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DEAR DR. ROACH: I had a complete hysterectomy in my late 40s due to endometriosis. I am now 68 and have been on 0.1-mg patches of estradiol since. Should I ask my gynecologist to do a hormone study, or should I just not worry? I have an annual checkup with her and a mammogram every year. -- J.S.

ANSWER: While many doctors no longer prescribe hormone replacement therapy, there are benefits to the use of estrogen. (I recommend estradiol, the bioidentical major human estrogen, rather than conjugated equine estrogens like Premarin.) Each woman must be considered individually as there is no single right answer. As with all treatments, there are risks and benefits.

In your case, your doctor has taken care to reduce some of your major risks. Excess growth of the lining of the uterus (called hyperplasia) and even endometrial cancer occur much more frequently in women who take estrogen -- unless they are taking a progesterone-type drug or, as in your case, they don't have a uterus. (Hysterectomy is the removal of the uterus.)

I think it likely that you also had your ovaries and fallopian tubes removed as well (called bilateral oophorectomy and salpingectomy) since you were started on estrogen immediately.

Since the publication of a large trial, estrogen has been commonly thought to increase heart disease risk and cancer, but the situation is much more nuanced. Estrogen alone (without a progesterone) probably decreases the risk of heart attack when given early after menopause, whether it's surgical or natural; however, oral estrogen given along with medroxyprogesterone in women over 60 (or women who are 10 years postmenopause) showed an increase in heart disease risk.

It may be that it is the progestin in this case that was responsible for the observed harm in heart disease. Newer progestins may not have as much of an increased risk. Estrogen patches, in particular, do not increase the risk of heart disease when used without a progestin.

Similarly, combined oral estrogen/progestin therapy clearly increases the risk of stroke and blood clots. But, once again, estrogen without progestins, especially given as a patch at a lower dose (0.05 mg per day), do not appreciably increase the risk of strokes and blood clots. This is because oral estrogen must first go through the liver, whereas this is not the case when it's given through the skin.

Estrogens both treat and prevent menopausal symptoms, especially hot flashes, but they also help with vaginal symptoms. Furthermore, estrogens help prevent osteoporosis and reduce the risk of colon cancer by almost half. Breast cancer risk is decreased slightly with estrogen alone, which is the opposite of what many people believe.

Oral estrogen plus medroxyprogesterone increased the risk of breast cancer slightly. Once again, it seems that medroxyprogesterone is much more of a danger than human estrogen. I do not think that you are at a high risk for a complication due to your estrogen patch, and I do not recommend checking blood levels.

Estrogen alone is still not recommended for the prevention of heart disease, breast cancer or colon cancer. The data we have are reassuring that there is little to no harm for these issues, but the types of trials to prove an overall benefit have not been done for estrogen-alone regimens.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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