(HealthDay is the new name for HealthScoutNews.)
WEDNESDAY, Aug. 20, 2003 (HealthDayNews) -- The barrage of recent news pointing to the mounting risks of hormone replacement therapy (HRT) has sent millions of worried women running to their doctors.
"This last year has been a very unhappy year for women," says Dr. Charles Farris, Jr., a gynecologist at the Ochsner Clinic Foundation in New Orleans. "Women are unhappy. They're mad. Some are hysterical."
With recent studies saying combination HRT can fuel deadly breast cancer and raise heart attack risk, many patients are too terrified to continue the therapy -- and some doctors are even refusing to prescribe it. This is in stark contrast to just a few years ago, when the therapy was prescribed for any number of reasons, including as a way to stave off heart disease.
But just as HRT should not be considered a panacea for every ill facing aging women, neither should it be completely abandoned, experts say.
An examination of the evidence shows that the place of hormone replacement therapy lies in a middle zone, not at either extreme, and that the therapy may be returning now to its original purpose: as a highly effective treatment for severe menopausal symptoms.
"There's a wholesale reluctance to prescribe hormone therapy," says Dr. Andrew M. Kaunitz, an obstetrics and gynecology professor at the University of Florida Health Science Center, who is a member of the North American Menopause Society and an investigator for the Women's Health Initiative (WHI). "I think that does women a disservice. There is nothing more effective for treating severe vasomotor symptoms and related symptoms, including sleep disorders, than hormone therapy."
HRT originally came on the scene to combat hot flashes, mood swings, disturbed sleep and other symptoms of menopause. But when observational data began to suggest that it might also reduce the risk of coronary heart disease, more women signed up.
Enter the WHI, which was designed to examine approaches to disease prevention in postmenopausal women and which included a section devoted to combined hormone therapy. This was the first large, randomized trial on the subject.
The biggest bombshell came last summer, when the WHI was unexpectedly halted several years early after women taking estrogen combined with progestin were seen to have a higher risk for heart attacks, heart disease, and breast cancer. Although the women also had a lower risk of colorectal cancer and fractures related to osteoporosis, researchers concluded that those benefits did not outweigh the risks.
The bad news continued two weeks ago, with a triple slam. A million-woman study in Britain found that the combination therapy may fuel a more aggressive and deadlier breast cancer, while American researchers, drawing again from the WHI, found that HRT poses the greatest risk of heart attack during the first year of use. The third study said the therapy does not slow the advance of atherosclerosis in women who already have the condition.
Where does that leave women? It seems pretty clear that HRT is not warranted for prevention. "Hormone therapy should be used only for treatment of substantial symptoms and not for the prevention of cardiovascular disease, not for the treatment of cardiovascular disease, not for the prevention of osteoporosis, even though there's documented efficacy there," Kaunitz says.
It's also probably not a good idea to take high doses for excessively long periods of time. "Doctors should be prescribing the lowest effective dose for the shortest period possible," says Dr. Steven Goldstein, a professor of obstetrics and gynecology at New York University School of Medicine in New York.
Women may even want to reconsider HRT for milder symptoms, he adds. "In the past, people took it because they didn't want to be inconvenienced by symptoms," Goldstein says. "People need to think long and hard about how disruptive their symptoms are. Simply being inconvenienced is no longer really a valid reason."
On the other hand, Goldstein adds, "it is appropriate to use for disruptive symptoms."
And once the initial anguish over the latest findings dies down, there may even be a silver lining.
"The use of hormones has to be tailored, and this involves a more dynamic approach in prescribing and following women who use them," Kaunitz says. That means more dialogue between patient and doctor.
There are also some other options that women can discuss with their physician, such as estrogen-releasing rings or vaginal tablets to maintain sexual function. Researchers are also looking at ways to minimize progestin use because it is this hormone, not estrogen, that appears to be the culprit in increasing health risks.
"Our job is to give the patient information and help them make informed responsible decisions," Kaunitz says. "That's very different from the hormone police policy that some doctors have adopted, a refusal to prescribe."
Faye Cannon, who owns a shoe boutique in New Orleans, had been on HRT for six years when the WHI results were announced. She was one of the women who went running to her doctor, Charles Farris. Farris sat her down with a pile of literature and talked her through the decision. In the end, Cannon stayed with the hormones.
"I feel strongly about women being frightened because of all this information," she says. "I'm going to continue until Dr. Farris says I don't need it any more. We'll discuss it."
More information
For more on the Women's Health Initiative, visit the National Heart, Lung, and Blood Institute. For more on menopause, visit the North American Menopause Society.
