Estrogen Therapy: WHI Initiative in Perspective (cont.)

The First surprise was that the WHI study was stopped early, after just 5.2 years, because there were early signs of increased harm (increase in coronary heart disease, stroke, and blood clots in the lungs) that outweighed the benefits (decreased fractures and colon cancer).

The WHI estimates that out of 10,000 women who take the particular EPT combination over the course of a year, we can expect additional cases of several serious health problems:

  • 23 additional diagnoses of dementia
  • 7 more heart attacks
  • 8 more strokes
  • 8 more pulmonary emboli
  • 8 more breast cancer cases

At the same time, however, there would be 6 fewer colorectal cancers and 5 fewer hip fractures. Many are women who are "hanging on" to EPT because of fear of Alzheimer's disease running in her family, only to be disappointed by the WHI study results.

The increase in breast cancer became especially apparent after 3-5 years, but the increase in heart disease and pulmonary emboli occurred early on, in the first year.

Some physicians, and their patients, would say that we finally have the answer, but we don't necessary like it. On the other hand, many points are worth emphasizing:

  1. There is still nothing that works better than estrogen therapy for hot flashes, moreover, no other therapy besides estrogen is approved for hot flashes.

  2. Women in the WHI study were not picked because they had hot flashes, so we really don't know the long-term risks and benefits for younger women who are beginning EPT when they are actively battling hot flashes.

  3. The increase in risk to an individual woman is still small.

  4. Many women in the WHI study were older yet most women begin EPT when they're younger.

  5. It seems that the progesterone part of the EPT may be the "bad guy" regarding breast cancer risk. (Progesterone is given to protect against uterine cancer during estrogen therapy). The part of the WHI study that is following women after hysterectomy who are taking estrogen alone is still ongoing. Maybe estrogen alone will be found to be a little safer in certain aspects, possibly reassuring to women with a hysterectomy.

  6. Only one type of EPT was used in the WHI study. We don't know how other brands and doses compare. For now, we have to assume the same risks apply to other preparations, until proven otherwise.

The upshot:

EPT is still the best therapy for hot flashes, and many women remain good candidates for EPT therapy, despite the WHI study. This is especially true if EPT is limited to the shortest duration possible, optimally less than 5 years. Women shouldn't stop EPT suddenly. They should wean down slowly to avoid having withdrawal symptoms. EPT should not be used to prevent or treat either Alzheimer's disease, heart disease, or stroke. Some alternatives to EPT are available to women who cannot or do not wish to take EPT, although these alternatives don't work as well as EPT to treat hot flashes and are not FDA-approved to treat hot flashes. Women (and men) should always question whether medical research comes from randomized controlled trials (the highest quality research method).

In regard to the use of EPT as osteoporosis prevention, many non-hormonal alternatives exist to treat osteoporosis.

As a final thought, women should speak to their physicians on an individual basis to determine the right treatment plan for them. At least that's something that still hasn't changed.

Last Editorial Review: 7/17/2003