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Review: Evidence of effectiveness in HT for chronic conditions in women
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After evaluating findings from trials during the past 10 years, researchers report updated evidence shows that hormone therapies decrease risk for fracture but increase risk for stroke, thromboembolic events, gallbladder disease and urinary incontinence.
In 2002, the US Preventive Services Task Force published recommendations against using HT to prevent chronic conditions for estrogen plus progestin, and for estrogen only in 2005.
“This update focuses on studies published since 2002 and evidence gaps that were unresolved at the time of the previous recommendations,” they wrote.
Heidi D. Nelson, MD, MPH, research professor in medical informatics, clinical epidemiology and medicine at Oregon Health & Science University, and other researchers said they also found that estrogen plus progestin increase risk for breast cancer and dementia. However, estrogen alone was found to decrease risk for breast cancer.
The data come from 51 full-text articles from nine placebo-controlled trials, with the Women’s Health Initiative trials comprising most of the results.
Estrogen plus progestin reduced fractures (46 fewer per 10,000 woman-years), increased invasive breast cancer (eight more per 10,000 woman-years), stroke (nine more), deep venous thrombosis (12 more), pulmonary embolism (nine more), lung cancer death (five more), gallbladder disease (20 more), dementia (22 more) and urinary incontinence (872 more).
Estrogen-only therapy also reduced fractures (56 fewer per 10,000 woman-years), but unlike estrogen plus progestin, decreased invasive breast cancer incidence (eight fewer). It also reduced death (two fewer), increased stroke (11 more), deep venous thrombosis (seven more), gallbladder disease (33 more) and urinary incontinence (1,271 more).
Patients were aged 60 to 69 years, but outcomes did not typically differ by age or comorbid conditions, they wrote. The review suggests continued research examining the long-term outcomes of HT, including cancer and death.
Disclosure: Dr. Nelson reports receiving grant money to her institution, and she received support for travel to meetings for the study and other purposes from the Agency for Healthcare Research and Quality.
Perspective
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Michelle P. Warren, MD
The article by Nelson et al reviews the issues of HT to prevent chronic disease. Most of the nine trials that met criteria for inclusion in the review were trials that enrolled women much older than the normal age of menopause (60 to 69 years). Thus, the women started therapy at an age that does not parallel normal clinical practice.
The review essentially confirms the findings of the WHI. There is important information on the significant decrease in breast cancer in women on estrogen alone, on follow-up, and a decrease in diabetes in women on estrogen plus progestin; both factors that are not well recognized.
Also, in estrogen plus progestin, the increase in coronary heart disease was not significant, and with estrogen alone, it was neutral, whereas stroke was increased in both. There was no overall increase in mortality. The greatest benefit seems to be the decrease in fractures in both trials.
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