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Hormone replacement therapy, Panacea or Poison? Dr N discusses
the findings of several medical studies. This is the 1st of a 3 part series...
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1 | | Part 2 | | Part 3 |
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PART 1 - HRT, PANACEA OR POISON?
Appropriate Hormone Replacement Therapy known as HRT, remains a viable and
important health care option for postmenopausal women.
The most significant effects of HRT are increased longevity, a better quality
of life and prevention of the accelerated aging associated with hormone deficiency. This remains true despite a
media conflagration generated by the publication of the findings of two studies: 1) The Heart and Estrogen/progestin
Replacement Study Follow Up (HERS II) and 2) The Women’s Health Initiative (WHI) study. Both studies were published
in the Journal of the American Medical Association (JAMA) in July 2002. The articles seem to question the wisdom
of hormone replacement.
The media response was explosive. While some of the coverage was accurate and
representative, much of it pandered to fears of women and health providers alike. Although there was no difference
in all-cause mortality in either study between hormone users and non-users, many postmenopausal women felt that
the underlying message was that hormone replacement represented a health risk and discontinued their therapy. This
impression was reinforced as scores of physicians informed their menopausal patients -based on the results of the
studies, which most had not read - that it was time to discontinue hormone replacement therapy.
Are these legitimate responses that reflect the findings of the published studies?
It doesn’t seem so. Five key points follow:
1) It was not clear to most women that both studies did not address hormone
replacement in general, but was limited to users of Prempro, which is a sub-optimal hormone replacement preparation
distributed by Wyeth-Ayerst. Prempro is a combination of conjugated equine estrogen (CEE) and medroxyprogesterone
acetate (MPA) and is taken daily as continuous combined therapy. It is indicated for use in women who have not
had a hysterectomy and require protection of the uterine lining with a form of progesterone, in this case MPA.
2) Hormone replacement with Prempro appears to have a less favorable risk/benefit
profile than other replacement preparations, particularly those that are non-oral and those in which a progestin
component is not used continuously. Studies completed following the commencement of the HERS II and WHI trials
suggested that the specific combination in Prempro demonstrated both: 1) a less favorable effect on coronary arteries
than other regimens and 2) a small, but significant excess of a relatively uncommon form of breast cancer, which
has not been associated with use of other forms of hormone replacement. Had this information been available it
is unlikely that HERS II or WHI studies would have been initiated.
3) The weight of previous research utilizing other regimens of hormone replacement
had suggested a more positive outcome. The commentary in both studies did state that it was “possible” that the
unexpected negative findings were due to the combination in Prempro. Surprisingly, unencumbered by the limitations
of the data, the researchers included all forms of hormone replacement in their conclusions and recommendations.
Dr. Wulf H. Utian, MD, PhD, Executive Director and Honorary Founding President of The North American Menopause
Society and a pioneer in menopause research, stated that the financial relationship existing between authors of
both studies and Wyeth-Ayerst (the manufacturer of Prempro), raised issues of ethics and potential bias.
4) Physicians are encouraging women to stop using HRT, without a legitimate
rationale. This is an irresponsible and potentially life-altering recommendation. The Director of the WHI study
Dr. Jacque E. Rossouw, of the National Institutes of Health, stated that it was his impression that few physicians
had actually read the studies or had an in-depth knowledge of the details, or conclusions. Dr. Rossouw went on
to say that in his opinion appropriate hormone replacement does not cause breast cancer, or coronary artery disease
and that he was “comfortable” with this type of hormone use “for as long as it is necessary.”
5) The big losers are menopausal women who have been deterred from using hormone
replacement as a valuable health care and quality of life enhancing strategy.
Dr. Trudy L. Bush, who was one of the nation's preeminent researchers and teachers
of issues related to women's health - particularly the effects of hormones and replacement therapy on the cardiovascular
and reproductive systems - published a hallmark study in the Journal of the American Medical Association in February
of 1983. This examined all-cause mortality in estrogen users compared with non-users. During the 5.6 years of the
study, the risk of death among non-users was twice as high as users of estrogen if they had no gynecological surgery.
It was three times higher if they had a hysterectomy and eight times higher if both ovaries had been removed. Since
that time, Dr. Bush and a number of other respected authors, have published numerous articles confirming the association
of estrogen use with lower all-cause mortality.
Accordingly, it is reasonable to postulate that the difference in the HERS
II and WHI studies was likely due to the specific hormone preparation. Therefore, it is not possible to extrapolate
any conclusions, or recommendations to other forms and types of hormone replacement. This was confirmed recently
by both the North American Menopause Society Advisory Panel on Postmenopausal Hormone Therapy and the Executive
Committee of the International Menopause Society.
 Next
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Dr Nosanchuk is currently in practice in Southeastern Michigan
and is accepting new patients. His office is located in Bingham Farms, a suburb of the Detroit Metropolitan Area.
Dr N specializes in the care and treatment of menopausal women and has a special interest providing treatment to
women whose lives have been altered by their menopause, hysterectomy, or both. This includes strategies to restore
quality of life, by resolving problems, such as persistent symptoms, loss of libido and disturbances of sexual
function.
Appointments with Dr Nosanchuk can be scheduled by calling (248) 644-7200
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