Hormone therapy is not recommended to prevent heart disease and other chronic illnesses, but it may be appropriate to relieve hot flashes and other menopausal symptoms in the short term for some women, a large 13-year followup study suggests.
The pendulum has swung widely in prescribing hormone therapy. Initially, it was used to manage menopausal symptoms and then in 1980s and 1990s it was prescribed for bone health and to prevent heart disease and Alzheimer's disease.
Prescriptions for HRT started to decline after 2002 after the landmark Women's Health Initiative (WHI) showed combined estrogen and progestin therapy increased women's risk of breast cancer, heart disease and stroke compared with taking a placebo. Now a followup study, published in Tuesday's issue of JAMA, reaffirms those findings and clearly makes a distinction about short-term use of hormone therapy in early menopause.
"Hormone therapy really should not be used for the express purpose of chronic disease prevention, but that it is appropriate for many women in early menopause who have moderate to severe menopausal symptoms," said study author Dr. JoAnn Manson, an endocrinologist at Brigham and Women's Hospital in Boston.
Manson said short-term use is generally five years and women tend to enter early menopause in their 50s.
While short-term use of hormone therapy may be useful to treat hot flashes, night sweats and other menopausal symptoms that harm quality of life, long-term use for chronic disease prevention "is not warranted," Dr. Elizabeth Nadel, of Brigham and Women's Hospital in Boston, said in a journal editorial published with the study.
The extended followup study looked at 27,347 postmenopausal women, ages 50 through 79 years, who were enrolled throughout the U.S. in 1993.
About 8,000 women with a uterus received conjugated equine estrogens (CEE) plus medroxyprogesterone acetate (MPA) and an equal number received placebos. Another 5,300 women with prior hysterectomy received CEE alone and about an equal number had placebo.
In the combination group, risks were increased for coronary heart disease, breast cancer, stroke, pulmonary embolism, dementia (in women 65 years of age and older), gallbladder disease, and urinary incontinence.
Benefits included decreased hip fractures, diabetes, and vasomotor symptoms like hot flashes.
Women got mixed messages
Risks and benefits were more balanced in the estrogen only group, Nadel said.
Increased risks of stroke and blood clots remains a concern for both groups, Manson said.
The re-emphasis of the study is useful for women who have received a mixed message, said Dr. Jerilynn Prior, a professor of epidemiology at the University of British Columbia.
Prior said there's a cultural concept about menopausal women being ridden with risks for disease and estrogen deficiency.
"Despite the fact that we have evidence that says hormone therapy doesn't prevent disease, the cultural concept has not changed," Prior said.
Menopausal women, a year past their last flow, who are waking night after night with hot flashes will be persuaded to take oral estrogen therapy with the hope it will prevent heart disease and osteoporosis, Prior said. But the new data confirms oral estrogen-based hormonal therapies carry small but real increased risks for stroke, blood clots, breast cancer, gall bladder disease, early dementia and incontinence, Prior said.
Prior suggested a lifestyle prevention package for hot flashes that includes:
- Stopping smoking cigarettes. (if relevant)
- Practicising relaxation or yoga breathing.
- Getting regular exercise.
- Eating a balanced diet.
Prior's own research at the Centre for Menstrual Cycle and Ovulation Research is looking at progesterone only therapy.
Doris Hopkirk, 69, of Mt. Pearl, N.L., took hormone therapy for 21 years after a hysterectomy. She says hot flashes and other menopausal symptoms were relieved, but it took a long time to wean herself off HRT.
The WHI study is funded by the U.S. National Heart, Lung, and Blood Institute. Wyeth-Ayerst donated the study drugs.