I recently attended the American Congress of Obstetricians and Gynecologists Annual Clinical Meeting and heard an excellent talk from one of George Washington University’s Professors, James Simon MD. The talk was inspirational! He spoke about a very important topic, “The Status of Hormone Replacement Therapy.”
By way of background, in the past many women were treated for symptoms of menopause with hormones, but in 2002 a report came out, called the “Women’s Health Initiative,” which changed everything by painting a very negative picture about the harm that hormones could cause. As a result, many women, all over the world, were scared into stopping hormones, and some of that fear persists to this day, despite much evidence to the contrary. Years later we have gradually discovered that the study was deeply flawed.
Dr Simon described this as an example of a “Zombie Idea,” an idea that should have been killed by evidence, but refuses to die! This actually is similar to the current situation involving fear of vaccines, which was originally based on a fraudulent and discredited study, but still lingers on despite overwhelming evidence of vaccine safety.
Similarly, the WHI Study from 2002 was also flawed and following its recommendations has caused harm.
We now know about the “timing hypothesis” that the safety of starting hormone replacement therapy depends on when it is started in relation to menopause. Studies show a much decreased risk of complications such as stroke or heart attack if the woman starts treatment within 10 years of menopause.
Transdermal patches as a way of receiving hormones appear to decrease the risk even further, according to an extensive French study.
Re-analysis of the old WHI data shows no effect of hormones on causing breast cancer.
A Finnish nationwide study showed a decreased chance of death from breast cancer if hormone therapy with either estrogen or estrogen with progesterone was used.
To make it even more definite, a review of 17 studies looking at the risk of recurrence of breast cancer in women who had previous breast cancer, showed that 16 of the 17 studies had either no change or a reduction in recurrence of cancer if they were on hormone therapy.
Another review showed women lived longer if they received hormones starting at age 50-59. This looked at death from all causes, death from cancer, and death from stroke or heart attack.
The risk of Alzheimer’s disease or dementia was decreased by use of hormones.
How do hormones compare with other medications? Surprisingly, recent studies found an increased risk of breast cancer from taking statins, which are often prescribed for high cholesterol levels. Medicines prescribed for improvement of bone density such as Pioglitazone showed an increased risk of breast cancer of 88 per 10,000.
Surprisingly, analysis showed one of the most dangerous medications causing breast cancer is Vitamin D, which caused 70 per 10,000 additional cases of breast cancer.
What was the aftermath of stopping hormonal therapy based on the WHI report when it came out in 2002? A study in 2009 showed a significantly increased number of bone fractures. Another study in 2011 shows more hip fractures in women who stopped hormonal therapy compared with those who continued it.
Was there an increased risk of death from stopping estrogen therapy? A study in 2013 showed over a 10 year span, starting in 2002, a minimum of 18,000 and as many as 91,000 US women died prematurely because of the avoidance of estrogen therapy.
The conclusions are that hormone therapy risks are rare, and even more rare when started in women who are less than 60 years old and/or within 10 years of beginning menopause. Starting it at a younger age does decrease the risk and increase the benefit.
The degree of risk, when it does occur, is similar to that of many commonly used medications or vitamin supplements. Hormone therapy significantly reduced the risk of bone fractures and is the most effective treatment for reducing the worst symptoms of menopause including hot flashes and atrophy of the vulva and vagina. If you have any symptoms of menopause, talk with us about being treated for it!
References:
- Benefits and Risks from WHI – Initiation of HT in Women 50-59 Years of Age: Manson JE, et al. JAMA 2013;310:1353-1368.
- Timing Hypothesis: Hodis HN, et al. J Am Geriatr Soc 2013;61:1005-1010, 1011-1018.
- CHD Events Associated with HRT in Younger and Older Women: Meta-analysis of 23 Randomized Controlled Trials: Salpeter S, et al. J Gen Intern Med 2006;21:363-366.
- Are Transdermal Preparations Safer? Canonico et al, BMJ 2008; 336 (7655);1227-1231.
- WHI E+P Trial: No Effect of E+P on Risk of in situ Breast Cancer: Chlebowski RT et al. JAMA 2003; 289(24):3243-3253.
- Finnish Nationwide Study – Risk of Breast Cancer Mortality in Women after Different Exposure Times to Estrogen: Mikkola TS, et al. Menopause 2016;23:1199-1203.
- Mortality Outcomes During the 18-Year Cumulative Follow-up in 50-59 Year Old Women: Manson JE, et al. JAMA 2017;318:927-938.
- Alzhemier’s Disease or Dementia Mortality During the 18-Year Cumulative Follow-up: Manson JE, et al. JAMA 2017;318:927-938.
- WHI-E in Perspective: RUTH. New Engl J Med 2006;355:125-137.
- Relative and Absolute Risks of Commonly used Medications and Supplements: Li Ci et al. JAMA Internal Medicine 2013;173:1629-1637. SPARCL Investigators N Eng J Med 2006;355:549-559.
- Relative and Absolute Mortality Risks of Commonly used Medications and Supplements: Hodis HN, et al. J Am Geriatri Soc 2013;61:1011-1018.
- WHI E-Only and E+P Evolving Conclusions 2017: Manson JE, et al JAMA 2017 Sep 12:318(10):927-938.
- Aftermath of WHI – Fracture Data: Karim R. Menopause 2011;18:1172-7
- Mortality Toll of Estrogen Avoidance: Sarrel PM, Njike YY, Vivante V Am J Public Health 2013;`03:1583-1588
Ob/Gyn of Greater Washington 