Hormone Replacement Therapy May Still Help, But Be Careful

(HealthDay News) -- For women on the brink of menopause or just past it, deciding whether hormone replacement therapy (HRT) is worth the risk is like listening to Tevye the Milkman argue with himself in Fiddler on the Roof.

On one hand, more options are available for managing menopausal symptoms than ever before, coupled with a wealth of information to answer crucial questions about long-term associated health risks like osteoporosis.

On the other hand, HRT's reputation as a safe method of easing those symptoms has never recovered from the 2002 findings of a large, ongoing study known as the Women's Health Initiative (WHI), which concluded that HRT increased risks for heart attack, stroke, blood clots, and breast cancer. As a result, the use of HRT soon fell dramatically.

To further confuse matters, newer studies have now cast doubt on earlier research, saying some of the conclusions are fundamentally flawed for a variety of reasons; e.g., some participants may have had heart disease at the start of a study; more and younger women were needed for statistical validity. Research has also recently linked HRT to increased breast density that can cloud MRI screenings, and to heightened severity and frequency of urinary incontinence.

As a result, the verdict is still out on the benefits and perils of HRT. Here is a brief rundown of recent findings:

Breast Cancer Link
High doses of progestin in HRT may explain its link to breast cancer recurrence in women with a history of the disease, according to a study by the Karolinska Institute in Sweden.

While hormone therapy is not usually recommended for women who have had breast cancer, the researchers said they launched the study to assess HRT's effect after a breast cancer diagnosis. Their findings suggest that HRT with minimal or no progestin is much safer. Of the HRT-breast cancer link, Dr. Eva von Schoultz, a member of the Stockholm Breast Cancer Study Group, said, "We and others think the combination of progestin and estrogen is to blame."

Endometrial Cancer Risk
A British report concluded that the kind of therapy that doesn’t increase the risk of breast cancer does indeed increase the risk of endometrial cancer. This study included 717,000 postmenopausal women, aged 50 to 64, who had no history of cancer and had not had a hysterectomy. Just under half of them reported that they had used some form of HRT.

"We are now in quite a dilemma about what to say. There is quite a debate about what women should be doing," said Dr. Valerie Beral, a professor of epidemiology at the University of Oxford and lead author of these findings.

Clouding Breast Cancer Screens
Another new study suggests breast imaging experts who rely on magnetic resonance imaging (MRI) for the early detection of breast lesions and malignant tumors say this critical technology can be thrown off by density increases in fibrous tissue among women taking HRT -- perhaps leading to false-positive readings.

The researchers, from the Caritas St. Elizabeth's Medical Center in Boston, Massachusetts General Hospital, and Harvard Medical School, reviewed MRI breast exams of 60 postmenopausal women aged 44 to 77 with French colleagues. However, they did not establish how long a patient would have to be taking HRT before such breast density increases would develop. Nor did they determine how long women would have to wait after discontinuing HRT before breast density levels might drop off.

The Incontinence Factor
Researchers from Wayne State University School of Medicine in Detroit looked over data on nearly 23,300 women aged 50 to 79, focusing on symptoms of urinary incontinence occurring within one year of initiating HRT. The team reported that the incidence of developing stress incontinence (urinary incontinence triggered by stressors such as heavy lifting or even coughing) more than doubled for women prescribed estrogen alone as a hormone therapy, compared to women given a placebo.

Urge incontinence, caused by an involuntary contraction of bladder muscles, was 32 percent more likely in women taking estrogen-only HRT, while the incidence of mixed incontinence, which has a multitude of causes, was increased by 79 percent. Hormone-related increases in risk for stress or mixed incontinence were somewhat lower in women getting a combination of hormones, such as estrogen plus progestin, and, in the case of urge incontinence, mixed hormonal therapy appeared to confer no increase in risk over a placebo.

Cardiac Muscle Benefits
A small study by the Cardiovascular Institute of Goteborg University in Sweden found that a combination of estrogen and a progestin shrank a dangerously enlarged heart muscle, acting much like the angiotensin-converting enzyme (ACE) inhibitor drugs doctors commonly prescribe for the condition. The one-year cardiac health of 20 postmenopausal women, whose average age was 56, was tracked. All had high blood pressure and were already receiving anti-hypertensive medications.

To Take or Not Take HRT
In the calm after the Women’s Health Initiative storm, critics keep chipping away at some of the initial findings:

• A Yale study found the conclusions fundamentally flawed because the earlier study focused the age of the participants. The age range of the women was from 50 to 79, with the average age being 63. Many of the women in the study, say the critics, may well have been in the early stages of heart disease when the trial started. As a result, the trial did not have enough statistical power to test the hormones for primary prevention, they say. The study needed additional younger women.

• Another post-WHI study, while not disputing the long-term risks, suggested that the benefits of short-term HRT are worth it, particularly for women with severe symptoms. Looking at women in three big studies, including WHI, the investigators found that short-term HRT therapy shortens life expectancy by a few days but increases quality of life.

In a report called Hormone Therapy, the American College of Obstetricians and Gynecologists (ACOG) came to similar conclusions about short-term HRT use:

• Combined hormone therapy should not be used for prevention of cardiovascular disease, due to the small but significant increased risk of breast cancer, heart attack, stroke, or blood clots.

• Estrogen-alone therapy, used for women who have had a hysterectomy, should also not be used for prevention of diseases, due to increased risks of blood clots and stroke. Although estrogen therapy carries fewer risks than combined HRT, women with a uterus should not use estrogen alone due to their increased risk of uterine cancer.

• Hormone therapies are appropriate for the relief of vasomotor symptoms -- such as hot flashes and night sweats -- as long as a woman has discussed the risks and benefits with her doctor.

In short, the ACOG researchers concluded that women on combined HRT or estrogen therapy should take the smallest effective dose for the shortest possible time and annually review the decision to take hormones.

On the Web

More information on HRT and breast cancer can be found at the site of the American College of Obstetricians and Gynecologists.

Author: Nancyann Rella, HealthDay Reporter
SOURCES: Eva von Schoultz, M.D., Ph.D., researcher, Karolinska Institute, Stockholm, Sweden; April 6, 2005, Journal of the National Cancer Institute; Valerie Beral, M.D., professor, epidemiology, University of Oxford, England; April 29, 2005, The Lancet; March 2005, Radiology; Feb. 23, 2005, Journal of the American Medical Association; May 14, 2005, presentation, American Society of Hypertension, annual meeting, San Francisco; Hormone Therapy, report, American College of Obstetricians and Gynecologists, Sept. 30, 2004
Publication date: June 6, 2005
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