If you're a healthy woman and you're past menopause, and you've been taking a combined (estrogen and progestin) hormone-replacement therapy to lower your risk of cardiovascular disease, should you keep taking it? The answer is no. The new Women's Health Initiative study builds on findings from earlier research showing that hormone replacement raises a woman's risk for certain cardiovascular health problems. Earlier studies had suggested that hormone replacement could cut the risk of heart disease. But several more recent ones using combined estrogen-progestin therapy showed that it raised the risk of heart disease within the first year a woman was on it. The current study found that hormone replacement slightly increases risk for heart disease, stroke and a pulmonary embolism, a clot in the lung that can stop the blood from circulating. What if you're that same woman as in the question above, but you've been taking the drug to lower your risk of osteoporosis -- should you keep taking it? Some doctors say maybe. Others say you shouldn't. The Women's Health Initiative went for more than five years before it was stopped. Women in the study who were taking the drug for that period were less likely to have fractures than women taking a placebo, leading the study authors to write that it was the "first trial with definitive data supporting the ability of postmenopausal hormones to prevent fractures at the hip, vertebrae and other sites." However, the hormones increased the risks of cardiovascular disease and invasive breast cancer. So overall, the treatment caused more harm than good.
Jennifer Blake, obstetrician and gynecologist in chief at Sunnybrook and Women's College Health Sciences Centre in Toronto, sees this question as a complicated one because, she said, "the women who are at risk for breast cancer are a different group than the women who are at risk for osteoporosis."
Though hormone replacement can prevent osteoporosis, so can other treatments (such as the drug Alendronate) that haven't been linked to an increased risk of cancer or heart disease. Donna Stewart, chairwoman of women's health at the University Health Network, said a woman needs to think about it as an individual risk-benefit decision. Someone whose mother or grandmother had osteoporosis and suffered from fractures may want to take it.
What if you are in menopause right now and suffer from hot flashes -- should you keep taking a combination hormone-replacement pill to prevent those symptoms? Most doctors say this is a very personal decision. Dr. Blake worries that women using it for menopausal symptoms "are being totally panicked" by the extensive press coverage the Women's Health Initiative has received. The drugs work well for symptoms of menopause and Dr. Blake says women shouldn't be told to stop taking them on the basis of the current study. Dr. Stewart said it depends how bad the menopausal symptoms are and what else has already been tried. She advises women experiencing hot flashes to dress in layers, keep cool, cut out hot drinks and reduce consumption of wine and beer. But if nothing else works, try hormone replacement.
McGill University epidemiologist and internist Louise Pilote said that since the current study found that the risks of hormone replacement build over time, women who decide to stay on hormone replacement for hot flashes should try stopping the drug once every six months or so by tapering down on their dosage and see if the hot flashes come back. Dr. Miriam Shuchman writes a weekly medical column in The Globe and Mail's Health and Wellbeing section.