Hormone Replacement Therapy: Safe or Not?
WEDNESDAY Oct. 24, 2012 -- Is hormone replacement therapy safe or not?
It has taken a decade of research to arrive at a conclusion that is far from definitive: The evidence suggests it may help in the short term to manage hot flashes and other symptoms of menopause in some younger, healthy women. But, taking it for long periods of time or later in menopause to help prevent certain chronic diseases isn't recommended.
On Monday, the U.S. Preventive Services Task Force once again backed the idea that long-term use later in menopause is unwise when it released recommendations that said the increased health risks outweighed the benefits of using the treatment in that medical scenario.
That was not always the prevailing view in the medical community, however.
For years, it was common for women suffering from hot flashes, night sweats and other life-disrupting symptoms of menopause to go on hormone replacement therapy -- typically a combination of estrogen and progesterone or progestin (a progesterone-like medication). That all changed in 2002, when the practice was halted by many after the landmark Women's Health Initiative trial found that rates for breast cancer and stroke were higher in women on hormone replacement therapy compared to women who weren't taking the treatment.
Although the study of more than 16,000 women reported some benefits, including lower rates of hip fractures and fewer cases of colon cancer, there were increases in heart disease, strokes and pulmonary embolisms (dangerous blood clots in the lungs) in women who took estrogen and progestin compared to women on placebo pills. The study, scheduled to run until 2005, was shut down early as a result.
"After 2002 and the Women's Health Initiative study, people just stopped their hormone therapy. I think the study was an amazing study and gave us really good information, but you have to look at it in the time it was organized and developed, in early 2002, 2003," said Dr. Anne Ford, associate professor of obstetrics and gynecology at Duke University School of Medicine.
Hormone replacement therapy formulations have since changed, and more recent research has teased out some groups of women who might benefit from the treatment, she added.
A Danish study of 1,000 women published earlier this month in BMJ suggested that women who began taking hormone replacement therapy early in menopause and who continued taking it for an average of 10 years cut their risk of having a heart attack, heart failure or dying without raising their risk for breast cancer or blood clots.
Two other recent reports also suggested that hormone replacement therapy holds benefits for some. One found that it was safe for the heart, and the other reported that it did not worsen memory in younger women.
"The new studies are well done and very important, since they address younger women," said Dr. Judi Chervenak, a reproductive endocrinologist at Montefiore Medical Center in New York City.
Although the newer research does not necessarily negate the findings of the Women's Health Initiative study, she said, it also does not have the power of that study in terms of how many women were followed. She said the new studies support that for some women -- especially younger women without any health problems -- hormone therapy might be a good option.
"Hormone therapy is no longer the arsenic it was once thought to be after the Women's Health Initiative," Chervenak said. A woman suffering from hot flashes, vaginal dryness or osteoporosis should discuss the pros and cons with her doctor, she said.
"They need to talk about family history of heart disease, blood clots and high cholesterol," she explained. "For someone with very high triglycerides, for example, estrogen could adversely affect those levels."
There are two issues at play, said Dr. Margery Gass, executive director of the North American Menopause Society.
"I want to get across the difference between taking something long term for prevention versus taking it short term when you're younger and healthier to treat symptoms for a limited amount of time," Gass said. "We recommend [hormone replacement therapy] as a viable option for treating menopausal symptoms in healthy women -- in women not at high risk for blood clots, breast cancer and stroke."
Gass said the newer research suggests that women should not be taking hormone therapy to prevent chronic diseases associated with aging.
That conclusion mirrors the latest opinion issued by the U.S. Preventive Services Task Force, an independent panel of experts in prevention and evidence-based medicine that makes screening recommendations for various conditions and diseases.
The panel's review of 51 articles published since 2002 recommended that postmenopausal women, including those who have had a hysterectomy, not take estrogen alone to prevent chronic conditions.
The potential harms of hormone replacement therapy outweigh any possible disease-prevention benefits in these women, the task force said.
For women seeking non-drug options to manage the discomforts of menopause, Ford suggested exercise, such as yoga, and a healthy diet. Other strategies: Layer clothing, meditate, practice paced breathing (also called relaxation breathing), maintain a healthy weight and avoid smoking.
Ford said there is probably a lot to be learned by looking at different communities and cultures, too. "Ethnicity seems to play a role in how women manage menopause," she noted.
Earlier research has shown that black and Hispanic women tend to enter menopause earlier than white women, and also tend to suffer more severe symptoms.
For more on hormone replacement therapy, go to the U.S. National Library of Medicine.
Posted: October 2012
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