HRT: Still a Useful Therapeutic Tool

Many experts are rethinking doubts about the therapy's value, risks

SATURDAY, March 5, 2005 (HealthDay News) -- Few bubbles burst with such apparent finality as long-term hormone replacement therapy (HRT) did in the summer of 2002. After many years of study and analysis, researchers determined that HRT, at the very least, increased a post-menopausal woman's risk for a variety of ailments, including heart disease.

Now, there are some second thoughts.

True, the conclusions of the Women's Health Initiative (WHI) in mid-2002 were ominous -- that HRT had some stealthy flaws. The huge WHI, a government-financed study, showed that women taking estrogen and progestin in a single pill had an increased risk of heart disease, breast cancer, stroke and blood clots. Beyond that, the combination HRT did not bestow an improvement in overall quality of life, as promised.

Disillusioned and frightened, women by the millions halted HRT abruptly, side effects of menopause taking a back seat to concerns about survival.

Yet, in the calm after the storm, critics have been chipping away at some of the initial WHI results, pointing out that they may be less threatening than they first appeared.

Indeed, a Yale study in the respected journal Fertility and Sterility found the WHI conclusions fundamentally flawed. The criticism focused on the age of the participants, and not for the first time. The age range of the women was from 50 to 79, with the average age being 63.

Many of the women in the study, say the critics, may well have been in the early stages of heart disease when the trial started. As a result, the trial did not have enough statistical power to test the hormones for primary prevention, they say. The study needed additional younger women.

Dr. Wulf H. Utian, executive director of the North American Menopause Society, is a major critic of the WHI. "Because they (WHI) had to have enough heart attacks to get statistical significance, they had to go with the group that had the highest prevalence of heart attacks -- and that was older women," he said.

He believes that the question of whether HRT reduces cardiovascular disease is still unresolved. It should be studied at the time of menopause, Utian maintains, when sex hormones are declining, rather than years later.

He concedes, however, that the WHI findings on breast cancer are valid. But he and others point out that the reported rise of 26 percent looks riskier than it is. This is marked by confusion over the relative risk of developing breast cancer (26 percent over five years) compared with the absolute risk (0.3 percent per year, increasing by only 0.1 percent per year). In other words, a woman on HRT is significantly more likely to develop breast cancer than a woman not taking HRT, but even so, that risk is minuscule if these statistics are divided down to an individual.

So, critics of the rush to abandon HRT feel that the absolute risk to an individual woman taking HRT is quite low and may be acceptable to those enduring severe menopause-related symptoms -- hot flashes and night sweats. Also, for some women, the risk of osteoporosis can be significantly reduced with HRT and could outweigh the other risks.

One post-WHI study, while not disputing the long-term risks, suggested that the benefits of short-term HRT are worth it, particularly for women with severe symptoms.

Looking at women in three big studies, including WHI, the investigators found that short-term HRT therapy shortens life expectancy by a few days but increases quality of life among women with mild or severe menopausal symptoms. The women's improvement in quality of life depended on the severity and duration of their symptoms, the relief provided by HRT, and their risk of cardiovascular disease.

The study found that an average 50-year-old woman using HRT for two years lost about 12 days of life expectancy. Women at high risk for cardiovascular disease lost about 37.5 days of life expectancy, while women at low risk for cardiovascular disease lost about six days.

In a report called Hormone Therapy, the American College of Obstetricians and Gynecologists (ACOG) came to similar conclusions about the short-term use of HRT. The report noted that while 65 percent of women taking HRT stopped doing so after the WHI findings were released, about a quarter of the group that stopped have re-started. Although the report did not dispute the basic WHI findings and recommendations, Hormone Therapy.

Hormone Therapy

  • Combined hormone therapy should not be used for prevention of cardiovascular disease, due to the small but significant increased risk of breast cancer, heart attack, stroke or blood clots.

  • Estrogen-alone therapy, used for women who have had a hysterectomy, should also not be used for prevention of diseases, due to increased risks of blood clots and stroke. Although estrogen therapy carries fewer risks than combined HRT, women with a uterus should not use estrogen alone due to their increased risk of uterine cancer.

  • Hormone therapies are appropriate for the relief of vasomotor symptoms -- such as hot flashes and night sweats -- as long as a woman has discussed the risks and benefits with her doctor.

  • Women on combined HRT or estrogen therapy should take the smallest effective dose for the shortest possible time and annually review the decision to take hormones.

More information

For more on hormone replacement therapy and menopause, visit the American College of Obstetricians and Gynecologists.

Related Stories

No stories found.
logo
www.healthday.com