Reflections on the WHI Findings: Avoiding a Pill Scare and Taking Sensible Steps Forward

Paul D. Blumenthal, MD, MPH

Disclosures

A little more than 25 years ago, the heretofore complacent world of estrogen replacement therapy (ERT) was rocked by papers indicating that unopposed estrogen, when provided over a long period of time to postmenopausal women, resulted in an increased risk of endometrial cancer.[1,2] This amounted to a "pill scare," which more commonly results after the publication of a study finding some adverse event in connection with oral contraceptives. Patients called their physicians in panic, the media was filled with fear-mongering articles, prescriptions for exogenous estrogen plummeted, and clinicians went to great lengths to provide symptomatic postmenopausal women with anything but an estrogen-containing compound. Similar to what happens in a contraceptive pill scare, women who were candidates for ERT even in the face of the newly reported results were denied access by their providers.

In the case of a contraceptive pill scare, what usually results is an increase in subsequent rates of unintended pregnancy and abortion. In the menopause setting, an ERT/hormone replacement therapy (HRT) pill scare is likely to mean that women with menopausal symptoms who could be helped through this life phase by low-dose, relatively short-term hormone therapy, which has not been implicated as being risky or dangerous, will be shifted away from the most effective means of treatment toward less effective modalities. This may satisfy a risk-averse medical community. However, clinicians, the media, and the general public should all be aware of the variety of effective alternative hormone regimens that are actually available.

To be sure, the Women's Health Initiative (WHI) results are noteworthy, and changes in clinical practice are indeed both likely and warranted. But health professionals, healthcare providers, the lay public, and the media need not panic. The media in particular need to put these results into perspective and avoid the temptation to create even more controversy and consternation than is necessary. No doubt, this week's top story will be replaced by a new crisis before you can say "hormone replacement therapy," but the crisis in confidence produced by reporting that is designed more to attract attention than to provide guidance will last for years.

In addition, as with any good study, the results presented this week generate more questions than hard answers, and both clinicians and the media need to be responsible in profiling the implications of the WHI results to their patients and to the public, respectively. The commentaries appearing in this journal by Dr. Randolph, Dr. Notelovitz, and Dr. Kaunitz are exactly what is required to provide the necessary perspective (absolute as opposed to relative risk) and to identify solutions (lower dose, different progestin, more counseling) instead of simply amplifying the problem.

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