Rethinking using hormones to help manage menopause
On May 6, 2024 PBS news hour interviewed Dr. Loren Streicher, a clinical professor of obstetrics and gynecology at Northwestern University School of Medicine. She said that 22 years ago a study called the women’s health initiative frightened doctors and women taking hormones for symptoms of menopause. Most doctors stopped prescribing the medicine.
Dr. Streicher pointed out that what she is saying is not based on a new study or new data. She is just posing another way of looking at data from the women’s health initiative. It was done at a time that doctors used hormone therapy that experts no longer use. (estrogens and progestins)
“We’re looking at short term and long term issues.”
Short term: Hot flashes, vaginal dryness, brain fog, moodiness, insomnia
Long term: Prevention of: heart disease. breast cancer, and uterine cancer; cognitive function down the road; joint pain; sexual function.
Clearly people with severe symptoms esp. hot flashes and insomnia initially benefit from hormones. “But hot flashes last an average of 7 to 10 years and hot flashes are “correlated” with heart disease and other serious long term medical issues.
The big question is bone health. It’s a “big deal.” Women lose bone after they enter menopause , and “women who start hormone therapy between the ages of 50 and 60 have a 33% decrease of fracture but the minute they go off hormones they start losing bone again. “
Women who take estrogen alone (as the only hormone) have a 20% decrease in getting breast cancer.
Women who are taking estrogens at the time they get breast cancer have a 40% decreased risk of dying of breast cancer.
---------------------
I then checked the JAMA article evaluating the Women's Health Initiative https://jamanetwork.com/journals/jama/fullarticle/2797867
The WHI trials enrolled postmenopausal persons aged 50 to 79 years; the mean age of participants was 63 years.
It compared 0.625 mg/d of oral conjugated equine estrogen, with or without 2.5 mg/d of medroxyprogesterone acetate, with placebo.
The median intervention of the estrogen only group was 7.2 years the median intervention of the estrogen and progestin group was 5.6 years Long-term follow-up lasted up to 20.4 years.
Findings:
Coronary Heart Disease –no significant difference
A pooled analysis of 3 trials (n = 18 085) showed no significant difference in risk of coronary heart disease events in persons treated with estrogen plus progestin compared with placebo (2.8% vs 2.6%) during a mean follow-up of 4 years. A pooled analysis of 3 trials (n = 11 310) found no significant difference in coronary events between persons taking estrogen alone and those taking placebo during a mean follow-up of 4.1 years. Heart disease—no effect noted.
Breast Cancer—estrogen alone may be protective (see interview)
Persons randomized to estrogen plus progestin had a significantly increased risk of invasive breast cancer compared with those taking placebo (2.4% vs 1.9%) the risk persisted during postintervention follow-up. Other trials either reported few cases of breast cancer or were generally consistent with the WHI findings in direction of effect. In the WHI, during 20.3 years of follow-up, the point estimate of the risk of breast cancer mortality was higher for persons in the estrogen plus progestin group than those in the placebo group. (So avoid dual therapy)
Four trials reported on the effects of estrogen alone on breast cancer; however, only the WHI followed participants for more than 3 years. At 20.7 years of follow-up, the WHI reported a lower risk of invasive breast cancer among persons assigned to estrogen alone compared with those assigned to placebo, although the risk of breast cancer was not significantly lower during the study’s 7.2-year intervention phase. The other trials reported very few cases of breast cancer. The WHI also reported on breast cancer mortality. At 20.7 years of follow-up, persons who received estrogen alone during the intervention phase had a lower risk of breast cancer mortality than those in the placebo group.
Fractures -- fewer when women take hormones
Five trials reported on fracture risk in persons randomized to estrogen plus progestin compared with placebo. A pooled analysis of these trials found a statistically significant reduction of fractures in persons taking estrogen plus progestin
The WHI (n = 10 739) also found a lower risk of total fractures in persons taking estrogen alone compared with placebo during the intervention phase which persisted during 4.3 years of postintervention follow-up. A smaller trial found fewer fractures at all sites in the estrogen-alone group, although the difference was not statistically significant.
Diabetes---reduced risk of developing diabetes
A smaller trial also found a reduced risk of incident diabetes, although that was a post hoc analysis. Fewer persons taking estrogen alone reported a new diagnosis of diabetes compared with those taking placebo
Colorectal Cancer -- no effect.
The WHI estrogen-alone trial reported no significant difference in the risk of colorectal cancer between persons randomized to estrogen alone and those taking placebo.
Thromboembolic Events—INCREASED RISK
Five trials reported on risk of thromboembolism. In the WHI (n = 16 608), persons randomized to estrogen plus progestin had an increased risk of venous thrombosis, deep vein thrombosis, and pulmonary embolism compared with those in the placebo group. Other trials either reported few thromboembolic events or were consistent with the WHI findings.
In the WHI (n = 10 739), persons randomized to estrogen alone had an increased risk of deep vein thrombosis the risk of pulmonary embolism was higher in the estrogen group than in the placebo group, but results were not statistically significant. There is an increased risk of venous clotting.
Stroke—increased risk
The WHI found an increased risk of stroke with both estrogen plus progestin and estrogen-alone therapy. Stroke risk was significantly higher in persons randomized to estrogen plus progestin compared with those randomized to placebo. Similarly, persons receiving estrogen alone had a statistically significant higher risk of stroke compared with those receiving placebo (3.2% vs 2.4%; A smaller trial reported that stroke risk was similar in estrogen plus progestin and placebo groups, although the confidence interval was quite wide. (stroke risk increased)
Dementia—no increased risk with estrogens alone
The Women’s Health Initiative Memory Study was a sub-study of the WHI, evaluating the risk of dementia in persons randomized to estrogen plus progestin or estrogen alone compared with placebo. That study found that persons randomized to estrogen plus progestin had a higher risk of probable dementia than those taking placebo. No significant increase in risk of probable dementia was found in persons taking estrogen alone.
Gallbladder Disease—increased risk
The WHI (n = 14 203) reported a significantly higher risk of gallbladder disease in persons randomized to estrogen plus progestin treatment compared with those randomized to placebo and in persons randomized to estrogen alone (n = 8376; 1.64% annualized vs 1.06% annualized;
Urinary Incontinence --increased incidence
Two trials reported on incident urinary incontinence (self-reported) in persons taking estrogen plus progestin; both found increased risk. In the WHI (n = 10 073), 16.6% (annualized) of persons taking estrogen plus progestin reported incident incontinence after 1 year of treatment, compared with 11.1% (annualized) of those taking placebo A smaller trial also reported increased risk. Similarly, in persons randomized to estrogen alone, the WHI found a higher risk of urinary incontinence at 1 year (22.6% annualized vs 14.0% annualized and 6.6 years after stopping treatment.
All-Cause Mortality---no significant risk
A pooled analysis of 3 trials (n = 19 580) showed no significant difference in all-cause mortality between persons taking estrogen and progestin therapy and those taking placebo during 3.2 to 5.6 years of follow-up. Similarly, a pooled analysis of 3 trials (n = 11 587) showed no significant difference in all-cause mortality between persons receiving estrogen alone and those receiving placebo during a mean follow-up of 7.1 years.
From England: Endometrial (womb) cancer: oestrogen-only HRT increases the risk of womb cancer. This increased risk gets bigger the longer HRT is used, and may stay for some years after HRT is stopped. This is why it is usually only prescribed to people who have had a hysterectomy.
Comments
Post a Comment