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Common questions about HRT. (Ask the Expert).

From the American College of Obstetricians and Gynecologists (AGOG) come the answers to these commonly asked questions about HRT and the WHI study: (10)

Q I was taking HRT to help prevent heart disease. Now what?

A HRT is no longer recommended to prevent heart disease in healthy women (primary prevention) or to protect women with pre-existing heart disease (secondary prevention). The WHI tells us that not only does it not work, it may actually increase your risk of a heart attack or stroke.

Why did medicine once think otherwise? Earlier observational studies compared women who took HRT with women who didn't. But these studies are not as sophisticated as the WHI study, which was "double-blinded"--that is, it compared patients on HRT with a "control group" on placebo, with neither group knowing which pill they were taking. The earlier observational studies suggested that HRT had a benefit in protecting the heart, since the women on HRT had better cholesterol levels, and they appeared to have fewer heart attacks and strokes. In addition, these women may have been younger when they started HRT than the women in the WHI study.

Now, we are all benefiting from the effort in years past to increase the size and sophistication of research trials in women s health. The higher-quality WHI evidence suggests that these earlier studies probably had an inherent bias, meaning that the women taking HRT already tended to be healthier than the women not taking HRT. Also, there may be other, still-unknown factors that are affecting a woman's heart disease risk as much as, or more than, such known factors as cholesterol levels.

Q Where does this leave me if I want to take HRT for hot flashes or sleep problems?

A HRT is highly effective in treating certain menopausal symptoms and may still be appropriate for you, depending on your circumstances. However, the small but real increased risks uncovered by the WHI study mean that this is now a more complicated decision.

You will have to evaluate, with your physician, the pros and cons of HRT use in your individual circumstance. This includes weighing any benefits of continued HRT use against your individual risks for conditions such as breast cancer, to decide whether taking HRT is an acceptable or an unacceptable risk for you.

To date, HRT is the most effective treatment for the relief of vasomotor symptoms such as hot flashes and sleep disturbances, which can affect both physical and mental health. It's also effective in treating genitourinary symptoms such as urinary incontinence, or vaginal dryness, which can affect sexual pleasure.

The effects of these menopausal symptoms on the quality of a woman's life can be considerable, and the severity and duration of symptoms can vary widely from woman to woman. Some women experience few or very short-lived symptoms, while others experience severe symptoms over many years. Yet too often, women are made to feel guilty about how they respond to menopausal symptoms, which are often trivialized by such comments that women should simply be able to "put up with it." In fact, each woman will have her own physiological reaction to menopause, and each will have to make the decision that is right for her.

Some women may choose to manage their symptoms without any use of HRT, either through lifestyle changes alone or with other therapies. Other women, particularly those with severe menopausal symptoms, may conclude that the benefits of short-term HRT use are worth the small increased risks.

Q I'm not taking Prempro[TM], but another type of HRT. Do these results apply?

A It's true that this part of the WHI only studied a specific combined estrogen and progestin pill and thus findings can be reasonably applied only to this formulation (which was .625 mg/d continuous conjugated equine estrogen and 2.5 mg/d medroxyprogesterone acetate; brand name Prempro[TM]). However, we cannot assume other hormone regimens or methods will be safer, without more conclusive data. Although future studies on lower hormone doses or different combinations may tell us more, for now all women taking all forms of HRT should be aware of the increased risks found in the WHI trial.

Q I'm at high risk for osteoporosis. Can I continue on HRT?

A If you are taking HRT solely for the prevention of osteoporosis consider stopping it, because there are other medications that can help prevent osteoporosis and fractures that appear to carry lower risks for conditions such as breast cancer or heart disease. If you are also taking HRT for treatment of menopausal symptoms, it may be appropriate.

Other preventive drug therapies include the family of drugs known as bisphosphonates, which can reduce the breakdown of bone. The selective estrogen receptor modulators, or SERMS, are a new class of synthetic estrogens that act like estrogen in certain parts of the body (such as the bones) while leaving other parts of the body unaffected.

Some women with heartburn or ulcer problems may be unable to take bisphosponates, and each of the medications discussed here will have its own side effects. Although these medications appear to have a better ratio of benefits to risks for you compared to HRT, studies are continuing on the effects of these drugs, some of which have been in use for only a few years. Talk to your doctor about whether these medications would be appropriate for you. Weigh any benefits of continued HRT use against your personal risks for cardiovascular disease and breast cancer.

For all women, lifestyle recommendations for healthy bones include a diet high in calcium (postmenopausal women should be taking 1,200 to 1,500 mg of calcium per day), a multivitamin containing vitamin D and regular weight-bearing exercise such as jogging or walking.

Q Am I safe if I take HRT for four years, since the increased risk for breast cancer appeared after that?

A We just don't know yet. There are no data from this or other studies to clearly establish what constitutes safe short-term use. Even the first four years of HRT use may not be risk free. In the WHI study, there was an increase in the diagnosis of breast cancer after four years. It's possible that hormones are having some effect on the biology of breast cancer even in the first year of use.

It's also possible that as the NIH conducts and releases further analyses of different parts of the WHI data, we may get a better picture of certain factors (such as a participant's prior use of HRT) to improve our understanding of why the increased breast cancer risk appeared when it did. Until we know more, if you do choose HRT, use it for the shortest possible time that works for you and have an evaluation with your physician at least annually to see whether you still need it.

- American College of Obstetricians and Gynecologists, Washington, DC

(10.) "Questions and Answers on Hormone Replacement Therapy In Response to the Women's Health Initiative Study Results on Estrogen and Progestin Hormone Therapy," American College of Obstetricians and Gynecologists.
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Publication:National Women's Health Report
Date:Oct 1, 2002
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