The WHI – Yet Another Follow up

This is the study that doesn’t end…
The longterm follow up extends…
Some people started studying hormones in menopause,
And they’ll continue publishing more data just because…
(repeat)

In yet another paper in a major journal, we hear once more from the investigators of the Women’s Health Initiative. This time it’s the long term outcomes of women who took estrogen alone, now seven years out from stopping their hormones. What new information can we learn from this extensive analysis of new data?

Nothing.

Really.

The WHI’s been telling us the same thing about ERT (Estrogen replacement therapy) and HRT (Combination estrogen/progestin therapy)  since 2002, and all each subsequent study does is reinforce and expand on that initial data. The data on breast cancer risk and estrogen alone was first published in 2004, but the media ignored it the. It is only now making it news.

Allow me to summarize what we know  – 

• HRT/ERT does not prevent heart disease when given to women of average age 64 years, or 10 years past menopause.
• HRT/ERT increases the risks of stroke and blood clots, a risks that trends upward with age. Once you stop HRT/ERT, these risks go away.
• HRT/ERT protects against osteroporosis, a benefits that goes away once you stop taking it.
• In younger women, particularly those who have just become menopausal, HRT/ERT may reduce heart disease risks. (The operational word here is may…)
• HRT increases the risk of breast cancer, on the order of about 1% if you use it for 20 yrs. This risk has been shown in almost every study of HRT ever done, is biologically plausible and supported by the fact that drugs that block estrogen have been shown to prevent and treat breast cancer.
• ERT, when taken alone by women 10 or more years post menopausal, may actually slightly lower breast cancer risks. We think this is because of the way estrogen acts when it is reintroduced after a long absence. Unfortunately, since this is not the way we prescribe estrogen (ie, starting it 10 years after menopause), this benefit is if no use to anyone.
• The latest data suggesting that women in their 50’s may also benefit from lowered breast cancer rates is not entirely explained. The data we have not seen is groupings of women by years since menopause in a meaningful way. (Although the authors state they have done this.) I”ll be blogging more about this later, but for now suffice it to say I am not relying on this benefit in my clinical practice at this point in time.

On balance, there is no compelling preventive health reason for most women to take HRT, and women who take it live no longer than those who don’t.

That said, some women may choose to use HRT to treat menopausal symptom or osteoporosis, conditions for which it is quite effective. But if you use HRT, you must accept a small but real risk of blood clots, stroke and breast cancer. (Although taking low doses through the skin may lower the clot risk.) These risks apply whether the estrogen you take is from pregnant mare’s urine, a plant or the moon, whether it is bio-identical or whether Suzanne and Oprah are taking it. If you take estrogen alone, I would not count on a breast cancer reduction. Especially if you are taking bioidentical hormones instead of Premarin. IThe WHI study evaluated Premarin and Prempro only.)

If you’re in early menopause and thinking that taking HRT will be good for your heart or brain, you can think it if you want, but I would not take it for these reasons alone. Stick to other proven methods for lowering your heart disease risks – maintain a healthy diet and body weight, exercise, quit smoking and treat high blood pressure or elevated cholesterol that does not respond to these interventions.

Once again, here are my rules for prescribing HRT.