Study of Hormone Use in Menopause Reaffirms Complex Mix of Risks and Benefits

October 1, 2013 - Hormone therapy for menopause is one of the most divisive subjects in medicine, hailed by some as a boon to women’s comfort and well-being, vilified by others as a threat to health. 
A new analysis finds truth somewhere in the middle, reaffirming previous warnings that the drugs have more risks than benefits for most women — but also stating that the harms are low early in menopause and that hormones are “appropriate for symptom management in some women.”
Dr. JoAnn E. Manson, the first author of the analysis and a professor of medicine at Harvard’s medical school, said in an interview that the findings “should not be used as a basis for denying women treatment if they’re in early menopause and have significant distressing symptoms.”
The new report, published on Tuesday in The Journal of the American Medical Association, is based on long-term data from the Women’s Health Initiative, a large, federally funded study that turned medical thinking on its head a decade ago by uncovering the risks of hormones.
The new report is the first to include extended follow-up data from the original health initiative study, an additional six to eight years’ worth of information on about 80 percent of the original participants. They took a combination of estrogen and progesterone, estrogen alone or placebos for several years.
For combined hormones, for every 10,000 women taking the drugs, the new analysis found that there were six additional instances of heart problems, nine more strokes, nine more blood clots in the lungs and nine more cases of breast cancer. On the benefit side, there were six fewer cases of colorectal cancer, one fewer case of uterine cancer, six fewer hip fractures and one fewer death. Most of the effects wore off once the drugs were stopped, but the risk of breast cancer remained slightly elevated.
Women who took estrogen alone actually had a reduced risk of breast cancer and heart problems; the reason is not known. For other conditions, the results were similar to those for combined hormones. But estrogen alone can be given only to women who have had their uterus removed, because estrogen alone increases the risk of uterine cancer. In women who still have a uterus, the estrogen must be combined with some form of progesterone.
For both types of hormone treatments, the risks were lowest in the youngest women, ages 50 to 59, and highest in women from 70 to 79.
In 1993, when the study began, millions of women were taking the drugs to relieve hot flashes and vaginal dryness. There was also a widespread belief that hormones would keep women youthful and feminine, and prevent heart disease and dementia.
The study, which included more than 27,000 women age 50 to 79, provided a rude shock: it found that hormones might actually cause the ailments they were thought to prevent. The most popular treatment, the combined hormones, increased the risk of heart disease, breast cancer, blood clots, strokes, gallstones, urinary incontinence and dementia. Another treatment, estrogen alone — given only to women who had surgery to remove the uterus — also increased the risk of blood clots, strokes, gallstones and urinary incontinence.
Hormone use dropped sharply after the findings came out in 2002. But some doctors and patients stuck with the drugs, arguing that the risks were relatively small and had been overplayed, needlessly frightening women away from the best treatment for hot flashes, night sweats, insomnia and vaginal dryness that can take the joy out of sex.
A few years after the findings came out, the incidence of breast cancer in older women dropped significantly, something that statisticians attributed to the decline in hormone use.
Dr. Elizabeth G. Nabel, a professor of medicine at Harvard who wrote an editorial accompanying the new report, said in an interview that seemingly small risks could be significant for individual patients, particularly people with family histories of breast cancer, heart disease or strokes.
By Denise Grady, NY Times