This past weekend, the International Menopause Society (IMS) issued a public statement calling on the National Institutes of Health (NIH) to revise current recommendations on use of hormone replacement therapy (HRT). In this statement, the IMS stated that it believed that the “NIH has been guilty of unbalanced reporting in failing to inform women of the latest information,” adding that it “calls on the WHI (Women’s Health Initiative) and the NIH to revise its advice to reflect current consensus — not just the initial WHI results.” IMS President Dr. Tobie de Villiers said “Of course there are differences between what the WHI thinks and what the menopause community thinks, but I think that it’s fair to say that in many ways the WHI has moved more towards our position over the last 10 years. In spite of this, they have not been particularly even-handed in presenting results. For example, the main NIH patient brochure on HRT has not been updated in the last 7 years, in spite of a wealth of new information…the least that they can do is agree that HRT is a good option for symptom relief for most women going through the menopause.”
If you’ve been following the news or this blog closely for the past four years, evolving analyses of WHI data don’t entirely support this last statement. Moreover, several organizations, including the US Preventive Task Force, the US Food & Drug Administration, the American Association for Cancer Research and the Canadian Cancer Society have issued warnings about of combination HRT or estrogen alone with regards to timing and duration of use. And, two years ago, I quoted lead study investigator for the Canadian Cancer Society — Dr. Prithwish De, who said that “The Canadian Cancer Society’s ongoing review of the evidence on HRT and breast cancer since 2003 led us to our current position and the research study findings reaffirm this position. The Society recommends that women avoid taking HRT for any reason other than to relieve severe menopausal symptoms that have not responded to other treatment. We understand that each woman’s experience with menopause is unique. If, after consulting with their healthcare professional, a woman decides to take HRT, it should be the lowest effective dose for the shortest time possible.” Notably, like the IMS, the North American Menopause Society’s recommendations also tend to minimize certain noted risks.
So, why the disconnect?
Is it at all possible that menopause has been overpoliticized, medicalized and poorly characterized, a “phenomenon not so much hijacked by medicine as gradually occupied, [with] authorities throughout the ages grimly trying and failing to define their subject?”1
In a recent editorial in Menopause journal, several authors express concern that the North American Menopause 2012 recommendations on use of HRT do not include caveats with regards to prevention of coronary heart disease (CHD) or stroke and also ignore data suggesting that longer-term use of estrogen-alone may not be safe. Noting that “long term observational data are especially unreliable for CHD (as they reflect the experience of women who were not susceptible to early risk), they add that 1) lifestyle choices have the ability to influence the likelihood of developing heart disease and 2), that generalizations as to ongoing lower risk rates should HRT not be used for longer periods cannot be assumed. They also point out that the NAMS statement blatantly understimates stroke risk on younger women who choose hormone therapy. These concerns are largely echoed by Jacques Rossouw, M.D., National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Chief, Women’s Health Initiative Branch, who sent me an email statement when I asked for a comment. He writes:
“WHI has made substantial contributions to our understanding of the effects of hormone therapy, providing women and their physicians with much better information on which to base an informed decision about the use of hormone therapy. In women close to menopause, the risks of short-term use of hormone therapy for treatment of hot flashes and night sweats are small, and WHI investigators have supported short-term use, provided that patients are fully informed of the risks and benefits. The main objective of the WHI was to address whether hormone therapy should be used to prevent cardiovascular disease in postmenopausal women ages 50 to79, and the data on this are overwhelming. The risk of coronary heart disease is particularly increased in older women, especially among older women with hot flashes and night sweats. Therefore, hormone therapy should not be used in older women to prevent coronary heart disease or even to relieve vasomotor symptoms (hot flashes and night sweats). Even in younger women, long-term hormone therapy is unwise because of the likely increasing risk of breast cancer over time, and uncertainty about long-term cardiovascular effects. The hormone prescriptions for older women have decreased more markedly than in younger women, and this seems an appropriate response to the data. It is not possible to evaluate whether hormone prescriptions to younger women are at an appropriate level.”
We’re drowning in politics, medicine and industry. And it’s difficult to discern truth from fiction, data from data, risk from benefit. Ongoing analyses will eventually reveal what’s what. Meanwhile, read the library of HRT posts on Flashfree. Talk to your physician. Avoid hasty decisions. And consider alternatives. If the medical community can’t agree, perhaps it’s time to put down the gauntlet and wait out the firestorm.
