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Hormone Therapy A Good Surprise. By Jon Nielsen, MD
May 16, 2011
There has been a bit of a "buzz" about a recent article in the Mpls/Star Tribune on April 6, 2011. Authored by Tara Parker-Pope, it was entitled "Menopause therapy yields surprise", was from the New York Times, and showed important and interesting findings. In my opinion, Parker-Pope is the most clear-headed journalist when it comes to women’s issues.
Background
As you may remember, the Women’s Health Initiative (WHI) study data published in July 2002 was reported and interpreted by most as very negative news for hormone therapy. More than 3 million women stopped their hormone therapy within one year based on those findings. This was data about "combination" therapy, Premarin (estrogen) and Provera (progesterone), used in women who still had a uterus and therefore needed the progesterone component to protect the uterus from unopposed estrogen.
The "surprise" referenced in Parker-Pope’s article was about the estrogen-alone portion of the WHI. The second portion of the WHI data, published in February 2004, on the estrogen-only (Premarin) group curiously received much less publicity. Bad news seems to get more play in the press, and the results were much less negative in this population. Little publicized from that study was the fact that in the subgroup of women aged 50-59 who took the estrogen as they were supposed to experienced statistically significantly less breast cancer.
The surprise
The "surprise" in the article published in the Journal of the American Medical Association (JAMA) on April 6, 2011 entitled "Health Outcomes After Stopping Conjugated Equine Estrogens Among Postmenopausal Women With Prior Hysterectomy" was less of a surprise to me than a validation of the earlier data, which had been under emphasized in the media presentation of earlier knowledge.
So today, with more than 10.7 years of follow-up, there is clear-cut evidence of a 23% reduction in invasive breast cancer in women on Premarin versus placebo. For those familiar with statistical analysis, there was a Hazard ratio of 0.77 and 95%CI, (0.62-0.95).
In the overall study population, there was no significant effect of Premarin alone on coronary heart disease (CHD), deep vein thrombosis, stroke, hip fracture, colorectal cancer, or total mortality. But in the younger women (ages 50-59 at enrollment), there were more favorable outcomes on Premarin than for the older women for CHD, heart attack, colorectal cancer, and all cause mortality. For heart disease endpoints, the risks were 40-50% lower in the hormone group than in the placebo group.
What does this mean for women considering hormones?
This news is very validating and encouraging. One must also remember that all of this data was for Premarin, a non-bioidentical estrogen, which has been the historical favorite of the past, and Provera, a strong synthetic progestin. There is also growing evidence and opinion that a further level of safety and efficacy is obtained using bioidentical formulations of estradiol, especially in the transdermal fashion (via skin) by patches or creams.
The other important take away from this study is the verification of the different risk/benefit profile for younger versus older women in the study. The predominance of studies done before WHI showed overall benefits from estrogen, usually in the younger women originally started on estrogen. So the usual patient starting hormone therapy for symptom relief in their late 40s or early 50s, especially if they have had a hysterectomy, should be reassured about their lower risk and more probable benefits from estrogen therapy.
It still is perplexing how the outcomes of Premarin/Provera therapy have been so much more negative than Premarin alone if it is actually the estrogen that is at fault. It seems likely that bioidentical estradiol and progesterone therapy as presently prescribed by many would have a better outcome than those older patients who started hormones in the WHI.
Studies are currently underway evaluating transdermal estradiol therapy. I expect these will offer further encouragement and reassurance about hormone therapy. Questions? Email comments@oakdaleobgyn.com.
