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Menopause
Matters
Postmenopausal Hormone Therapy: Where Do We Go From Here?
Wulf H. Utian, MD, PhD
Today, more than 2 years after the
publication of initial results from
the Women's Health Initiative (WHI)
regarding postmenopausal hormone therapy (HT), midlife women and their
clinicians continue to look for answers about the treatment's safety and
effectiveness.
As the largest-ever randomized, placebo-controlled trial of postmenopausal
HT„estrogen therapy alone (ET) or estrogen plus progestogen therapy
(EPT)„the
WHI was supposed to answer many of the questions regarding the
safety and effectiveness of HT. However, concerns and controversy
persist. When making clinical decisions about the use of postmenopausal
HT, health care providers should not just consider the results
of a single study, but should review all of the available evidence.
For this reason, The North American Menopause Society (NAMS) has,
for the third time since the initial publication of the WHI findings,
convened a panel of experts to closely examine the WHI results
in light of all the important studies on the topic. Some of the
recommendations, based on the expert panel's report, are discussed
below.
While the substance of this latest report remains similar to that of the 2003 report, the primary
clinical question put to the 2004 Panel was to differentiate the risk-benefit ratio of postmenopausal ET/EPT for disease prevention
and treatment of specific menopause-related symptoms.
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HT Is Still the Most Effective Treatment for Menopause-Related Symptoms
Estrogen is still the most effective treatment for moderate to severe hot flashes, night sweats, and sleep disturbances related to hot flashes. Estrogen is also highly effective for vaginal atrophy, such as vaginal dryness and thinning. Estrogen is the only therapy that is government-approved for treating these conditions.
Because estrogen increases the risk for uterine cancer and a progestogen effectively protects against this risk, women with a uterus who take estrogen must also use a progestogen. Women who have had a hysterectomy (surgical removal of the uterus) do not require a progestogen; they should use estrogen alone.
For hot flashes, a systemic (circulates throughout the body) estrogen product, such as a pill, patch, or gel, is recommended. For vaginal symptoms, a local (affects only localized tissue) vaginal estrogen product, such as a cream, ring, or vaginal tablet, is recommended.
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HT and Breast Cancer Risk
Studies show that the risk of breast cancer probably increases with EPT use beyond 5 years, although the risk is small. Use of estrogen alone (ET) for fewer than 5 years appears to have little impact on breast cancer risk, but further research is needed. Studies also show that the risk of dying from breast cancer does not increase with the use of HT.
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HT Is an Option for Women Who Want to Protect Their Bone Health
The WHI proved that EPT effectively reduces the risk of bone fracture from the bone-thinning disease osteoporosis. Although the long-term effects of HT for osteoporosis prevention are not known, it can still be considered for bone health, weighing its risks and benefits as well as those of alternative bone-building therapies.
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HT Should Not Be Used Solely
to Prevent Heart Disease, Stroke, or Dementia
Although the role of ET/EPT in preventing heart disease is unclear, it did not reduce the risk in the WHI study. With regard to the risk for stroke, some, but not all, studies have shown that ET/EPT increases the risk in postmenopausal women. For these reasons, HT should not be used to prevent heart disease or stroke.
Estrogen plus progestin therapy does not prevent dementia (a more serious, chronic condition than minor memory loss) when started in women older than age 65 years and should not be prescribed to these women for this purpose. It is not clear whether HT prevents dementia if started during perimenopause or soon after menopause.
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Bioidentical Hormones Should Not Be Considered Safer Than Traditional HT
The so-called "bioidentical hormones" (custom-made formulations prepared
by a compounding pharmacist from a prescription ET/EPT product) have
not been adequately studied for safety and effectiveness. Thus, they should
be considered
to have the same safety issues as traditional, government-approved
ET/EPT.
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Making the Decision
About ET/EPT Use
There is no universal recommendation for all women regarding the use of ET/EPT. The panel recommends that, as with any therapy, the decision to use, or not to use, postmenopausal HT is a personal one. It should be made in consultation with a womanÍs health care provider and be based on that womanÍs individual health needs, concerns, and risk factors, taking into account menopause-associated symptoms that may have an impact on quality of life.
Before considering ET/EPT, women should have a complete health evaluation that includes a comprehensive medical history, physical exam, and mammography. Other exams, such as a bone densitometry test, should be considered on a case-by-case basis.
As many symptoms are triggered by foods, beverages (alcohol or caffeine), stress, and other factors, a discussion of triggers and lifestyle modification may go a long way toward alleviating symptoms and improving health without the use of medication. Daily weight-bearing exercise, a nutritious diet, and learning to manage stress in a healthy way can also reduce the risks of osteoporosis and heart disease.
Women who have made the decision to take HT should consider the following:
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Use of HT should be monitored closely and re-evaluated regularly.
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Hormone therapy should be used in the lowest effective dose and time consistent with treatment goals.
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Women without a uterus (after hysterectomy) should not take HT containing a progestogen, as the main reason for taking this hormone is to protect the uterus from the effects of estrogen.
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The decision to continue ET/EPT should be based on the severity of a womanÍs symptoms, any changes in her health status, as well as her desire to continue therapy. A woman should talk with her physician before stopping ET/EPT, which may cause some symptoms to recur.
The latest NAMS recommendations may be viewed at the NAMS Web site (www.menopause.org)along with other important information about menopause and related health issues.
Wulf H. Utian, MD, PhD, is executive director and honorary founding president of NAMS.
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