1. Louise Foxcroft, Hot Flushes, Cold Science. A history of the modern menopause. London: Granta Press. 2009.
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Liz, I trust you to report on the most important aspects of this subject but… why is NO ONE saying, “If hormone replacement therapy doesn’t work, what does?” Why is no one talking about quality of life? If I have tried other avenues and my quality of life is increasingly bad, should I just say, “Oh well. I have to live with this misery because HRT isn’t good for me.”? This statement is especially troubling, “The risk of coronary heart disease is particularly increased in older women, especially among older women with hot flashes and night sweats. Therefore, hormone therapy should not be used in older women to prevent coronary heart disease or even to relieve vasomotor symptoms (hot flashes and night sweats).” Really? And… what then? I suggest that if men were experiencing half the symptoms women experience, this problem would have a solution.
While I love your last comment, “If the medical community can’t agree, perhaps it’s time to put down the gauntlet and wait out the firestorm” I don’t agree with it. Wait out the firestorm? For some women that’s unacceptable. Me, I gave in. I’m on HRT and I love it. Will it shorten my life? I don’t know. But, I do know that whatever life I have left will not be spent in utter, senseless misery – which is all I experienced before going on HRT.
Thanks for keeping us up on this topic. Wouldn’t it be great if we could find a solution before our own daughters and granddaughters have to go through this?
@YvonneDiVita I am surprised to hear you say that other avenues have not improved life quality. I and several women I know have virtually shut down many of the symptoms of peri and post menopause through alternative strategies. It makes me think that perhaps, you’ve not hit the right cocktail, so to speak. My intention is not to dissuade you from HRT if that’s what you want, but rather to insure that you are making the most informed choice possible. And if you want to remain on HRT, perhaps you should try a compounded formulation individualized to you. Regardless, when you refer to quality of life and the fact that HRT has given that back to you, what you ignore is that living with a chronic illness likewise, will rob you of your quality of life and it will be more than troublesome side effects. The good news about menopausal symptoms is that they do stop. Heart disease and cancer on the other hand? They have long lasting consequences insured to not only rob you of your life quality but also potentially end your life.
@Liz Yes, I’ve thought of that, Liz. The chronic illness aspect of using HRT. I have a chronic illness, I have fibromyalgia… so, on top of menopause, I deal with that. And, my mother, who is well into her 80s, still suffers from menopausal symptoms so I do not see a light on the horizon for me. I admit that having tried alternatives (diet mainly), that didn’t work, and already challenged on a daily basis with other issues, I’m reluctant to give up my HRT. I was on HRT for a few years after a hysterectomy and at my then doctor’s advice, stopped it. The ensuing misery made me so unhappy, I was thrilled when my new Dr said we could try it again. It’s a low dose but it’s made such a difference in my life, I just cringe at the thought of stopping it again. And yet, I have considered it recently – giving diet and other options another try.
I still think quality of life is overlooked in these studies. Are you saying women should live in misery because they MIGHT get heart disease or breast cancer? Neither of those issues is prevalent in my family tree, by the way. From my perspective, it’s like telling a mountain climber not to climb because she might fall, or cause an avalanche or get lost. Life if full of risks. I’m following the information being shared and weighing my options. For now, I’ll continue my HRT until I can figure out a different, active, positive solution.
@YvonneDiVita There are scientific indices for menopausal symptoms and how they relate to quality of life. But the data that are being cited are from older studies that are undergoing reanalyses, like WHI and the ongoing SWAN or the Australian study I wrote about today. If quality of life was not originally included as an outcome measure, they would not be looking at that today, if that makes sense. What they are looking at, however, are chronic disease risk. If you are achieving relief on the hormones, you should do what’s best for you. No one is asking that you defend your choice or right. But as a women’s health advocate, it is my duty to share as much information as possible so that choices can be informed. Wishing you the best.
Hi
I am late to this discussion.
Just a short note to Yvonne DiVita…….you are right….Quality of life is what is missing in most of our research…..as this is a very relative term.
I am a women’s health advocate too.I am a menopausal woman gynaecologist….I believe in choice and information for my patients. With today’s easily available information on line, I guide my patients to read and be informed as they make a choice suitable to their lives.
If a woman has a very good quality of life between 50-70 years of age(this is a relative age, it could be early 40s in premature menopause/having ovaries removed for non malignant causes),not having hot flushes, sleep disorders,
anxiety and depression, no sexual problems, no bone loss (I do not suggest that HRT is an answer to all these problems)…..but understands that she might have breast cancer, or might have cardiac problems, or other possibilities of diseases that might cause her chronic problems for the next 10-20 years of her life…..
She should have a choice, and make an informed decision.
If your quality of life is better on HRT, then you have your answer…..Life style changes are great help, and to reduce the long term use of your HRT, you could try periods of break from your HRT, and see how it works for you.