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Panel Rejects Routine Use of HRT

Finds risks too great to recommend for chronic ailments

WEDNESDAY, Oct. 16, 2002 (HealthDayNews) -- A U.S. health panel has given a failing grade to hormone replacement therapy as a routine treatment for chronic ailments, saying whatever benefit the treatment provides is outweighed by its risks.

The announcement by the U.S. Preventive Services Task Force follows by five months the suspension of a major federally funded study of hormone replacement therapy.

The task force said today that it could not recommend the combination of estrogen and progestin to women with chronic problems like heart disease, osteoporosis, and memory trouble.

"On average, it's not a good deal," said task force chairman Dr. Alfred Berg, a family medicine specialist at the University of Washington in Seattle.

"Some women may find a strong benefit and the potential harms modest and would still go ahead," he adds. "This policy permits individual shared decision making."

The panel did not rule out the possibility that women who've had a hysterectomy might benefit from taking estrogen alone -- since their risk of uterine cancer from the hormone is negated -- but it said the evidence so far was inconclusive.

Nor did the task force look at the benefits of taking hormones to relieve the symptoms of menopause, like vaginal dryness, insomnia, and hot flashes. And it found no conclusive evidence that soy-derived estrogen can prevent brittle bones due to osteoporosis or reduce the risk of heart and blood vessel problems.

Berg said women who are already taking HRT should pay as much attention to the new recommendations as those considering starting the treatment.

The guidance is in line with the current wisdom about the value of hormone replacement therapy, which has been shaped significantly by recent events.

Earlier this year, researchers halted a major trial of estrogen plus progestin treatments for postmenopausal women after determining that the combination increased the risk of stroke, blood clots, and invasive breast cancer. Those taking the common combination hormone therapy, as part of the Women's Health Initiative, experienced a 29 percent higher rate of coronary heart disease problems than those taking a placebo.

Stroke rates were 41 percent higher in women receiving both hormones, and the rate of blood clots doubled. Invasive breast cancer rates were 26 percent higher. And total cardiovascular disease increased by 22 percent.

Another arm of the trial, exploring the benefits of estrogen therapy alone, was allowed to continue.

On the positive side, the task force concluded that estrogen and progestin treatment does increase bone density and probably cuts the risk of fractures in women. The panel also saw "fair" evidence that the drugs can lower the odds of colorectal cancer.

But those benefits were undermined by evidence that hormone replacement therapy (HRT) triggered more heart and vessel problems, breast cancer, and other undesirable side effects. For every 10,000 women who take the two hormones for a year, there would be seven extra heart attacks or other episodes of heart disease, eight extra strokes, eight more cases of lung clots, and eight additional cases of invasive breast cancer, the panel said.

Meanwhile, the treatment would lead to six fewer cases of colorectal cancer and five fewer hip fractures.

Women who decide not to take HRT for chronic conditions aren't necessarily stranded in a treatment-free desert, experts said. Effective alternatives exist to prevent several of the ailments reviewed by the task force, including osteoporosis and heart disease.

However, for other health problems, like colorectal cancer and dementia, the options aren't there yet, Berg said.

Until half of the Women's Health Initiative was halted, roughly 17 million American women were taking HRT. That number has dropped, though by how much isn't clear.

If the recommendations of the preventive services task force don't sway doctors' prescribing practices, another force might. At least one large malpractice insurer, COPIC, of Denver, Colo., now requires its doctors to obtain informed consent signatures from women receiving HRT.

"It's unusual," said Dr. Paul Miller, a Denver bone expert covered by COPIC. "I don't have to do this form for anything else."

If other insurers follow suit, said Miller, it would be the "nail in the coffin" for hormone replacement therapy, scaring women off the drugs. That, he added, wouldn't be warranted, even with the results so far from the Women's Health Initiative.

Miller and other experts have pointed out that the suspended trial included women older than the typical age of onset for menopause -- their average age was 63, while menopause usually happens around age 50. The risks and benefits in early menopausal women may be different, he said.

What To Do

For more information on hormone replacement therapy and its risks and potential benefits, try the Women's Health Initiative or MEDLINEplus.

SOURCES: Alfred Berg, M.D., professor and chairman, department of family medicine, University of Washington, Seattle; Paul Miller, M.D., medical director, Colorado Center for Bone Research, Denver; U.S. Preventive Services Task Force, Oct. 16, 2002
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