HRT – Still No Place for Prevention

In a much-needed and thoughtful analysis, the United States Preventive Service Task Force has summarized what we have learned about HRT since the Women’s Health Initiative was published in 2002. (See summary chart above.)

They have also issued draft recommendations on the use of HRT for prevention of disease.

The U.S. Preventive Services Task Force (USPSTF) recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women.

The USPSTF recommends against the use of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.

I wholeheartedly agree. 

The USPSTF Recommendations do not address the use of HRT for treatment of menopausal symptoms

That’s an important message for women who may want to consider using HRT for a few years around menopause. In that setting, the heart disease risks are probably minimal for an otherwise healthy woman, while the breast cancer risks, while real,  are quite small.

I tell my patients their breast cancer risk is about 1% higher for 20 years of HRT use, so HRT use for a few years conveys far less than even that risk. On balance, using HRT to get through the peri-menopause is not a terribly risky decision, and for women with severe symptoms, it is not an unreasonable choice.

Despite this reassurance, most of my patients with mild to moderate symptoms are choosing to forgo HRT and deal with their symptoms in other ways – exercise, reducing or eliminating alcohol, trying to lower stress. Those with more severe symptoms are still using hrt, but they are aiming for lower dosing and transdermal regimens, or considering non-hormonal alternatives such as SSRI’s instead.

It’s called informed choice. And when given that choice, these days,  more women than not are choosing against using HRT.

And just in case you’re interested, here are my rules for prescribing HRT.

The USPSTF Recommendations do not address premature menopause

Most practitioners agree that women with early menopause benefit from HRT. The risks for osteoporosis in this group is quite high, and symptoms are often quite severe.

In my practice, almost all of these women choose to use HRT until they reach the usual age of menopause, at which they begin to think about it the same way the rest of my patients do and usually wean off over time.

The USPSTF Recommendations do not address vaginal estrogen use

The one symptoms of menopause that does not get better over time is vaginal dryness. Most women, unless they are very frequently sexually active, will need to use something to treat dryness.

One treatment option is low dose vaginal estrogen.  Most practitioners feel comfortable prescribing vaginal estrogen, even in women at risk for blood clots and even in most women with breast cancer.

My patients, however, tend to want to avoid estrogen in any form and so they usually will try non-hormonal treatments first.  I’d say that about half of these women eventually end up using vaginal estrogen.

Those who might disagree with the USPSTF

The window theory believers

The WHI naysayers will argue that no one has properly studied HRT the way in which it is most often used, and in which it is most likely to prevent heart disease – namely, starting at menopause and continuing indefinitely.

They hypothesize that there is a “window of opportunity” during which estrogen will protect against heart disease, and after which starting estrogen will worsen pre-existing heart disease.

Subgroups analysis of WHI findings suggest that they may be correct in this regard. In the WHI, women starting HRT shortly after menopause had a lower risk of cardiovascular disease than those starting 20 years or more later.

Unfortunately, even if HRT were cardio-protective, the risks of breast cancer (and stroke and blood clots) with combination HRT use cannot be ignored, and mitigate against prescribing hormones for reason of heart disease prevention.

The Gap Theory Believers

There are those who argue that the estrogen-only arm of the WHI actually showed less breast cancers, indicating a potential protective effect of estrogen on breast cancer. They theorize something called the “gap theory”, which states that estrogen, when started 10 years of more after menopause, actually acts to inhibit breast cell growth. They are supported in this by in vitro data.

Unfortunately, while the gap time theory may explain the findings of the WHI estrogen-only arm, it is irrelevant to clinical practice, since the way most women use HRT is to start it at menopause. (ie., there is no gap)

They are both right – and both wrong

If both the gap and window theories are correct (and I suspect they are), when considered together they actually support the findings of the WHI and the recommendations of the USPSTF.  Starting estrogen at menopause may prevent heart disease, but it increases breast cancer risk.  Waiting to start HRT may decrease breast cancer risks, but it increases the risks of clotting and stroke and dementia. Or, as my mother used to say, “You’re damned if you do and damned if you don’t.”

The benefits of HRT as they exist in practicality and theory come at a price. That price is high enough to recommend against  the use of hormone replacement for the prevention of chronic disease.

If you have any issues with the USPSTF Recommendations on HRT –

You can submit a comment to the Task Force between now and June 26, 2012.


Chart above from USPSTF Draft Recommendations on HRT

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