Never
in my career have I seen such conflicting information on the benefits
versus risks of hormone replacement therapy (HRT). Preliminary findings
from the Women’s Health Initiative Study (WHI) which were published in
JAMA on July 17, 2002 revealed an increased risk of metastatic breast
cancer and clotting disorders including stroke, deep venous thrombosis,
and fatal heart attacks in women taking combined hormone replacement
therapy . I must have gotten close to 100 phone calls in my office from
concerned patients. However, I explained to them that this study was
biased, and I educated them on the numerous reasons to continue
their HRT.
The
WHI study was stopped prematurely because, as the investigators claimed, a
small but significant number of women developed metastatic breast cancer
on HRT. What the public may not know is that 38 out of 10,000 women
developed breast cancer on HRT and 30 out of 10,000 women developed breast
cancer who were not on HRT. This is not a significantly different finding
in my mind, and the numbers could have gone the other way if the study
were repeated. Women who are chosen for such studies are usually seen on a
regular basis for testing. Let’s face it, the more mammograms a woman
undergoes, the higher the pick-up rate is for even a small breast cancer.
Overall, a review of all epidemiological trials on HRT fails to show an
association between HRT and breast cancer. In fact, the American College
of Obstetrics and Gynecology has concluded that HRT is not a risk factor
for breast cancer.
Secondly,
before the WHI study began, many doctors were placing patients with a
history of stroke, heart attack, and other cardiac diseases on hormone
replacement therapy. These patients already have small blood vessel
disease, and synthetic hormone replacement therapy such as Prempro has a
known hyper coagulation effect which makes clotting easier in small blood
vessels. As expected, women with underlying cardiac disease on HRT had a
higher incidence of fatal heart attacks. Therefore, these women
should be advised to refrain from taking HRT.
Negativity
about HRT is permeating television, newspapers, magazines and radio today.
HRT has overwhelmingly positive health benefits for postmenopausal women.
HRT not only allows women to sail through the menopause without hot
flashes, moodiness, irritability and sleeplessness, but it also prevents
osteoporosis, heart disease in women without preexisting cardiac problems,
Alzheimer’s Disease, and colon cancer. Furthermore, HRT has beneficial
effects on the vaginal tissue and bladder, preventing painful intercourse,
pelvic relaxation or prolapse of the uterus, bladder and rectum, frequent
urinary tract infections, and urinary incontinence.
Every
woman should discuss the risks versus benefits of HRT with her doctor
before starting the medication. Breast cancer, with a lifetime risk of 11%
by the age of 80 is a reasonable concern to a postmenopausal woman;
however, HRT is associated with protection against heart disease, which
threatens nearly five times as many women.
There are numerous brands of HRT on the market with different modes of delivery. Every patient is different.
The
take-home message that seems to make the most sense to me as a clinician
is that healthy women without cardiac disease have a 1 in 2 chance of
dying of cardiac disease throughout their lifetimes whereas women have a 1
in 28 risk of dying of breast cancer because they take hormone replacement
therapy. Which do you choose?
Dr.
Tara Solomon, FACOG
South Florida Woman’s Health Associates, Inc.
e-mail tarasolomon@bellsouth.net
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