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Cleveland Clinic menopause experts advise each woman to determine her
"personal risk profile" with her physician before abruptly stopping
hormone replacement therapy (HRT) due to fears that the risks of HRT outweigh
the benefits. "For some women, HRT may be very beneficial. For others, it
may be contraindicated," says Wulf Utian, M.D., a Cleveland Clinic
gynecologist who is executive director of the North American Menopause Society.
Fears arose when the National Institutes of Health on July 9 halted a $750
million Women’s Health Initiative (WHI) study of Premarin, a combination of
estrogen and progestin (a form of progesterone), after four years.
These female hormones wane at menopause, leading to various adverse health
effects. Yet hormone replacement produced more overall health risks than
benefits in the 8,506 women receiving Premarin, compared with the 8,102 women
taking a placebo. The study found increased rates of breast cancer, heart
attack, stroke and blood clots, and decreased rates of hip fractures and
colorectal cancer.
Holly Thacker, M.D., a Cleveland Clinic internist and director of the
Cleveland Clinic Women's Health Center, says "Unfortunately, the hype and misunderstanding surrounding this
study has caused unnecessary panic. This was a prevention—not a treatment—study,
and two-thirds of the women were over 65 and well beyond menopause."
"The study did not look at risks associated with short-term use of HRT
to control menopausal symptoms," says Dr. Utian. Adds Dr. Thacker,
"For women whose lives are currently made miserable by menopausal symptoms,
HRT is the best treatment available. Hot flashes, sleeplessness, mood swings and
painful tissue thinning can interfere with work performance, relationships and
sexual function.
"This study also looked at only one pill, and it’s not ‘one pill
fits all.’ At midlife, each woman needs an individualized menopausal risk
assessment that takes into account her values and preferences, and her personal
and family history," Dr. Thacker explains.
Selected tests would then assess the risk of diseases associated with
estrogen depletion and aging in women, such as osteoporosis, breast and colon
cancer, diabetes and cardiovascular disease.
Dr. Utian recommends that women considering HRT should ask three questions of
their doctors: "What is my current health status? Am I at risk for diseases
that will threaten or decrease the quality of my life? Do I have early signs of
any of these diseases?"
"Alterable risk factors—smoking, poor diet, lack of exercise, alcohol
abuse, unsafe sex and habit-forming drug use—can be eliminated by lifestyle
changes," he says. If unalterable risk factors or early signs of diseases
related to estrogen depletion are found, they should discuss how best to manage
menopausal symptoms.
"As long as the woman understands the risk/benefit equation, HRT targets
these symptoms very well," says Dr. Thacker.
The WHI confirmed earlier findings that HRT reduces hip fractures from
osteoporosis, "a common, devastating disease in aging women that we need
all available options to fight," says Dr. Thacker. The study proved that
HRT decreases the risk of colon cancer as well, which claims more women’s
lives than ovarian and cervical cancer combined.
There were no increased deaths from breast cancer in the HRT group, and the
women who developed breast cancer were on HRT before the study began.
Deaths from heart disease were equal in the HRT and placebo groups. "The
study suggests that HRT should not be taken to prevent heart disease," says
Dr. Utian, "although estrogen alone may be protective."
"Unfortunately, stopping this arm of the study will not gives us
long-term data on the effects of HRT on memory and cognition," says Dr.
Thacker.
In the other, ongoing arm of the WHI, women are taking estrogen alone. These
women have had hysterectomies and can do without progestin’s protective
effects against uterine cancer.
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