ACP Internist has a nice article on the continuing debate on HRT. (Disclosure – I’m quoted in the article.)
The article summarizes nicely the absolute risks of HRT use as described in the Women’s Heath Initiative (WHI), the landmark study from 2002, as well as the ongoing debate around the strengths and weaknesses of the design and findings from that study.
It’s good to get caught up on the issues in anticipation of the release of early results from new clinical trials of HRT prescribed the way we docs tend to use it – starting at menopause.
You may recall that the biggest criticisms leveled at the WHI were that the average age of that study’s participants was over 60 years old and that women with menopausal symptoms were actually excluded from the study. Later subgroup analyses of younger women in that study suggest an absence of adverse cardiac effects and possible markers of cardio-protection when HRT is started at menopause rather than 10 years later. (The so-called Window Hypothesis – ie, there is a window of opportunity during which HRT, if started, is actually good for the heart. Exceed that window and it’s bad for the heart.)
Researchers are now studying to see if that elusive heart disease benefit of HRT might still be found when HRT is started at menopause. Early results from the Kronos Early Estrogen Prevention Study (KEEPS) are expected to be presented at the Annual Meeting of the North American Menopause Society in October. If evidence is reported for cardio-protection, that would certainly be reassuring information for symptomatic women looking to use HRT to combat symptoms.
I would be surprised, however, if KEEPS finds a difference in breast cancer risks from HRT in this age group compared to those in the WHI. It is this risk, in this docs humble opinion, that leads many women to take HRT off the table at menopause and beyond, or to limit its use to just a few years around the time of worst symptoms.
So stay tuned – it’s going to be an interesting season of HRT news.
Essential reading on the HRT and the WHI from TBTAM
- HRT – A Four Part Series – explaining the WHI. Everything I know.
- Who Killed HRT? or “Stick a fork in the WHI – it is so done.”
- HRT – Still No Place for Prevention – addresses the USPSTF recommendations against HRT use for prevention.
- The Estrogen Dilemma – Hype, Hype or Just One Woman’s Story?
- Estrogen and Memory
- TBTAM’s Ten Commandments for Prescribing HRT