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Hormone replacement therapy questions continue

Perhaps if there were other really effective medications to treat menopausal symptoms people wouldn’t care so much about the safety of hormone replacement therapy.

But there aren’t medications that work as well as estrogen alone (for women who have hysterectomies) or estrogen plus progestin (for those with a uterus) to stop hot flashes, night sweats, sleep problems, foggy thinking, vaginal dryness, mood swings and other problems that crop up for some women during the menopausal transition.

That’s why studies such as one released Tuesday that further clarify the safety of hormone replacement continue to remain of keen interest to women and their doctors.

Researchers reported Tuesday that women who took estrogen alone had a decreased risk of breast cancer incidence and death up to five years after stopping the medication. Taking estrogen alone, however, is still linked to an increased risk of blood clots and stroke. And the decreased risk with estrogen use was not found among women who had an elevated risk for breast cancer due to family history or benign breast disease.

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The study is a follow-up of the Women’s HealthInitiative, which examined the pros and cons of hormone replacement therapy on many aspects of health and quality of life. The original study was begun in 1993 but was halted prematurely when the data suggested more harm than good came from both forms of hormone replacement therapy-- estrogen alone and estrogen plus progestin. Women were advised that if they need HRT for menopausal symptoms to take the lowest dose possible for the shortest amount of time possible.

However, that’s not the final word on hormone replacement therapy. Follow-up studies have uncovered much more complexity regarding its effects on women’s health and the need to tailor advice to individual women. For example, whether Hormone replacement therapy prevents heart disease or worsens it may depend on the age at which women start taking hormones. Studies are still ongoing on this question.

Tuesday’s study, in the Lancet Oncology, shows that some women may also benefit from estrogen-only use in terms of a lower risk of breast cancer. Estrogen alone is prescribed for women who have had hysterectomies while women with uteruses must take estrogen and progestin.

“What this study is really about, fundamentally, is it gets the entire clinical and research community to reengage in this question” regarding the risks and benefits of hormone therapy for subgroups of women,” said a co-author of the new study, Dr. Rowan T. Chlebowski, an investigator at the Los Angeles Biomedical Research Institute in Torrance and chief of medical oncology and hematology at Harbor-UCLA Medical Center.

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Last week, the North American Menopause Society, a nonprofit group of health professionals who work on women’s mid-life health issues, released an updated position statement on hormone replacement therapy that stressed the need for personalized treatment. The statement noted that most healthy women under age 60 will have no increased risk of heart disease by taking hormones and even the risks of blood clots and strokes are low in these women.

“Hormone therapy remains the most effective treatment available for menopausal symptoms, including hot flashes and night sweats that can interrupt sleep and impair quality of life,” North American Menopause Society officials said in a statement. “Many women can take it safely.”

But, so far, no one is saying that hormone therapy should be used for any other reason than alleviation of severe menopausal symptoms, said Marcia L. Stafanick, a professor of medicine at Stanford and WHI investigator.

“There is rationale to use hormones, combined or estrogen only, for severe hot flashes,” she said. “But you need to take into context what are the risks.”

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Here’s a recap of some of the major findings of the WHI in the past 10 years.

Estrogen-alone hormone replacement therapy:

  • The estrogen-alone study was stopped in April 2004 after showing that estrogen alone caused an increased risk of stroke and blood clots, an unclear effect on breast cancer risk and no impact on heart disease prevention.
  • A June 2004 study found that older women (ages 65 to 79) using estrogen alone could have an increased risk of dementia.
  • A 2006 study found no increased risk of breast cancer with estrogen alone. (Tuesday’s publication updates this to find a decreased risk in some women.)
  • A 2007 study found that women who begin hormone therapy within 10 years of menopause may have a lower risk of heart disease. The further a woman was from the onset of menopause when she began hormone therapy the greater her risk of heart disease.
  • A 2007 study found that younger postmenopausal women taking estrogen alone had less build-up of calcium plague in their arteries compared with women who did not take hormone therapy.
  • A 2011 study found no overall difference in health among women taking estrogen alone on heart disease risk, stroke, breast and colorectal cancer, hip fracture or death from all causes. However, among women ages 50 to 59, estrogen alone seemed to reduce the risks of heart disease, heart attack and death from all causes compared with women who took the placebo.

 Estrogen plus progestin hormone replacement therapy:

  • The estrogen plus progestin study was stopped early, in 2002, after data showed an increased risk of breast cancer, heart disease, stroke and pulmonary embolism, although there were fewer cases of hip fractures and colon cancer among women taking hormones.
  • A 2003 study found older women taking estrogen plus progestin had twice the rate of dementia compared with women who did not take the medication -- especially women 65 and older taking hormones.
  • A 2004 study found a 44% decreased risk of colorectal cancer among women taking estrogen plus progestin.
  • A 2008 study showed that three years after stopping estrogen plus progestin women no longer had an increased risk of heart disease, stroke or blood clots. The decreased risk of colon cancer also disappeared after stopping hormones as did the decreased risk of fracture. Death rates from all causes was somewhat higher in women who had taken estrogen plus progestin compared with those who took a placebo.

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