LIFESTYLES by Ronda Gates Smart Pharmacist

To HRT or not to HRT? That is the question

The Women's Health Initiative (WHI) results have been extensively covered in the news. There is nothing like a new research study to generate media frenzy, and this story is no exception. It has also generated a lot of confusion. The following is my take on the information.

This National Institutes of Health (NIH) study has been following more than 160,000 post-menopausal women (average age 63) who have not had hysterectomies. They were divided into two groups to study the effects of hormone replacement therapy (HRT). Half of the women in the study took the drug, Prempro (0.625 mg of premarin as estrogen made from pregnant mare urine and 2.5 mg of Provera, a synthetic progestin). The other half did not take HRT. The idea was to see if these particular hormones prevent disease in healthy women -- especially the silent killers of women heart disease and osteoporosis -- without compromising other aspects of their health.

Although the study was planned to continue for 8.5 years, it was stopped after 5.2 years when the safety committee decided the benefits of the drug did not offset the risks. Their data indicated that if 10,000 women take Prempro for one year (when compared to an equal number of women not taking this HRT):

  • 8 more women will develop invasive breast cancer
  • 7 more women will have a heart attack
  • 8 more women will have a stroke
  • 8 more women will have blood clots in the lungs.
  • Additionally
  • 6 fewer women will have colorectal cancer,
  • 5 fewer women will have hip fractures.

The increased breast cancer risk did not appear in the first 4 years of use. Risk for blood clots were greatest during the first 2 years of hormone use. The reduced risk for colorectal cancer showed up after 3 years.

I don't believe panic is justified. Based on the study's calculations, a woman's personal risk is very small--less than one tenth of one percent per year. But this study did raise concerns for the more than 40 million women who are currently menopausal, one third of whom have been taking some form of hormone replacement therapy.

In this study use of Prempro did not meet expectations. Most researchers believed this was due to the "pro," or progesterone part of the drug, not the estrogen part of the drug. (Women who have had hysterectomies have no need for progesterone and are typically prescribed estrogen only. There is an identical ongoing study for these women that uses estrogen only. It has not shown the minimally increased risk shown with the Prempro. )

My professional opinion is that women who have been on estrogen/progesterone for more than five years should consider stopping or changing to another form of HRT. They should NOT stop taking any hormone cold turkey, as it can create a hormonal crash which could precipitate a return of menopausal symptoms and withdrawal bleeding. To reduce the dose (check with your doctor first) you can drop from a daily dose to an every-other-day dose for a couple of weeks then three times a week for several weeks, then twice a week and finally stop. If bleeding occurs or menopausal symptoms return, you have to weigh the pros and cons of this medication with your doctor. (Interestingly there was no segment of the group that was separated out as exercisers vs. non-exercisers. Wouldn't it be interesting if only non-exercisers had the increased risk for disease?)

Personally, I choose to take a low-dose natural estrogen-only preparation (I've had a hysterectomy) because without it I experience incontinence which seriously interferes with my active lifestyle. My blood pressure is also higher without the estrogen, despite my daily exercise routine.

In short, use of hormone replacement therapy (HRT) is your individual choice. You must weigh the pros and cons for your particular situation taking into account your family history and risk for the diseases of longevity. There is no doubt that HRT prevents osteoporosis, a disease that will ultimately debilitate or kill more women than any other disease. However, there are also some sophisticated drugs that can help keep bones strong--especially for the exercising woman.

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LIFESTYLES by Ronda Gates
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