Careful Risk–Benefit Balance Necessary When Prescribing Hormone Therapy

Of many lessons gleaned from the Women’s Health Initiative (WHI), one in particular rings true when considering treatment with hormone therapy (HT)—“Accept and embrace complexity,” according to JoAnn E. Manson, MD, DrPH, Chief, Division of Preventive Medicine, Brigham and Women’s Hospital, Professor of Medi cine and the Elizabeth F. Brigham Professor of Women’s Health, Harvard Medical School, Boston, MA.

There is “no simple one-size-fitsall” formula when it comes to prescribing hormone therapy, said Dr Manson, who was a lead investigator of the WHI. The risks and benefits for individual patients must be carefully weighed before initiating HT, and many patient factors should be considered, she said. At the recent ACOG annual meeting she discussed the results of the WHI, and the use of HT in postmenopausal women.

“There have been major discrepancies between observational studies and clinical trials,” Dr Manson said, adding that observational studies have overstated the benefits of HT, particularly for cardiovascular health. Part of that perceived benefit, she said, is because women who use HT are typically healthier than those who do not, as a result of better access to healthcare, being nonsmokers, and other lifestyle factors.

The results of the WHI show that women between the ages of 50 and 59 years who received estrogen alone or estrogen plus progestin had a 30% reduced mortality risk, whereas women between the ages of 70 and 79 years had a 14% increase in mortality risk. In all the WHI subanalyses, older women faced more risks associated with HT, including cardiovascular risks, cancer, and stroke, Dr Manson said.

Her recommendations for the use of HT largely mirrored those of the North American Menopause Society (NAMS):

• HT should not be used long-term and should not be used for the express purpose of preventing diseases
• If there is no quality-of-life benefit for the patient, HT should not be used
• If a patient’s quality-of-life will benefit from the use of HT, balance the time since menopause with the patient’s overall risk of cardiovascular disease