 years.

More research is needed to see if estrogen plus progestin

affects ovarian cancer risk—and on other aspects of

menopausal hormone use. For instance, another recent

study found that estrogen alone or estrogen plus progestin

used on a sequential basis increased the risk of ovarian cancer, while estrogen plus progestin used continuously did not

increase ovarian cancer risk. The WHI trial of estrogen plus

progestin found a small increase in ovarian cancer, which is

not statistically significant.

Menopausal Hormone Therapy and Ovarian Cancer Risk
Facts About Menopausal Hormone Therapy

19

Recent findings about risks of long-term menopausal hormone

therapy do not apply to use of birth control pills, which have

not been found to increase breast cancer risk.

There had been concern about birth control pills’ effect on the

risk of breast cancer because, until recently, studies had found

conflicting results. For example, a 1996 analysis of 54 small

studies found a slight increase in breast cancer rates among

women who were or had recently used oral contraceptives. But

the 54 studies differed in quality and some included oral contraceptive preparations no longer in use. Other studies, such as

the 1986 Cancer and Steroid Hormone (CASH) study, found no

increased breast cancer risk.

In June 2002, findings of the Women’s Contraceptive and

Reproductive Experiences Study (also called the Women’s

CARE Study) were released and showed no increased risk of

breast cancer, regardless of length of oral contraceptive use,

timing of use, age at use, or the users’ risk factors for developing breast cancer. The study, supported by the NIH’s National

Institute of Child Health and Human Development, involved

more than 9,257 women between the ages of 35 and 64. 

The women were interviewed about their contraceptive use.

Oral contraceptives do pose risks, however: combination oral

contraceptives increase the risk of blood clots. Oral contraceptives should not be used if you are at an elevated risk for blood

clots because of diabetes or another condition, or if you

smoke. Taking oral contraceptives and smoking increases your

risk for heart attack and stroke.

Oral contraceptive use has benefits too: it can reduce the risk of

ovarian cancer, endometrial cancer, colorectal cancer, and pelvic

inflammatory disease (an infection that can lead to infertility). 

What About Birth Control Pills?

Box 19

Box 20

It’s important to be involved in your health care. Ask questions

and express your concerns. Here are some questions that 

may help you talk with your health care provider about 

hormone therapy:

■ Why am I taking hormone therapy? or Why should I take

hormone therapy?

■ Which hormone therapy am I on?

■ What are my risks for heart disease, breast cancer, 

colorectal cancer, or osteoporosis?

■ Should I stop taking the hormone therapy?

■ What’s the best way for me to stop? What side effects will

I have?

■ Is there an alternative therapy that I can use long term?

■ What alternatives can help me prevent heart disease?

■ What alternatives can help me prevent osteoporosis?

■ What can I do to keep menopausal symptoms from returning?

Your risk for heart disease, osteoporosis, breast cancer, 

and colorectal cancer may change over time. So remember 

to regularly review your health status with your doctor or other

health care provider.

It’s also important to bear in mind that your doctor or other

health care provider may not be able to answer all of your questions—many questions about menopausal hormone use remain

unanswered. For instance, it’s not yet known if disease risk

increases when long-term use of estrogen-plus-progestin drop

use stops. As with any treatment, you need to carefully weigh

your personal risks against the possible benefits and make the

best choice possible for your health and lifestyle needs.

Finally, your doctor or other health care provider can speak with

a WHI principal investigator about the study results. For a list of

the principal investigators, check the NHLBI WHI Web site or

contact the NHLBI Health Information Center (See page 24.).

Talking With Your Doctor
20

Box 21

One in three American women dies of heart disease. 

Heart disease kills more American women than any other

cause. It also can lead to disability and decrease one’s 

quality of life. Yet, many women don’t take the threat of 

heart disease seriously.

But menopause is a time when you need to get very 

serious about heart disease because that’s when your 

risk starts to rise. Risk factors are behaviors or habits 

that make a person more likely to develop a disease. 

They can also increase your chances that an existing 

disease will get worse. Having more than one risk factor 

for heart disease is especially serious, because risk 

factors tend to “gang up” and worsen each other’s effects.

So it’s vital to prevent the development of risk factor, 

if you already have any, keep them under control.

So, it’s more important than ever to talk with your health 

care provider about how to lower your risk of heart disease—

or, if you already have it, to keep it under control. Ask 

about your “heart disease profile,” a check for heart 

disease risk factors you already have, or are at an 

increased risk of developing.

