COMMENTARY

Treating Menopause: Are We Going Loco?

Charles P. Vega, MD

Disclosures

August 06, 2013

In This Article

Background to the Study

The year was 1999, clearly the Greatest Year Ever. I could not understand why everyone was so excited about The Sixth Sense, so I walked out on the last 10 minutes of the film. Time was very precious; I had bought thousands of dollars' worth of equipment to prepare for Y2K and I needed many hours to install it on everything from my PC to my toaster. Thankfully, Ricky Martin's "Livin' La Vida Loca" kept me grooving right along.

I was a brand-new physician just out of residency, and therefore I was completely immersed in our area's drug culture. Meaning, I prescribed a lot of drugs. And my drug of choice for women going through menopause was clear: hormone replacement therapy (HRT).

As physicians, we understood that HRT could improve everything from bone health to cognition to the risk for cancer, and if there was any pessimism as to whether HRT could improve a certain condition or symptom, that was probably because the observational study just had not been completed as yet.

My toaster continued to perform like a superstar in the following years, but the practice of HRT sure did change. Studies such as the WHI and Million Women Study found positive associations between HRT and breast cancer, and the WHI also found a link between HRT and the risk for heart disease.[1,2] Within 6 months of publication of the WHI, more than half of women receiving HRT attempted to stop treatment.[3] Overall, more than one quarter of women stopped within a year of its publication and the number of new HRT users declined by half.[4] The effect of WHI was so overwhelming that even the name "hormone replacement therapy" failed to survive; "hormone therapy" was now the accepted term.

Given its past popularity and subsequent fall from grace, it seems that everyone has an opinion on hormone therapy. While these opinions vary substantially, there has been a clear trend that, as a medical community, we -- and patients as well -- overreacted to the WHI and other similar studies. Although WHI has served well as the landmark randomized trial of hormone therapy, it focused on a cohort of women who, with an average age of 63 years, were older. It did not address the short-term use of hormone therapy for symptoms in early menopause, and subsequent research has found that the risks of hormone therapy are much less pronounced among younger women.

In fact, hormone therapy appears to reduce the risk for coronary heart disease among women younger than age 60 years, while not significantly adding to the risk for breast cancer.[5,6] Although this is encouraging news regarding hormone therapy among younger women, it has not altered the basic indication for treatment: for symptoms of menopause only, not disease prevention, and with the lowest dose of estrogen over the shortest time period.

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