July 15, 2004 -- It has been two years since the widely publicized Women's Health Initiative showed that the popular menopausal hormone therapy increased the risk of heart attacks and breast cancer. The study, however, was limited to older women who were years past the menopause. Now a review of smaller studies concludes that the benefits of HRT probably outweigh the risks for many younger women.
After combining the data from 30 trials comparing hormone use to nonuse, the researchers found a survival advantage for women who begin HRT before the age of 60. In women younger than 60, HRT reduced the risk of dying from any cause by 39% compared with women who did not take HRT at all. A survival advantage was not seen in studies on older women regardless of whether the women took HRT.
"These data indicate that a large distinction needs to be made between the risks for women who start hormone therapy around the time of menopause and those who wait until they are older," researcher Edwin E. Salpeter, PhD, tells WebMD.
Millions of women abandoned hormone therapy after the WHI findings were published in July of 2002, but most physicians still recommend its use in women who have hot flashes and other menopausal symptoms. The risks vs. benefits of treating younger women with hormone therapy, however, remain controversial.
In this study, Salpeter, who is a professor emeritus at Cornell University, and daughter Shelley Salpeter, MD, of Stanford University, analyzed trials involving almost 27,000 women followed for an average of 4.5 years. Most of the studies were conducted between 1990 and 2002, and all compared various outcomes among hormone users and nonusers.
The authors concluded that hormone replacement was linked to a lower death rate among women beginning menopausal hormone treatment before the age of 60, but this was not true of women beginning menopausal hormone treatment later in life. Regardless of age, treatment did not appear to influence the risk of dying from cardiovascular disease or cancer. The reduction in death rates among younger women taking HRT was attributed to other causes and not to a reduced incidence of heart disease or cancer.
Breast Cancer Risk
So who should take HRT and for how long? As University of Florida Health Science Center ob-gyn Andrew Kaunitz, MD, explains, the answer is not a simple one.
Kauntiz tells WebMD that most, but not all, women should consider combination hormone therapy only for the relief of menopausal symptoms such as hot flashes. The one exception, he says, is women without uteruses who might be candidates for long-term estrogen-only hormone therapy to prevent osteoporosis.
That is because the WHI and other large studies suggest that it is the progestin and not the estrogen in combined HRT that increases breast cancer risk. Since women who have had hysterectomies take estrogen-only hormone therapies, long-term treatment may convey fewer risks for them.
"Breast cancer is the main thing my patients are worried about, " Kaunitz says. "The studies do indicate a small increase in breast cancer risk with the long-term use of combination therapy, but this does not appear to occur with estrogen-only therapy."
For women with bothersome menopausal symptoms who have not had hysterectomies, decisions about whether or not to take combination HRT should be made on a case-by-case basis, he says.
"A woman with menopausal symptoms in her 50s who has a mother or aunt who has had hip fractures damned well better be on HRT," he says. "But a woman with a close family history of breast cancer may not feel comfortable taking it."