DEAR DR. ROACH: What are your thoughts on hormone replacement therapy (HRT) for women? I’ve heard that the results that essentially stopped HRT for decades were flawed in their interpretation. Is this correct? If so, are there new recommendations for women to start HRT?

I am a 63-year-old female in excellent health and am trying to research the topic before my next doctor’s appointment in a couple of months. I am also concerned that my own doctor may not have the appropriate training to prescribe HRT, as I’ve heard there is a whole generation of doctors who have not been trained in prescribing hormones.

— B.H.

ANSWER: I wouldn’t say the studies (primarily the Women’s Health Initiative but several others) were flawed so much; their interpretation needs to include the age of subjects in the study and the intervention given, particularly the choice and dose of both the estrogen and progestin. (In women with a uterus, a progestin must be given to reduce the risk of uterine cancer that is associated with estrogen therapy alone.)

I do agree with you that HRT is probably underused as the most effective treatment of many symptoms of menopause. The mean age of women starting HRT in the WHI was 63, exactly your age as it turns out. In this group, there was a significant increase in the risk of heart disease and stroke.

A careful reinterpretation of the data suggested that younger women (aged 50-59 or those within 10 years of stopping their periods) probably had no excess risk of heart disease and may have had a reduction.

Estrogen has beneficial effects on cholesterol and on the lining of the blood vessels, but it also increases blood-clotting risk (when given by mouth). So, estrogen may prevent blockages but also make an existing blockage develop a clot, which is the essential step in a heart attack.

The current estrogen that is most commonly used by experts (estradiol, the bioidentical major human estrogen) and the current most frequently used progestin (micronized progesterone, also a bioidentical hormone) have less risk of causing cancer than the types used in most studies (conjugated estrogen and medroxyprogesterone). Some studies have shown a reduced risk of breast cancer in estrogen-only regimens, while others have still shown an increase.

The blood-clotting risk is a significant consideration, with all oral estrogens increasing risk. Women who used an estrogen patch had no significant increase in clotting risk. In my opinion, the benefits of HRT in symptomatic women under 60 or within 10 years of menopause may outweigh the risks, but the decision still needs to be made after a careful discussion of risks and benefits.