Feature: Hormone Replacement Therapy. Just the facts.

June will see the publication of an international position paper on the use of Hormone Replacement Therapy (HRT) by a panel of experts.  Why the need for this paper?  It seems that evidence-based medicine is discouraging the use of HRT for many postmenopausal conditions⁶.  However, in certain conditions, such as induced termination of menstruation due to chemotherapy, postpartum depression, and ovariectomy ^{1 3}, even young woman are searching for the correct HRT to use.

What do we know now?

• HRT does not reduce the risk of coronary heart disease in postmenopausal women with established coronary disease.
• HRT prevents bone loss, but only when taken continuously.
• Estrogen therapy failed to benefit Alzheimer cases.
• Strong evidence that HRT does positively affect genitourinary symptoms such, as urinary incontinence.
• HRT helps reduce Hot flashes⁵.
• Estrogen therapy increases the risk of endometrial cancer^{4 5}.
• Estrogen therapy increases risk of deep venous thromboembolism.
• Breast cancer increase with long term HTR use (5 + years)⁵.

A few studies have indicated the HRT may increase the risk of coronary heart disease in the short term (1 to 2 years) in healthy women. Therefore, until further data is presented HRT should not be given for the purpose of preventing heart disease.  The drug family of statins may be considered as an alternative medication for heart disease⁴.

HRT should only be used for woman with high risk of bone fractures.  The use of bisphosphonates  and selective estrogen receptor modulators, like raloxifene, may be alternatives for women with osteoporosis.  However, older woman may consider the use of the bisphosphonates: alendronate or risedronate, due to their bone specific fast acting response ^{4 6}. 

Longterm use of HRT increases the incidence of breast cancer 2.3 % per year.  This effect decreases upon termination of the use of HRT and completely disappears by 5 years of discontinuation HRT use. The use of combination estrogen/progestin therapy increases the risk of breast cancer. However the cyclic use of estrogen/progestin therapy reduces the risk of endometrial cancer almost entirely 7.

The use of serotonin reuptake inhibitors, such as venlafaxine and paroxetine, can also reduce hot flushes ⁶. For mild to moderate intensity hot flashes Soy, which contains phytoestrogens, and vitamin E may possibly be beneficial ^4. However, it is important to note that more controlled trials are needed to prove Phytoestrogens usefulness in treating postmenopausal symptoms and their safety². Low dosage vaginal estrogen may be used for vaginal symptoms⁴.

Lifestyle changes can also contribute to alleviating symptoms and thereby lessen the need for HRT.  For example, quitting smoking reduces the adverse effect on cardiovascular disease, cancer and vascular disease.  A routine exercise regime will affect the immune system, hormonal system, and mood in a positive manner, while weight bearing exercise will have a positive effect on bone density.  As always, a balanced diet will positively affect certain cancers, improve immune function, help with bone deposition, and help prevent chronic disease⁴.

Particular attention must be given to obtaining adequate levels of calcium and vitamin D.  The recommended dietary allowance (RDA) is 800 mg/day, however many researchers are recommending 1 to 1.5 g per day to help minimize bone loss ⁸.

People with limited exposure to sunlight may require vitamin D supplementation.

Unfortunately, for more concrete information, women must wait for the results of two important studies that will be completed in the year 2005 and another in 2012.  These studies will help define the benefits and risk of HRT use ^5.

Given the current state of knowledge of HRT, the recommendation for use of HRT needs to be individualized.  Clinicians must consider the woman’s family history for breast cancer, susceptibility to osteoporosis, and presence of coronary heart disease ^{5 7.}

Please note that neither Dr. T Craig nor TARA endorse the use of any specific drugs. 

References: Feature Hormone Replacement Therapy.  Just the facts.

1. Andreoli, T. E.  2001.  Cecil Essentials of Medicine 5^th ed.  W. B. Saunders. Co, Philadelphia
2. Ayman, A. A. E.  2002.  Phytoestrogens in the Management of the Menopause: Up-to-Date.  Obstetrical and gynecological survey 57(5):306-313.
3. Berkow. R.  1977.  The Merck manual.  13^th ed.  Merck and Co, Rahway N. J.
4. Friedrich, M. J.  2001.  Recent studies bring risks, benefits of hormone replacement therapy under scrutiny.  J National Cancer Institute.  93(17):1287-1288
5. Manson, J. E. and Martin, K. A.  2001.  Postmenopausal hormone-replacement therapy.  N Eng J Med.  345(1):34-40.
6. Vastag, B.  2002.  Hormone replacement therapy falls out of favor with expert committee.  JAMA 287(15): 1923-1924
7. Vecchia, C. L., Brinton, L. A., and McTiernan, A.  2001.  Menopause, hormone replacement therapy and cancer.  Maturitas 39:97-115.
8. Weigley, E. S., Mueller, D. H., Robinson, C. H.  1997. 
9. Basic Nutrition and Diet Therapy.  8^th ed.  Prentise Hall, NJ.