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Fear of HRT May Deprive Women of Its Health Benefits, Experts Say
A string of recent papers pokes holes at studies that concluded hormone replacement therapy causes breast cancer — a concern which stops many women from receiving the potentially beneficial treatment.
By Jaimie Dalessio Clayton
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THURSDAY, March 14, 2013— Hormone replacement therapy (HRT) remains taboo for some women and an uncomfortable subject even for some doctors. But this generalized fear of hormone therapy at menopause may be doing more harm than good for women today.
"There's this hysteria over estrogen so that women who clearly would benefit go without," said Lauren Streicher, MD, an assistant clinical professor of obstetrics and gynecology at Northwestern University's medical school in Chicago, and an expert on menopause.
Hormone replacement therapy can refer to estrogen and progestin prescribed together or estrogen prescribed alone. The original rationale behind HRT was to replace hormones lost naturally at menopause, both to alleviate menopause symptoms and to help prevent conditions such as osteoporosis and heart disease, which were more likely to strike after menopause.
Widely held concern about hormone replacement therapy stemmed from studies that concluded it caused breast cancer, the first of which was published in 2002. That same year, the U.S. Preventive Services Task Force (USPSTF) recommended against routine, long-term HRT for the prevention of chronic conditions. The studies also found inconsistent evidence regarding breast cancer risk from estrogen plus progestin therapy versus therapy with estrogen alone.
But in recent papers critiquing previously published HRT studies — the latest appearing today in the Journal of Family Planning and Reproductive Care — researchers are concluding that past studies lacked sufficient evidence to support or refute the possibility that HRT was a cause of breast cancer.
"The allegation has been made that HRT causes breast cancer and in my judgment studies that have made that allegation are not conclusive," said study author Samuel Shapiro, PhD, an epidemiologist at the University of Cape Town in South Africa. "And lots of women have decided on the strength of that alone to stop using HRT. I think the main fear in the minds of women is breast cancer."
The papers echo what Dr. Streicher and others have been saying for years, she said.
Women who refuse to consider hormone replacement therapy for fear it will give them breast cancer, and gynecologists who refuse to raise the subject, may be missing an opportunity for these women to live even longer and healthier lives, according to Streicher. The benefits of estrogen therapy span the short and long term. They include:
Heart health:A study published in October in the British Medical Journal found that women who took HRT for 10 years (starting soon after menopause) had lower risks of mortality, heart failure, and heart attack. "Heart disease is the No. 1 killer of women, not breast cancer," Streicher said. "In thinking they are protecting their breasts they are actually hurting the heart, which is a much bigger issue."
Bone health:After menopause, loss of estrogen facilitates loss of bone mass, which puts women at risk for osteoporosis. "Osteoporosis is a serious, life-threatening disease," said Streicher. "It's not just bad posture, and the younger someone is when they start losing their estrogen the more likely they are to develop problems."
Cognitive function:Early loss of estrogen can hasten cognitive decline, a recent study out of Harvard Medical School in Boston suggested. The study associated early surgical menopause with cognitive decline, hinting that the duration of HRT following early surgical menopause might slow declines in cognition.
Sexual health and overall quality of life:"People look at sexual health as not as important as other things, but first of all it is a quality-of-life issue, and secondly, a good healthy sex life does correlate with other health benefits," Streicher said. After menopause, loss of estrogen can cause vaginal dryness that makes sex uncomfortable and even painful. The current USPSTF guidelines for HRT do not address the use of hormone therapy for treating menopausal symptoms. "The USPSTF did not review the evidence related to this possible indication because it falls outside of the mission and scope of the USPSTF," according to its website.
Understanding Hormone Replacement Therapy
Two main issues block proper understanding of estrogen therapy: types and timing of treatment. "Not only are women lumped together in terms of age at which they getting [hormone therapy], there are also types of estrogen therapy," Streicher said. "It's all different and yet lumped together."
Much of the HRT prescribing Streicher does is estrogen alone, and she does it in the critical window for estrogen therapy, she said — the first 10 years after menopause.
The paper published today points out there is much still misunderstood about hormone replacement therapy, as does an accompanying paper written by Nick Panay, MD, chair of the British Menopause Society.
"[While] epidemiologists argue whether small relative risks are valid, we must not forget the main point of the argument, which is how are we going to optimize the lives of millions of women going through the menopause transition in the ever-aging population of the 21st century? If there is a risk, the risk is small, and the benefits of HRT can be life altering; it is vital that we keep this in perspective when counseling our patients," Dr. Panay wrote.
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