HRT Statement
Statement by the Tepeyac Family Center On the Estrogen Plus Progesterone Trial Of the Women's Health Initiative
Many of our patients have expressed concerns and questions about the action taken by the Women's Health Initiative to halt an 8 year trial testing the long term use of hormone replacement therapy in postmenopausal women after only 5.2 years because of the increased risk of invasive breast cancer.
Specifically, the prospective randomized double-blinded trial concerned conjugated estrogens (Premarin) and medroxyprogesterone acetate (Provera) vs. estrogen alone vs. placebo. 27,000 women between the ages of 50-79 years were enrolled in the study, and 16,608 were randomized to the estrogen plus progesterone group. The estrogen plus progesterone arm of the study was stopped, but importantly, the estrogen alone arm of the study is being continued.
Evidence on the potential risks and benefits of combined estrogen/progesterone has slowly accumulated in previous studies, suggesting that the addition of progesterone may further increase health risks above that observed with estrogen alone. It is also unclear whether this data concerning synthetic progesterone can be extrapolated to natural formulations such as micronized progesterone.
The increased breast cancer risk did not appear in the first four years of use. Risks for blood clots were greatest in the first 2 years of hormone use. The reduced risk of colorectal cancer emerged after 3 years of hormone use.
38% of postmenopausal women in the United States use HRT, but what does this study mean to one unique woman? We at the Tepeyac Family Center realize this question poses great difficulties, and we have considered the options and the literature including this study, and reached into the depths of our hearts in prayer before making this recommendation.
Don't Panic! The increased risk of breast cancer applies to an entire population of women, rather than to an individual woman. The actual increase to one woman is very small…less than one tenth of 1% per year. A decision about hormone use should take into account a woman's individual risk for specific conditions that may be harmed or benefited by hormone use.
We realize that it is always difficult to make general statements concerning the health of individuals. We feel these are good general guidelines to use in making this important decision. Of course, please feel free to make an appointment to consider any specific concerns.
- If a woman has had a hysterectomy and is taking estrogen alone, she may continue to do so, although she may want to consider other means to treat symptoms and lower the risk of osteoporosis.
- If a woman's uterus is intact and she is taking estrogen and progesterone for relief of hot flashes and vaginal dryness, it is reasonable to continue that treatment for a short duration; this study supports up to 4 years. Again it is uncertain whether the type of progesterone makes a difference.
- Although this study demonstrated a lowering of the risk of colorectal cancer and hip fractures, estrogen and progesterone for treatment of chronic health problems is no longer recommended because the study demonstrated an increase in heart attacks, stokes, and blood clots.
- If a woman wishes to discontinue HRT, it is easier to tolerate the removal of estrogen if it is tapered over 4-6 weeks by decreasing the dose, then taking it on alternate days and finally discontinuing it as tolerated by your symptoms.
Other means are available to protect women from osteoporosis. This includes weight bearing exercise, calcium supplementation, and anti-resorptive drugs such as Fosamax and Actonel. - After a woman is no longer troubled with hot flashes, she has the option of taking one of the SERM's (Selective Estrogen Receptor Modulators) such as Evista, to protect her bones and improve her cardiovascular risks and lipid profile. This is key because it acts an anti-estrogen in the breast, and may actually lower the risk of cancer.
- Lubricants and vaginal estrogen can be used to improve vaginal dryness, and painful relations.
We at the Tepeyac Family Center realize that decisions about a patient's health are sometimes difficult. We hope these guidelines help our patients with this daunting task. As always, we will keep them in our prayers, and hope to serve as a resource. We would be happy to schedule a consultation should these guidelines fall short in terms of helping a patient make the decision. God bless.
Bibliography:
Writing Group for the Women's Health Initiative Investigators
Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women
JAMA 2002;288
www.jama.com