HRT Update: What The Experts are Saying
By Kathleen O'Grady, Director of Communications for the Canadian
Women's Health Network, and the research team from A Friend Indeed, the
newsletter for women in menopause and midlife: www.afriendindeed.ca
With all the controversy
about HRT, it is sometimes difficult - even for health care practitioners -- to
keep up with the most recent scientific information since every few months brings
a flurry of new data. So here's an update of the most significant recent practice
guidelines and studies:
Paper on Women's Health and Menopause: An international team of experts
in women's health have established new clinical guidelines for the treatment of
patients going through menopause. At a recent symposium sponsored by the Office
of Women's Health Research at the National Institutes of Health and the Giovanni
Lorenzini Medical Science Foundation in Milan, 28 doctors and scientists evaluated
the most current HRT research and collectively recommend that HRT should NOT be
prescribed for heart disease, fractures, depression and urinary incontinence.
The authors of the position paper note that most of the evidence in favor
of HRT in the past had come from observational studies and clinical experience
- so called, "soft data". New randomized, controlled clinical trials
- the "gold standard" for health research -- are causing many health
specialists to reconsider their views on HRT and revise their clinical practice.
The expert panel notes that:
- There is no reliable evidence to
suggest that HRT arrests or delays the onset of Alzheimer's disease, relieves
depression, or aids urinary incontinence.
- While studies indicate that
HRT helps to prevent bone loss in postmenopausal women, there is no direct evidence
to determine if HRT reduces the risk of fractures. And for HRT to be effective
in maintaining bone mass, it must be taken continuously, and not just in the short
term. Since long-term HRT use has several serious side-effects, including blood
clots, biliary disease and breast cancer, the panel recommends non-hormonal drug
options, such as bisphosphonates, as well as dietary and lifestyle changes, to
address bone mass in place of HRT.
- HRT has been shown to alleviate hot
flashes and night sweats, but diet and lifestyle changes as well as SSRIs (selective
serotonin reuptake inhibitors) are other viable options.
- The new evidence
on HRT and coronary disease indicates that HRT does not reduce the risk for heart
attack and stroke, but may, in fact, increase that risk. Diet and lifestyle changes,
as well as nonhormonal drugs to lower cholesterol and blood pressure, may address
coronary health in place of HRT.
The bottom line: HRT should not
be prescribed to reduce the risks associated with Alzheimer's disease, heart disease,
severe depression, urinary incontinence and fractures.
The final report
will be published in June by the National Heart, Lung and Blood Institute. A chapter
summary is available at: www4.od.nih.gov/orwh/
JAMA 287,15; NY Times 04 18 2002 and 04 23 2002.
of the American Medical Association Editorial: A panel of experts examines
the new data on HRT and notes that long-term HRT use has been linked to an increased
risk of cardiovascular disease, breast cancer, venous thromboembolism and gallbladder
disease. Given these significant risk factors, the authors recommend that caution
should be employed before embarking on treatment. While studies have demonstrated
that HRT may improve bone density, the authors note that there are other, non-hormonal
means available for the prevention and treatment of osteoporosis.
02 06 2002:287,5.
Revised Guidelines for the
American Heart Association and the Heart and Stroke Foundation of Canada:
Both the AHA and the HSF have recently issued new guidelines regarding hormone
- Hormone therapy should not be prescribed to women who already
have a history
of heart disease.
- Hormone therapy should not be prescribed
solely in order to reduce the risk of
developing heart disease.
non-medicinal measures can be undertaken to reduce the risk of heart
such as stopping smoking, becoming more active and reducing blood
and cholesterol levels.
The shift in expert opinion
has been based on findings from a number of important recent clinical trials:
Heart and Estrogen/Progestin Replacement Study (HERS): This randomized,
blinded, placebo-controlled trial of women with a history of heart disease found
no overall benefit after four years of treatment with estrogen plus progestin.
Participants in the first year of the study had more heart attacks and deaths.
AFI, Vol. XV, No. 5.
The Women's Health
Initiative: (WHI): Randomized trials of more than 27,000 healthy women.
Based on the first 3 years of the Estrogen Plus Progestin Study (16,608 postmenopausal
women), researchers reported that estrogen and estrogen plus progestin were associated
with an increased risk of heart attacks, blood clots and strokes compared to placebo.
Study participants were updated about these findings and encouraged to continue
in the trial. Final results were not expected before 2005, but the trial was stopped
on July 9, 2002 due to increased risks of invasive breast cancer, coronary heart
disease, stroke and pulmonary embolism in women taking active medication over
288, No. 3, July 17, 2002.
Replacement in Atherosclerosis (ERA) trial: This study finds that atherosclerosis
(degeneration of the arteries due to fatty deposits) is not slowed by taking estrogen
or estrogen plus progestin in women with pre-existing heart disease.
The Women's Estrogen for
Stroke Trial (WEST): Finds no reduction in risk of stroke and death
or coronary events among 664 postmenopausal women treated with estrogen or placebo
for 2.8 years. Women in the hormone group have an increased risk of stroke in
the first 6 months of treatment.
SEER Cancer Stat Rev, NCI 2001.
HERS data: Also shows that women who took
hormones for a mean of 4.1 years do not have a lower risk of any type of fracture
compared with those taking placebo. While hormone therapy reduces bone loss in
postmenopausal women, no large randomized trial has been done to demonstrate that
HRT reduces the risk of fractures.
Am J Med 2001;110:442-450.
ERT and Breast Cancer: Many types of research suggest a link between
estrogen use and increased risk of breast cancer among long-term hormone users
(i.e. over 5 years), however randomized control data is lacking. Data from the
National Cancer Institute suggests that HRT may increase the risk of breast cancer
beyond that associated with estrogen alone, but more definitive research is needed
on progestins and breast cancer risk.
JAMA 2002;287(16); See AFI, Vol.
XVII, No. 1.
--Reprinted with permission from A
Friend Indeed, the newsletter for women in menopause and midlife.
Menopause Myths and Facts: What Every Woman Should Know about Hormone Replacement Therapy - book by Lorraine Rothman MS and Marcia Wexler PhD.
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