Risks Small; Benefits Depend on Individual
"I think there is a lot of evidence that the observational studies of HRT are generally getting the right answers," Grodstein says. "Generally the risks seen for stroke, breast cancer, colon cancer, and pulmonary embolism are identical to those seen in clinical trials. Why the findings on heart disease were so different -- there are not a whole lot of answers right now. It may be that the women in the clinical trials were older. In terms of heart disease, there is some suspicion that if the disease process has gone a certain distance, it is hard to help it. Early intervention could work, but starting later in the disease process may make that same product have harm instead of benefits."
Caren Solomon, MD, MPH, deputy editor of TheNew England Journal of Medicine and a physician at Brigham and Women's Hospital, is co-author of the other NEJM paper.
"I think Dr. Grodstein's goal was to make sense of why randomized clinical trials looked so different from observational data," Solomon tells WebMD. "What we tried to do is say OK, given everything that is out there, what do we do? When should women use HRT, and if they should not use it, how should they stop it? We wanted to offer clinicians some very practical information."
Here's Solomon's advice to women:
- Get your bone mineral density measured if you're over 65 -- or if your doctor says you have an increased risk of osteoporosis. Those with bone loss should take Actonel or Fosamax.
- Get plenty of calcium and vitamin D.
- Get plenty of weight-bearing exercise.
- Stop smoking.
- Have your doctor check your risk of heart disease. If you have high cholesterol levels, consider treatment with the class of drugs known as statins. If you have high blood pressure, consider treatment with blood-pressure-lowering drugs.
- Eat a healthy diet.
These steps, she says, are much more likely to preserve health than HRT. Both she and Grodstein say HRT should be used only to get over symptoms of menopause, and that long-term use -- five years or more -- isn't advised for prevention of heart or bone disease.
"People shouldn't forget there is value to HRT in some women," Solomon says. "This was ignored at first when WHI came out and there was this widespread panic. It has been a good medicine for years for some women with menopausal symptoms. It is reasonable for symptomatic women who are in the early stages of menopause and who don't have risk factors for the drug. The risks are real, but on an absolute basis they are quite small for young women without other risks of complications. Estrogen helps symptoms enormously."
However, Solomon says there is no convincing evidence that estrogen keeps a woman looking younger, or that it prevents mental decline.