ATLANTA -- Emory University and University of California, San Diego (UCSD) researchers are taking a bold stand in the sea of information and confusion on hormone replacement therapy (HRT) in postmenopausal women, saying HRT given at the appropriate time ¬ at the start of menopause and continued long-term ¬ is beneficial, not harmful. This information goes against previous recommendations, based largely on studies in women well past menopause, that were interpreted to show that HRT should not be used in an attempt to preserve health in postmenopausal women.
The findings were published in the March issue of Fertility and Sterility by Lawrence S. Phillips, MD, professor of medicine in the Division of Endocrinology, Emory University School of Medicine, and Robert D. Langer, MD, MPH, professor of family and preventive medicine, University of California San Diego School of Medicine. Both authors have been directors of major HRT trials that have influenced the current controversy.
The researchers noted that findings in recent years seemed to be in conflict with each other. Some studies were interpreted as showing that HRT should help reduce the risk of major chronic diseases that are common in postmenopausal women ¬ osteoporosis, coronary heart disease (CHD) and dementia. However, other studies were interpreted to show that HRT carried more long-term risk than benefit. Based on the latter studies, HRT is currently recommended only for short-term use to relieve menopausal symptoms such as hot flashes and night sweats.
Drs. Phillips and Langer disagree with that view; they believe that long-term HRT treatment can provide important additional benefits. (HRT usually involves estrogens alone in women who have had a hysterectomy to remove their uterus, or estrogen plus a progestogen in women who still have their uterus.)
"We hypothesize that HRT initiated at the time of menopause and then continued should produce a decrease in CHD, osteoporosis and dementia over time," says Dr. Phillips. "In contrast, HRT begun years after menopause should produce an increase in CHD and dementia (due to blood vessel problems) shortly after therapy is begun, followed later by long-term benefit. In women who require a progestogen, there should be greater CHD benefit either from use of a progestogen that gets mainly to the uterus so that very little appears in the bloodstream, or from use of a progestogen such as progesterone that is less likely to antagonize the beneficial effects of estrogens."
For the past several decades, HRT was used in an attempt to decrease the risk of major chronic diseases that are common in postmenopausal women. The HRT strategy was supported both by basic science, and by observational studies of women after menopause. The basic science analyses of bone, blood vessels and brain indicated that estrogens should be beneficial, and the observational studies ¬ such as the Nurses' Health Study ¬ showed that women who were given HRT at the time of menopause were less likely to develop osteoporosis, CHD, colorectal cancer and dementia. The observational studies also showed that use of HRT did carry a risk of breast cancer, but this risk varied by treatment and appeared to be small relative to the benefit for the other health problems ¬ particularly CHD, which is the major cause of death in postmenopausal women. Based on such findings, use of HRT became a standard in medical practice.