Hormone Replacement Therapy

Position Statement on Hormone Replacement Therapy
from Dr. Kenneth H. Cooper

In view of the findings from the Women's Health Initiative (WHI) study , released May 31, 2002, showing that the risk of hormone replacement therapy (HRT) in healthy menopausal women may exceed the benefits, the following recommendations are given to those women who have been taking or are considering taking hormones:

1. Do not stop or start HRT without discussing this with your personal physician. There is no one recommendation that is appropriate for all menopausal women.
   
   
2. Women entering menopause who do not have menopausal symptoms, such as night sweats, hot flashes, etc., should weigh carefully the pros and cons of HRT, particularly using Prempro. The present study provides evidence that starting HRT for prevention of cardiovascular disease does not appear to be warranted. Individuals at particular risk for breast cancer should be cautious about starting HRT.
   
   
3. Women already taking HRT should re-evaluate the reasons they are on this medication to see if continued use is still warranted. Risk of breast cancer with HRT seems to increase the longer the medication is taken.
   
   
4. Women with an intact uterus who are using hormone replacement therapy must use progesterone along with estrogen, since estrogen alone has been shown to increase the risk of uterine cancer. In such cases, alternatives to Prempro should be considered.
   
   
5. The WHI study has not reached a conclusion regarding the effects of estrogen alone in women who have had a hysterectomy, although another recent study conducted by the National Cancer Institute did show a correlation between estrogen replacement only and an increase in ovarian cancer. This relationship increased over time with the greatest possibility occurring after 20 years. However, since there is only one study to date which documents this adverse effect, we are not recommending that estrogen therapy be discontinued in these women.
   
   
6. Remember, only Prempro was evaluated in the WHI study, so specific recommendations regarding use of any other hormones, different dosages, or other ways in which the hormone is given (patch or injection) cannot be made at this time. Nonetheless, three studies reported to date in the United States with other regimens have all found an increased risk of breast cancer.
   
   
7. The results of the heart and estrogen/progestin replacement study (HERS) of postmenopausal women with coronary heart disease (CHD) initially showed that women taking HRT had more CHD events than the placebo in the first year, but fewer in years 3 to 5. Followup studies showed that lower rates of CHD events among women in the hormone group in the final years of HERS did not persist during additional years. Postmenopausal hormone therapy should not be used to reduce the risk for coronary heart disease events in women with CHD. Also, treatment for 6.8 years with estrogen plus progesterone in older women with coronary disease increased the rates of venous thromboembolism (blood clots) and biliary tract (gallbladder) surgery.
   
   
8. In conclusion, these studies indicate that combined postmenopausal hormones should not be initiated or continued for the primary prevention of coronary artery disease. To reduce heart disease risk, rely on proven therapies such as controlling cholesterol and high blood pressure, exercising regularly, and not smoking. Use estrogen as a second choice for the prevention of osteoporosis, hip fractures, and colon cancer. And remember, the final decision as to whether or not to continue hormone replacement therapy must be individualized and discussed with one's personal physician.
   
   

References:

• Writing Group for the Women's Health Initiative, "Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women," JAMA Vol. 288, No. 3 (July 17, 2002): 321-333.
  
  
• James V. Lacey, Jr., Ph.D. et al, "Menopausal Hormone Replacement Therapy and Risk of Ovarian Cancer," JAMA Vol. 288, No. 3 (July 17, 2002): 334-341.
  
  
• Suzanne W. Fletcher, M.D., M.Sc., Graham A.Colditz, M.D., Dr.PH., "Failure of Estrogen Plus Progestin Therapy for Prevention," JAMA Vol. 288, No. 3 (July 17, 2002): 366-368.
  
  
• Deborah Grady, M.D., M.P.H., et al, "Cardiovascular Disease Outcomes During 6.8 Years of Hormone Therapy," JAMA Vol. 288, No. 1 (July 3, 2002): 49-57.
  
  
• Stephen Hulley, M.D., M.P.H., et al, "Noncardiovascular Disease Outcomes During 6.8 Years of Hormone Therapy," JAMA Vol. 288, No. 1 (July 3, 2002): 58-66.