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Hormone Replacement Therapy: One Size Does Not Fit All

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WebMD Health News

Jan. 25, 2000 (Los Angeles) -- The finding that hormone replacement therapy (HRT), especially preparations that combine estrogen and progestin, may increase the risk of breast cancer presents women with an agonizing decision: continue taking HRT and live with an increased cancer risk, or stop taking the hormones and face a possible increased risk of heart disease and bone fractures. What factors should be considered?

First of all, "Don't panic!" says George Peters, MD, professor of surgery and executive director at the Center for Breast Cancer at the University of Texas Southwestern Medical School in Dallas. "You have to put the risks and benefits in perspective. If you come from a family with a history of heart disease or severe osteoporosis, concerns about breast cancer may be less important to you." On the other hand, he says, women who have a family history or other risk factors for breast cancer will probably be more worried about these findings. "You need to determine your individual relative risk-benefit ratio." His center at the University of Texas has a special risk-assessment clinic where they calculate each woman's risk based on her personal collection of risk factors and medical history. "Studies of risk-assessment tools like ours have shown that a woman's risk is lower than she thinks it is approximately 80% of the time," he tells WebMD.

"HRT is not for everyone. Women with a family history of breast cancer may not want to take it," says JoAnn Manson, MD, chief of preventive medicine at Brigham and Women's Hospital in Boston and a professor of medicine at Harvard. In general, she tells WebMD, it's best to limit the duration of HRT use. "Several studies have linked increased breast-cancer risk to increasing duration of use, especially after five years." In this study, risk went up appreciably after four years. She suggests that women "discuss with their doctors the idea of limiting duration to five years or less." Manson also suggests that women ask their doctors about the possibility of taking the hormones in lower doses. HRT might be most useful during what is known as perimenopause, the period in which a woman makes the transition into menopause. Women could take HRT for two to three years during the perimenopause to relieve the insomnia and hot flashes associated with this time, and then switch, if necessary, to different kinds of drugs or make lifestyle changes that can decrease her risk of osteoporosis and heart disease.

Both doctors point out that women have many alternatives to HRT. A new class of drugs called selective estrogen receptor modulators (SERMs), including Evista (raloxifene), has been designed to prevent osteoporosis without the stimulating effect on breast tissue seen with estrogen. However, these drugs are too new for doctors to know what their long-term effects will be. Other drugs also are available that may lower osteoporosis risk, such as Fosamax (alendronate).

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