Hormone Replacement Therapy (Revisited)

So much has changed over the last 10 years in terms of recommendations for Hormone Replacement Therapy (HRT). In the 1990’s and before we routinely recommended HRT for most postmenopausal women touting its multiple benefits from control of hot flashes and night sweats to better bone health and decreased cardiovascular risk and improved sexual function. But the HRT world was turned upside down with the initial and subsequent findings of the study known as the Women’s Health Initiative (WHI).

This study originally was suppose to be the “end-all” of studies, finally confirming, once and for all, the benefits of HRT. However, their results sent things in the opposite direction. The investigators for the WHI reported that HRT actually increased cardiovascular risks and increased breast cancer risks and, perhaps, there were not any benefits at all to taking HRT. Telephones in physicians offices began ringing off the hook with terrified patients, many of whom quit taking their hormones immediately.

I felt at that time, and still do today, that the WHI study perpetrating one of the great injustices to women around the world. There existed significant problems with design of some of the arms of the study, including problems with the patient populations chosen to participate in the study. And, unfortunately, when the WHI results began to be published, funding for other similar studies in other parts of the world, studies with exact opposite results, had their funding discontinued. This was disastrous because, in all likelihood, we will never see these types of studies repeated because they are simply too expensive to conduct.

Over time, even some of the WHI’s most ardent supporters began to back away from some of the study’s conclusions. Many of us believed then and now that there are benefits to taking HRT and many women are not receiving those benefits because of the conclusions of this flawed study.

The reason I chose to report on this topic again this week is because of more results coming from the WHI folks were published this month in the Journal of the American Medical Association. This follow-up reported that women in the study who were taking estrogen-only HRT, as opposed to estrogen and progesterone in combination, actually had a 23% lower risk of breast cancer than patients taking placebo. This report separated the estrogen-only patients from the women who were taking estrogen and progesterone in combination. The estrogen-progesterone group still demonstrated an increased risk of breast cancer.

This report demonstrates the most frustrating aspect of the Women’s Health Initiative study. That is, that immediate and sweeping changes were made based on the results of this flawed study, and its results were generally applied across different segments of the population without regard to potential important differences such as each individual woman’s health status or her age or the type of hormone replacement utilized.

The bottom line really has not changed. The fact is that HRT has, like most things in medicine (or life, for that matter), risks and benefits. There are risks in some women AND there are clearly benefits in some, as well. The point is we cannot practice cookie-cutter medicine. The decision on whether or not to take HRT is a personal choice of each individual patient. With guidance from her physician, she must make the decision that is best for her. If she decides she would like to take HRT she should still strive to take the lowest possible dose that will provide benefits while minimizing the risks.

At the end of the day, the Hormone Replacement Therapy data-base is a work in progress.