Aging Begins at 30

Menopausal Women's Hormone Treatment

Ian Maclean Smith, M.D.
Emeritus Professor
Department of Internal Medicine
University of Iowa Hospitals and Clinics
Creation Date: February 2003
Last Revision Date: February 2003
Peer Review Status: Internally Peer Reviewed

The Hormone Replacement Trial (HRT) using a combination of estrogen and progestin (Premaquin R) was stopped early. The other studies of the Women's Health Initiative using estrogen only, diet studies, calcium and vitamin D are continuing. All the women in the study were postmenopausal aged 50 to 79 randomly allocated to either placebo or hormone replacement. The participants in the two groups matched excellently in regard to blood pressure; cholesterol levels, smoking history and general health. The study participants received either estrogen (Premarin) and progesterone (Provera) hormone replacement treatment or were given identical appearing placebos. The objective was to see if HRT would prevent blood vessel/high cholesterol complications such as heart attacks and strokes.

There was no difference in overall death rates from all causes and no difference in the occurrence of cancer of the uterine lining (endometrial cancer). The latter is good news as the possibility has been worrying physicians for a long time.

There was some benefit in the HRT treated group with reduced hip fractures and cancers of the colon or rectum. Both are common diseases of older women and so this advantage is welcome.

However, there was increased breast cancer (for which the study was stopped), more leg vein clots (deep venous thrombosis or DVTs) with associated lung clots, extra strokes and more heart attacks. To put it in context, for every 10,000 women treated for five years or more there were 8 extra breast cancers, 7 extra DVTs and 7 extra strokes and 8 extra heart attacks (fatal and non-fatal). These are very significant findings for the women. Stated differently, a woman on Premaquin for 10 years would have a one percent increased risk for developing breast cancer, and about a two and one half percent increased risk of developing heart disease, stroke or blood clots. The highest rates were in women in their 50s shortly after they started treatment. Graphs were shown of adverse events by duration of treatment. The differences appeared early, and the difference was maintained except with breast cancer, which only increased after 4 years on HRT.

So how does this affect our office practice? What do we say to near-menopausal women? First this is not a hurried or emergency decision. A summary should be presented to the woman. "The benefits in preventing hot flashes, hip fractures and lower intestinal cancer are real." "Other strategies are available to prevent heart attacks and strokes." Smokers should be strongly discouraged from starting HRT. Hot flashes and associated symptoms are usually limited to a short period of time and a trial of 3 to 5 years of HRT is reasonable. Whether the results of this study apply to other HRT is not known, but there is no evidence to the contrary.

Alternative treatments for symptoms of menopause include activilla, estrogen alone, clonidine (a high blood pressure medicine), phyto (plant) estrogens, for example I to 3 cups of soy milk (provided these extra calories are balanced and calcium is added). Other treatments to be considered are unopposed progesterone, black cohosh (Remifemin), an Algonquin plant remedy, transdermal creams, SSRI (selective serotonin reuptake inhibitors) for example effexos. Bellergal at night, a multiple component preparation containing phenobarbital, or a more recently developed neurological drug neurotonin 300 to 2400 mgms daily which may be very effective (but expensive). In treating vaginal atrophy (in women with painful intercourse) estrogen cream works well and is not absorbed. But none of these alternate treatments have been rigorously tested the HRT trial to determine their long-term benefit or detriment.

If you are stopping the hormonal treatment it is best to taper the, dose. More details are available in the JAMA issue for August 21, 2002.

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See related Patient Topics Endocrine System (Hormones), Hormone Replacement Therapy, Menopause, Procedures and Therapies, Seniors' Health or Women's Health.

See related Provider Topics Endocrine System (Hormones), Menopause, Procedures and Therapies, Seniors' Health or Women's Health.

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