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:
- 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.
- 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."
- 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
- 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
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.
- 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
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
- 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?