Younger Women Misinterpret Risks of HRT, Forgo Benefits

Nancy A. Melville

January 14, 2019

A new study examines in detail how and why the use of menopausal hormone replacement therapy (HRT) declined in the aftermath of the premature halting of the 2002 Women's Health Initiative (WHI) trial.

The prevalence of prescription HRT declined immediately afterwards, and today is still lower than pre-WHI levels.

Although the new analysis is not the first to document the decline in HRT use as a result of the initial WHI findings, it examines how the declines differed in terms of initiation versus continuation of HRT.

And it sheds more light on why, suggesting that safety concerns arising from the risks of HRT documented in older women led younger symptomatic women — who could in fact gain benefit from the therapy — to forgo HRT for symptom relief.

"The results of this analysis support the need for more education about personalized risk-benefit profiles for women and [healthcare] providers...to ensure evidence-based care of women through menopause and beyond," say the authors, led by Sybil L. Crawford, PhD, of the Graduate School of Nursing, University of Massachusetts Medical School, Worcester.

In the new analysis, published online in Menopause, the journal of the North American Menopause Society (NAMS), Crawford and colleagues evaluated data on 3018 participants in the prospective Study of Women's Health Across the Nation (SWAN), which followed women for an average of 5 years before WHI was stopped and around 10 years afterwards, from 1996 to 2013.

According to JoAnn Pinkerton, MD, NAMS executive director, the new findings underscore the continued misinterpretation of the WHI study by patients and healthcare providers alike.

"Further analysis of the WHI has shown hormone therapy to be safe and effective for menopausal women who have bothersome hot flashes, night sweats, or sleep disruption if they start hormone therapy while aged younger than 60 or within 10 years of menopause," she said in a NAMS press statement.

"Unfortunately, fear continues to keep symptomatic women from being offered, or using, hormone therapy."

WHI Results Most Affected Rate of Initiation of HRT

Crawford and coauthors found that the rate of starting HRT declined from 8.6% prior to the WHI trial to just 2.8% afterwards, and HRT continuation among those already receiving therapy declined from 84.0% to 62.0% (both P < .0001).

Despite current medical guidelines recommending HRT as an important treatment for menopausal symptoms in younger women at lower risk, the decline in use of HRT was seen in those lower risk groups, although there was a greater reduction in starting HRT observed with increasing age (P = .002).

The most common reasons given for not starting HRT reflected guidelines issued post-WHI, including concerns about heart disease and advice that the therapy should not be used to reduce osteoporosis risk.

Leading reasons cited for the discontinuation of HRT were the influence of media reports and healthcare provider advice. The increase in media reports as a reason occurred primarily in the first 2 years post-WHI.

"Virtually all subgroups exhibited post-WHI declines in both menopausal hormone therapy initiation and continuation," Crawford and colleagues say.

But overall, the WHI study appeared to have had a greater influence on the initiation of HRT than continuation, they conclude.

Reasons for Discontinuation of HRT

The new analysis is also one of the only known studies to document reasons for discontinuation, concluding that many symptomatic women declined to use HRT because of concerns about study findings that were not truly applicable to them.

This specific group includes women in their 50s, when vasomotor symptoms such as hot flashes are most prevalent but the risks associated with HRT are lower.

Although initial media reports after WHI were alarmist, a better understanding of the risks and benefits of HRT emerged afterwards, along with recognition that the age at HRT initiation has profound effects on the risk-benefit profile.

In 2017, NAMS issued a new position statement in support of HRT use when appropriate, as reported by Medscape Medical News.

HRT remains "the most effective treatment for vasomotor symptoms and genitourinary syndrome in menopause, and has also been shown to prevent bone loss and fracture," it stressed.

The position statement further states that "treatment should be individualized to identify the most appropriate HRT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic re-evaluation of the benefits and risks of continuing or discontinuing HRT."

The risk-benefit ratio for HRT is considered most favorable for the treatment of bothersome vasomotor symptoms and those at risk for bone loss or fracture in women younger than 60 years or within 10 years of menopause onset.

The study received financial support from the National Institutes of Health (NIH). SWAN has received grant support from the NIH, Department of Health & Human Services, through the National Institute on Aging, National Institute of Nursing Research, and NIH Office of Research on Women's Health. Joffe has reported receiving research funding from Merck and Pfizer, and is a consultant/advisor to Merck, KaNDy Therapeutics, and Sojournix. The other authors have reported no conflicts of interest.

Menopause. Published online December 21, 2018. Abstract

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