Fortunately, most heart disease risk factors can be 

prevented or controlled. Here’s a breakdown of both types:

Risk factors beyond your control:

■ Being age 55 or older

■ Having a family history of early heart disease—this 

means having a mother or sister who has been 

diagnosed with heart disease before age 65, or a 

father or brother diagnosed before age 55

Risk factors you can control:

■ Cigarette smoking

■ High blood cholesterol

■ High blood pressure

■ Diabetes (high blood sugar)

■ Overweight/obesity

■ Physical inactivity

For more on how to start reducing your heart disease 

risk, see the resources list on page 24.

Your Heart Disease Risk Profile
Facts About Menopausal Hormone Therapy

21

Box 22

Here’s a prescription for better health:

■ Blood pressure—healthy women should have it

checked every 2 years; others may need it checked

more often.

■ Lipoprotein profile—checks blood levels of LDL, HDL,

and total cholesterol and triglycerides; healthy women

should have it once every 5 years.

■ Blood glucose—tests blood levels of glucose (a sugar)

and indicates risk for diabetes; healthy women age 45

and older should have blood glucose tested, especially

if they are overweight; if it’s normal and women are

healthy and not overweight, it should be taken again in

3 years, while others will need it more often.

■ Overweight and obesity check—this is done by calculating your BMI (body mass index) and measuring your

waist circumference. BMI is a measure of your weight

relative to your height, while waist circumference measures abdominal fat. Box 23 tells you how to calculate

your BMI. A BMI of 25 or higher is overweight or

obese. For women, a waist circumference of more than

35 inches indicates an increased risk for heart disease

and other conditions. Your health care provider also will

check you for other risk factors and conditions associated with obesity to determine the best treatment.

■ Mammogram—a special x ray of the breast; healthy

women age 40 and older should be screened for

breast cancer with mammography once every 1 to 2

years; studies show screening is especially important

for those aged 50–69; women also should do breast

self-exams and have their doctor or health care

provider do a clinical breast exam during routine 

physical exams.

■ Pap test—this test checks a sample of cervical cells for

changes that may lead to cancer; begin by having it as

part of an annual gynecological exam and if normal 3

years in a row, talk with your doctor about how often to

have it after that.

■ Colonoscopy—examines the inside of the colon and

rectum using a thin, lighted tube called a colonoscope;

healthy women should have it once every 10 years 

starting at age 50.

■ Bone density—this x ray measures bone thickness and

strength (See Box 13.); postmenopausal women with

one or more risk factors for osteoporosis (besides

menopause) or who suffer fractures, and women age

65 and older regardless of added risk factors should

have this test.

■ Electrocardiogram (EKG or ECG)—this tests the heart’s

electrical activity as it beats; women over age 40

should have a baseline EKG.

Check It Out
How Do I Stop Therapy?

If you are on menopausal hormone

therapy, talk with your health care

provider about whether or not to

stop it.Also ask about the best way

to discontinue the treatment.You

can stop abruptly or by gradually

reducing the dose over several

months.With either method of

stopping the medication, you may

have menopause-like symptoms.

Bone loss will likely resume after

discontinuing hormone therapy.

So if you have been taking hormones to prevent osteoporosis,

be sure to talk to your health 

care provider about other FDAapproved medications and lifestyle

actions that can help to minimize

further bone loss. (See Box 13.)

If you stop treatment and

menopausal symptoms occur,

talk with your health care provider

about alternative treatments 

(See Box 4.). But be aware that

some of these remedies have not

been proven effective or safe.

22

Box 23

Body mass index—or BMI—relates weight to height and is used as an indicator

of total body fat. It is used with waist circumference to see if you’re overweight

or obese.

To find your BMI, use the method below or go to the Aim For A Healthy Weight

Web page at www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm,

which offers tables and an automatic calculator.

Here are three steps to find your BMI:

Step 1: Multiply your weight* in pounds by 703.

Step 2: Divide the answer by your height in inches.

Step 3: Divide the answer again by 

your height in inches.

The BMI score means:

18.5–24.9 Normal

25.0–29.9 Overweight

30.0 and above Obese

*Weight wearing underwear but no shoes

Check Your BMI
Questions Remain

As noted, the WHI will 

continue to follow women 

in the menopausal hormone 

therapy trials until 2010.Among

the questions yet to be answered

are if and when increased risks 

and benefits decline after use 

of the therapy ends.

The WHI observational study is

also examining other forms of

hormone therapy, including other

estrogens, progestins, and SERMs.

