Good to Know

I was just reading about the value of evidence in science today, and lo and behold, out comes this article about one of the most hotly debated topics in women's health: hormone replacement. HRT has been controversial for some time in medical circles because physicians could not reach consensus on how to interpret the results from the WHI (stopped in 2002 because of a surprising and alarming increase in CVD and breast cancer rates in users of HRT compared to placebo). Some, however, argued that the increase reflected long-term use of HRT in older, postmenopausal women, and did not accurately reflect risk in younger women who were using HRT short term.

Even as I started medical school, the conventional wisdom was that it was acceptable to use HRT in women just entering menopause with severe symptoms (eg, hot flashes), but not to use it to prevent osteoporosis or other problems associated with decreased estrogen. But that was the educated guess. Now a new study from the WHI has come out that gives us a better sense of timeframe of the risks of HRT, and thus better guidance for physicians.

In brief, the new WHI study states:

Three years after stopping hormone therapy, women who had taken study pills with active estrogen plus progestin no longer had an increased risk of cardiovascular disease (heart disease, stroke, and blood clots) compared with women on placebo. The lower risk of colorectal cancer seen in women who had taken active E+P disappeared after stopping the intervention. The benefit for fractures (broken bones) in women who had taken active E+P also disappeared after stopping hormone therapy. On the other hand, the risk of all cancers combined in women who had used E+P increased after stopping the intervention compared to those on placebo. This was due to increases in a variety of cancers, including lung cancer. After stopping the intervention, mortality from all causes was somewhat higher in women who had taken active E+P pills compared with the placebo.

Based on the findings mentioned above, the study’s global index that summarized risk and benefits was unchanged, showing that the health risks exceeded the health benefits from the beginning of the study through the end of this three year follow-up. The follow-up after stopping estrogen plus progestin confirms the study’s main conclusion that combination hormone therapy (E+P) should not be used to prevent disease in healthy, postmenopausal women. The most important message to women who have stopped this hormone therapy is to continue seeing their physicians for rigorous prevention and screening activities for all important preventable health conditions.

An article summarizing the findings can be found here.

So what does this mean for physicians? I still think that we should prescribe HRT to women who are suffering intolerable symptoms of menopause. However, given the study's results, I would be more vigilant about screening them for breast cancer while they are on HRT, and be more aggressive about weaning them off of HRT as they reach the 3 year mark in usage. I've seen so many women who have been on HRT for years and years and years (I'm talking like since 1980 when they had their hysterectomy), without close follow-up. Sometimes, we'll get them in clinic and they can't even tell us why they're on HRT. With this new data, there is a lot more incentive to be clear about the proper uses of HRT, and to prevent this sort of "slipping through the medication regime cracks."

The next study to come out is on women who have been only using estrogen, and not estrogen and progestins. That ought to be enlightening too, as hysterectomies are becoming an increasingly common procedure in the field of ob-gyn.