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Some Hormone Replacement Therapy Has Value

Report endorses limited estrogen use

SUNDAY, Dec. 5, 2004 (HealthDayNews) -- The value of hormone replacement therapy for postmenopausal women has taken a pounding in recent years.

While it doesn't dispute the major findings that some forms of hormone replacement therapy (HRT) can be dangerous, a recent report from the American College of Obstetricians and Gynecologists says some variations of short-term use can be effective and safe.

Dr. Isaac Schiff, chairman of the 21-member ACOG Task Force that created the report, Hormone Therapy, describes it as an "encyclopedic effort" that "catalogues what medical science knows so far about the effect of reproductive hormones on everything from sex life to mental health, cancer to weight gain."

That's why the report, released as a supplement to the October issue of ACOG's Obstetrics & Gynecology, may become a useful guide in the somewhat bewildering landscape menopausal women currently must traverse to decide whether estrogen, estrogen plus progestin or some other course of treatment is appropriate for their menopause-related symptoms and conditions.

Hormone Therapy reaffirms most of the recommendations the medical community made after the Women's Health Initiative (WHI) study results in 2002 and 2004 found that estrogen plus progestin (or combination therapy) can cause increased risk of heart attack, stroke, blood clots and breast cancer. But it includes new conclusions about the length of time and specific reasons some women might benefit from hormone therapy.

There was a good reason for the nation's leading obstetrics and gynecological organization to create a report outlining the ways some form of estrogen therapy could be used: abruptly stopping HRT therapy was not a good idea for many women.

"Approximately 65 percent of women on hormone therapy stopped taking hormones after the WHI study findings were made public," Schiff said.

"Two years later, reports suggest that about one-in-four women who stopped taking hormones have gone back on them because hormones still offer the best relief for some specific menopausal symptoms. So we're moving back to an appropriate balance -- accepting that hormone therapy has risks, but recognizing that it can be appropriate for conditions like hot flashes, so long as women are informed about these risks and weigh their decisions with their doctors."

For example, Hormone Therapy recommends that although women should use hormone therapy for the shortest possible time, estrogen remains the most effective treatment for hot flashes or night sweats. Nasal sprays or transdermal (patch) hormone treatments can provide comparable results to hormones taken as pills. According to the report, about 10 percent of postmenopausal women continue to suffer from hot flashes beyond the usual four-year period experienced by most women.

Hormone Therapy reaffirms many of the recommendations made immediately following publication of the 2002 WHI findings on combined hormone therapy and the 2004 WHI findings on estrogen-alone (ET) therapy, including:

  • 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.

But the ACOG report also concludes it's inappropriate to withhold hormone therapy from persistently symptomatic women who prefer to continue taking hormones or who do not derive relief from currently available alternatives. "Hormone therapy is appropriate to treat women who feel better on it or who feel it improves their sexuality," said Schiff.

The new guidelines also include a review of research studies on alternative treatments for women who can't or don't want to take hormones, including antidepressants known as selective serotonin reuptake inhibitors (SSRIs), the anticonvulsant gabapentin, and a host of herbal alternatives. And, although it is still ACOG's position that hormone therapies should not be used solely for disease prevention, the new guidelines make clear there are instances when disease prevention is appropriate as a secondary benefit for women who are already taking hormones for vasomotor symptoms.

Dr. Steven Petak, vice president of the American Association of Clinical Endocrinologists, gives the example of hormone therapy playing a role in protecting against the bone loss fractures associated with osteoporosis in some postmenopausal women.

Petak noted that the Women's Health Initiative study provides evidence that combined hormone therapy can reduce osteoporosis-related hip and spine fractures by about one-third and osteoporosis-related fractures of other bones by almost one-fourth.

"Hormone therapy isn't necessarily the option of first choice to prevent osteoporosis," he said, "but it can be of definite value for women who have significant hot flashes and sleep disturbances, if they do not have a history of blood clots, strokes or other cardiovascular conditions."

More information

Find out more about postmenopausal hormone therapy from the National Institutes of Health.

SOURCES: Isaac Schiff, M.D., chairman, Chief Women's Care Division, Massachusetts General Hospital, Women's Health Issues and Specialty Care, Boston, and chair, ACOG Hormone Therapy Task Force; Steven Petak, M.D., associate, Texas Institute for Reproductive Medicine & Endocrinology, Houston, and vice president, American Association of Clinical Endocrinologists
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