Menopausal Hormone Therapy . . . Current Concepts (cont.)

There are 2 ways to think about decision-making regarding hormone therapy (HT). In general terms, we can group the "good things" together and the "bad things" together and compare them. The way scientists do this is to multiply the numbers of women by the number of years that they are taking the hormone therapy. This measure is called "person-years". In the WHI, the numbers of expected good things (protection against colorectal cancer and hip fracture, were less than the number of expected bad things (heart disease, stroke, blood clots in the lungs, and breast cancer) - specifically, 11 extra "good things" as compared to 31 extra "bad things" per 10,000 person-years for the women taking estrogen/progesterone therapy compared to taking placebo. For the women taking estrogen therapy, the corresponding numbers are 18 extra "good things" and 15 extra "bad things". Each individual woman will have a different opinion about whether the 31 extra "bad things" per 10,000 women taking estrogen/progesterone therapy for a year is enough to make her avoid hormone therapy. Because of this, the decision whether to initiate hormone therapy is a highly personal decision.

If this is too confusing, consider the following seven possible scenarios:

  1. A woman just recently becomes menopausal. She had her last menstrual period a year ago and is began taking CEE/MPA due to bothersome hot flashes. What should she do with the CEE/MPA she is taking?

If she is at otherwise low risk for stroke, heart disease, or blood clots (which she will determine with her physician), she can consider continuing her CEE/MPA to control her hot flashes. Although this is a highly personal decision, the otherwise healthy woman who takes the hormone therapy for a short-term period (fewer than 4 or 5 years) to relieve hot flashes is in fact currently the best candidate for hormone therapy. The "risk and benefit" is likely to be in her favor because she is otherwise healthy, she will only use the hormone therapy for a short period, and hormone therapy is an the most effective therapy (the only FDA-approved therapy) for reducing hot flashes.

  1. A woman has been taking hormone therapy for 2 years due to hot flashes, but a different hormone preparation, not CEE/MPA. She wants to know how to apply the results of the WHI in her own case.

The WHI did not include any preparation other than CEE/MPA. Therefore, we cannot make firm conclusions. It is probably reasonable to say that similar overall risks and benefits apply as in the woman in example 1 above. Again, each women has to carefully consider her individual health profile and balance of risk versus benefit, optimally with her physician. If her overall health is good (no particular risk of heart disease, stroke, blood clots, or breast cancer prior to starting therapy); if she is going to use the therapy for only a few years; and if her hot flashes are bothersome enough that she wants to take therapy; she can reasonably opt to continue the therapy with an generally low risk of complication. Again, as mentioned above, each individual woman has to decide what level is increased risk is "acceptable."

  1. A woman has been taking hormone therapy for 8 years. She feels great and is afraid of stopping because her mother has terrible osteoporosis. She needs to know what to do about her family history of osteoporosis. Her mother had a hip fracture.

This answer is relatively clear and established even before the WHI results: A logical plan is to check bone density results. If the woman has low bone density, or has already experienced an osteoporosis-related fracture, there are other non-hormone options for her bones that she can try. If she does not have low bone density, she can just continue bone monitoring at appropriate intervals.

  1. A woman has been taking hormone therapy for 8 years because she was already found to have osteoporosis when she was 58 years old.

In this case, she wouldn't need to have a bone density test because we already know she has osteoporosis. She needs to consider and discuss with her physician the possibility of switching to a non-hormone osteoporosis medication. The irony is that the WHI actually did show us for the first time ever, conclusive proof that hormone therapy prevents osteoporosis fractures; however, the problem is the balance of risk and benefit would lead us to avoid long-term hormone therapy because of the possible risks of breast cancer, heart disease and vein clots, and because there are safer non-hormonal options available.

  1. A woman has been taking hormone therapy for 8 years. Several 1st degree relatives had heart attacks at an early age. She has never had any heart trouble herself, and she does not have hot flashes.

Although we used to think hormone therapy reduced heart disease risk, we recently began to realize (even before WHI) that hormone therapy (either estrogen therapy or estrogen/progesterone therapy) does not prevent heart disease, and indeed may actually increase coronary heart disease risk in otherwise healthy women, i.e., women who are not taking hormone therapy to reduce hot flashes. Neither estrogen/progesterone therapy nor estrogen therapy should be used primarily for protection from, or therapy of, coronary heart disease. The WHI results provided additional sound proof for this recommendation. The woman with a strong family history of coronary heart disease should generally be recommended to avoid hormone therapy for any purpose.

  1. A woman was diagnosed with a heart attack about 9 years ago. Two years after her heart attack her doctor recommended CEE/MPA due to her osteoporosis, and because at the time her physician felt it might prevent recurrence of heart events in the future. What should she do?