HRT white pills
Credit: Karrie Nodalo/camerakarrie on Flickr, under Creative Commons (CC BY 2.0).

(WOMENSENEWS)–On a routine visit to a new obstetrics-gynecologist, a woman recalls being recommended hormone replacement therapy to prevent osteoporosis.

She was shocked, since a few years earlier a landmark government study found hormone therapy’s risks outweighed the benefits. She declined the recommendation and did not go back to that physician.

True story from the life of Corinna Barnard, editor of Women’s eNews.

But Barnard said she wondered a tiny bit about her decision to not see that doctor again. Wouldn’t the doctor know best?

She isn’t alone in her confusion and uncertainty.

The Endocrine Society, based in Chevy Chase, Md., commissioned a national survey in June of physicians on their experiences in treating menopausal symptoms. Nearly 90 percent said women are not receiving hormone therapy because they are uncomfortable with the risks and are unwilling to consider the option.

But more than half of ob-gyn physicians surveyed also said women were confused about hormone therapy.

Ten years ago a study published by the Women’s Health Initiative, part of the National Institutes of Health based in Bethesda, Md., changed the landscape for the treatment of age-related illnesses in older women.

It found that hormone therapy, often prescribed to relieve menopausal symptoms and protect against osteoporosis, in healthy postmenopausal women increased the risk of breast cancer, heart disease and stroke.

Participants in the study were taking the treatment so researchers could assess how well it prevented aging-related diseases, not menopausal symptoms.

There were some benefits to the treatment, including a reduced risk of bone fractures and colorectal cancer, but the risk of breast cancer and heart disease was high enough that researchers halted their work five years into the eight-year study.

Impact Assessment

The National Women’s Health Network, an advocacy organization based in Washington, D.C., hosted a July 9 congressional hearing to assess the impact of the Women’s Health Initiative on clinical practice and women’s health.

If they knew of the decision by Barnard, who went to the doctor with no symptoms of any illness, they would have approved of her choice not to take hormone therapy as a preventive measure.

“Its results remain relevant today for women and their health care providers who need evidence-based information about the safety and effectiveness of medications,” said Cynthia Pearson, executive director of the National Women’s Health Network, in a press release.

Panel members included Dr. Vivian Pinn, the former director of women’s health at the National Institutes of Health, and Robert Smith, director of cancer screening at the American Cancer Society.

Hormone therapy was introduced in the 1960s and was widely prescribed to manage symptoms of menopause under the assumption that it provided other benefits, including reducing the risk of heart disease.

The type of therapy studied by the Women’s Health Initiative was the most commonly prescribed one — a combination of estrogen and progestin meant to replace hormones that are in decline when a woman reaches menopause.

Pfizer manufactured the combination drug Prempro, one of the drugs in the 2002 study. Another study from 2010 indicated that Prempro not only can cause cancer but leads to types of cancers more likely to cause death.

In June Pfizer settled about 6,000 lawsuits that argued the drug caused cancer in women. It cost the New-York based pharmaceutical company $896 million to resolve and there are still 4,000 suits pending.

But there remain uses for hormone therapy that are still seen as acceptable.

The Women’s Health Initiative results explicitly stated the study was not meant to look into the effectiveness of hormone therapy for treatment of menopausal symptoms, such as hot flashes and vaginal dryness. However, after the shocking results many women taking it for this purpose also abandoned use.

Since the groundbreaking study, many have turned to lower-dose therapies or alternatives such as low-dose vaginal rings.

The Right Balance

“All medications carry risks and benefits,” said Dr. Cynthia Stuenkel, an endocrinologist at the University of California-San Diego and a leading expert on menopause, in an e-mail interview. “The trick is finding the balance that makes sense for the individual considering that therapy.”

The Endocrine Society released a joint statement on July 9 with the North American Menopause Society and the American Society for Reproductive Medicine emphasizing that hormone therapy is key to the quality of life for those women for whom it is recommended and that research in the last 10 years shows the degree of risk depends on the individual.

The groups emphasized in the statement that individualization is key in the decision to use hormone therapy.

Stuenkel said any treatment decision should be determined by symptoms. She helped develop the Menopause Map, an online tool launched in May to guide women through different options based on their symptoms.

“The major benefits relate primarily to symptom relief (best thing for hot flashes and vaginal dryness) and improved quality of life. That is why the decision to go with hormone therapy is so personal,” she said.

For other issues, such as bone loss, Stuenkel says other drugs are available and usually preferable.

Pearson, of the National Women’s Health Network, is thrilled with the impact the Women’s Health Initiative has had. Chief among the effects is a 2007 study that estimated 160,000 U.S. women have avoided breast cancer in the last decade partly as a result of avoiding unnecessary hormone therapy.

She says now that it has been well-established that hormone therapy is not worth the risks in preventing aging-related diseases in women, research needs to be focused elsewhere.

“We don’t think there is good evidence of any form of hormone, whether alone or in combination, the specific ones tested in Women’s Health Initiative or others, to have the kind of proof women deserve that they work to help healthy women up their chances to avoid one of those conditions of aging,” said Pearson in a phone interview.

Sadiya Ansari is a Pakistani-Canadian freelance journalist, currently reporting from New York.

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