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estrogen) all month long and added Provera® (a form of progestin) for two weeks; by contrast, the WHI used Prempro®, a combination of estrogen and progesterone, all through the month. So comparing the two protocols is a bit like comparing oranges and grapefruits: Sure, they have a lot in common but they have considerable differences that may be significant to the HT risk-benefit analysis. “The WHI is not the definitive answer because the study design should more exactly have mimicked the way the hormones were prescribed and it didn’t,” Schiff says. Despite the “earlier is


better” theory, more evidence is needed before HT can be used for cardiovascular protection in anyone. At this point, HT is recommended only for the treatment of moderate to severe hot flashes and vaginal dryness. Still, for many women, the findings about short-term use of HT being less risky in younger women than previously thought should come as a bit of relief in and of itself. After all, it is estimated that two-thirds of postmenopausal women will have vasomotor


symptoms such as hot flashes, and up to 20 percent of those women are likely to find those symptoms virtually intolerable. “Most women come into the


office for hot flashes but have a whole laundry list of symptoms,” says Douglas H. Kirkpatrick, MD, past president of The American Congress of Obstetricians and Gynecologists (ACOG), an ob- gyn in private practice in Denver, and an assistant clinical professor at the University of Colorado Health Sciences Center. “And the reality is: Hormones are still the most effective treatment for hot flashes, vaginal dryness, and other menopausal symptoms.”


Weighing the Benefits and the Risks Nearly every medication known to man- and womankind carries some benefits and some risks— and that’s true of HT. Deciding whether the benefits outweigh the risks, or vice versa, is a highly individual decision, but if menopausal symptoms are making you miserable, this much is clear: HT can improve your quality of life. “A substantial proportion of


women are going to have symptoms when they reach menopause, and some of them are going to have them severe enough that they will want therapy,” says Herbert B. Peterson, MD, professor and chair of the department of maternal and child health and professor in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. “For women with moderate to severe symptoms, HT clearly improves quality of life.” When it comes to long-term


health risks, the picture is slightly more complicated. At this point, the risk of developing cardiovascular disease seems to depend largely on a woman’s age, her overall health risks, and which hormones are used. As far as matters of the heart go, “hormone therapy might be protective in younger women but harmful when started in older women,” says Schiff. “One of the newer theories is that it has to do with the development of plaques and atherosclerosis in older women: Estrogen can lead to plaque rupture and heart events. Younger women don’t have that plaque, and estrogen can prevent plaque formation.”


WHI Updates


Just this past April 2011, the latest WHI study looking at women who have had hysterectomies found an overall lower risk of breast cancer and heart disease in women who started taking estrogen-only therapy beginning in their 50s. But among older women in their 70s who had their uteruses removed, the use of estrogen alone was associated with increased health risks. The results are reassuring for millions of middle-aged women who’ve had a hysterectomy and take estrogen to relieve hot flashes and other menopausal symptoms. In October 2010, after a follow-up of 11 years, another study of WHI participants reported a slight elevation


of the risk of breast cancer and slightly higher risk of dying from breast cancer among those women taking combined HT compared with non-users. “This is a very powerful study and I will share the results with my patients, but I don’t think it makes the case for removing hormones from the market,” says Schiff.


FALL / WINTER 2011 pause 11


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