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.