Additionally, scientists funded by

the NHLBI, the National Cancer

Institute, the National Institute 

on Aging, the National Institute 

of Arthritis and Musculoskeletal

and Skin Diseases, the National

Center for Complementary and

Alternative Medicine, the National

Institute of Mental Health, and

other units of the NIH are 

supporting research on the effects

of menopausal hormones and

alternative therapies on menopause

symptoms and postmenopause

conditions.The research includes 

studies of: The effects of soy 

phytoestrogens on cardiovascular

disease and osteoporosis, postmenopausal use of phytoestrogens

on cardiovascular risk and health,

black cohosh and antidepressants

on hot flashes, botanical dietary 

supplements on women’s health,

plant estrogens on breast cancer,

and estrogen on cognition.

Facts About Menopausal Hormone Therapy

23
24

For More Information

The following resources can help you learn more about hormone therapy-related topics:

National Heart, Lung,

and Blood Institute

National Institutes of Health

NHLBI Health Information Center

P.O. Box 30105

Bethesda, MD 20824-30105

Phone: (301) 592-8573

TTY: (240) 629-3255

Fax: (301) 592-8563

Web site: www.nhlbi.nih.gov

WHI Web site: www.whi.org

National Cancer Institute

National Institutes of Health

Phone: (800) 4-CANCER

(800-422-6237)

Web site: www.nci.nih.gov

National Center for Alternative 

and Complementary Medicine

National Institutes of Health

NCCAM Clearinghouse

P.O. Box 7923

Gaithersburg, MD 20898-7923

Phone: (888) 644-6226

TTY: (866) 464-3615

International Phone: (301) 519-3153

Fax: (866) 464-3616

Web site: www.nccam.nih.gov

National Institute on Aging

National Institutes of Health

P.O. Box 8057

Gaithersburg, MD 20898-8057

Phone: (800) 222-2225

TTY: (800) 222-4225

Web site: www.nia.nih.gov

Publications Web site:

www.niapublications.org

Alzheimer’s Disease Web site:

www.alzheimers.org

National Institute of Arthritis and

Musculoskeletal and Skin Diseases

Information Clearinghouse

National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-3675

Phone: (301) 495-4484 

or (toll free) (877) 22-NIAMS

TTY: (301) 565-2966

Fax: (301) 718-6366

Web site: www.niams.nih.gov

NIH Osteoporosis and Related Bone

Diseases—National Resource Center

1232 22nd Street, NW

Washington, DC 20037-1292

Phone: (202) 223-0344 

or toll-free (800) 624-BONE

Fax: (202) 293-2356

TTY: (202) 466-4315

Web site: www.osteo.org

National Institute of Child Health 

and Human Development

National Institutes of Health

NICHD Clearinghouse

P.O. Box 3006

Rockville, MD 20847

Phone: (800) 370-2943

Fax: (301) 984-1473

Email:

NICHDClearinghouse@mail.nih.gov

Web site: www.nichd.nih.gov

Food and Drug Administration

U.S. Department of Health and

Human Services

5600 Fishers Lane

Rockville, MD 20857

Phone: (888) INFO-FDA

(888-463-6332)

Web site: www.fda.gov

Office on Women’s Health

U.S. Department of Health 

and Human Services

200 Independence Avenue, SW

Room 730B

Washington, DC 20201

Phone: (202) 690-7650

Fax: (202) 205-2631

Web site: www.4women.gov/owh

National Women’s Health 

Information Center

Department of Health 

and Human Services

8550 Arlington Blvd

Suite 300

Fairfax,VA 22031

Phone: (800) 994-WOMAN

(800-994-9662)

or (888) 220-5446 

Web site: www.4women.gov

North American Menopause Society

Post Office Box 94527

Cleveland, OH 44101

Phone: (440) 442-7550

Automated Consumer Request Line:

(800) 774-5342

Fax: (440) 442-2660

E-Mail: info@menopause.org

Web site: www.menopause.org

Alliance for Aging Research

2021 K Street, NW, Suite 305

Washington, DC 20006

Phone: (202) 293-2856

Fax: (202) 785-8574

American Heart Association

National Center

7272 Greenville Avenue

Dallas,TX 75231

Phone: (800) AHA-USA-1

(800-242-8721)

Web site: www.americanheart.org

American Stroke Association

National Center

7272 Greenville Avenue

Dallas TX 75231

Phone: (888) 4-STROKE

(888) 478-7653

Web site: www.strokeassociation.org

National Osteoporosis Foundation

1232 22nd Street, NW

Washington, DC 20037-1292

Phone: (202) 223-2226

Web site: www.nof.org

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication No. 05-5200

Originally Printed October 2002

Revised June 2005