Hormone Therapy

By J. M. Anderson, M.D. published in Style Magazine Jan. 2004

Postmenopausal hormone therapy is one of the leading controversies facing today's perimenopausal/postmenopausal woman, as well as the gynecologist and primary care physician. With a growing number of women transitioning into menopause, physicians are finding that more and more are asking touch questions, which at times do not have specific answers.

The value of hormone therapy is under scrutiny from the medical community and, secondarily, from the media. Physicians are finding that the perceived risks of hormone therapy have been greatly exaggerated within the general population, but this is no doubt due to real and significant risks recently uncovered by a collection of scientific studies- in particular, the initial results of the Women's Health Initiative (WHI)

Perspectives very between different types of physicians ( gynecologist versus a cardiologist) and between doctors in the same field of study as to the role of exogenous hormones. It's no wonder that women worldwide are finding themselves in the middle of hot flash, wondering if life could be better and at what cost. Many gynecologists currently feel that in the absence of absolute contraindications, hormone therapy can greatly benefit a woman's health status and quality of life. The beginning step is risk stratification on an individual basis.

The issues that need to be addressed when considering a patient for postmenopausal hormonal therapy are many including:

• What menopausal symptoms is the patient experiencing?

• What is the patient trying to prevent by initiating hormonal therapy?

• What regimen is appropriate for the patient?

• How old is the patient and is she still have periods?

• What coexisting medical conditions are pertinent in the decision-making process?

What are the real risks associated with oral hormone therapy, and does changing the method of delivery or the type of estrogen/progesterone change the risk significantly?

The last question is the subject of much debate. Earlier studies have shown conflicting results about the risks of hormonal therapy. The ongoing study, the WHI, terminated one arm of the study where the participants were taking a specific type of daily oral estrogen and progesterone. What women need to be aware of is the risks demonstrated by taking the combination therapy have not been found to be true for the group of participants taking estrogen alone. That arm of the study is currently active and will continue until 2006, completing its 10 year investigation of the health risks/benefits or oral estrogen to postmenopausal women. The identified risks were a slight increase in the incidence of breast cancer, an increase in heart attack, strokes and blood clots. Additionally there were fewer hip and vertebral fractures, and fewer incidents of colon cancer. It is vital, however, to put this information into perspective for the individual patient. Based on the study, 8,056 women took the combination hormone therapy and 166 (1,952 percent) were found to have breast cancer. This si opposed to 8,102 women who took a placebo, with 124 (1.52 percent) breast cancers identified.

It is important to understand that not taking hormones does not impart protection from breast cancer, which still has a baseline incidence, and that taking hormones only slightly increases that incidence. Another way to view the results from the WHI study on an individualized standpoint is to say that for every 10,000 women who elect to take combination oral hormonal therapy for one year, there will be eight episodes of breast cancer.

Is the relationship causal or do hormones increase the growth of pre-existing cancers sot hat they are detectible earlier? Currently, we simply don't know. Overall, 97.5 percent of women in WHI who took combinations therapy had no adverse events.

So where does that leave Baby Boomer women who are facing the onset of menopause? As a physician, the first step is educating the patient on her options, risks and the potential benefits of hormonal therapy as well as alternative therapies. It si my responsibility to provide patients with an accurate interpretation of evolving scientific data. The decision to or not to take hormonal therapy ultimately falls into the hands of the informed patient.