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Hormone Replacement HRTin Postmenopausal Women

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HERS: comparable increase in breast cancer in women on estrogen/ MPA over 6.8 years ... Breast Cancer ... breast cancers. 6 fewer cases of colorectal cancer. 5 ... – PowerPoint PPT presentation

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Title: Hormone Replacement HRTin Postmenopausal Women


1
Hormone Replacement (HRT)in Postmenopausal Women
  • Sorting Through the Issues

2
Underlying Concerns
  • Increasing life expectancy after menopause
    average is 30 years
  • Uncomfortable symptoms associated with hormonal
    decline
  • Bone loss and increased LDL levels associated
    with hormonal decline
  • Potential risks with hormonal replacement

3
Interesting Facts
  • HRT is one of most commonly prescribed drug
    regimens for postmenopausal women in the US
  • Women can lose up to 10 of their bone mass in
    the first 5 years after menopause
  • Up to 70 of women 80 have osteoporosis

4
Likelihood of Chronic Disease
  • In postmenopausal woman
  • Heart disease 47
  • Stroke 20
  • Hip fracture 15
  • Breast cancer 10
  • Uterine cancer 2.6

5
Additional Concerns
  • Postmenopausal women have a 1.4 to 3.0-fold
    higher risk of Alzheimers disease than do men
  • Lifetime risk for colorectal cancer for a US
    woman is 6, with 90 of cases occurring after
    50 years of age
  • Many of these causes of chronic disease appear
    influenced by estrogen/ progestins

6
What Does the Research Show?
  • Wide range of trials on HRT
  • Varying estrogen/ progestin combinations,
    although most studies have used conjugated equine
    estrogren (CEE) and/or medroxyprogesterone (MPA)
  • US Preventive Services Task Force has compiled
    the best evidence from a number of trials

7
Osteoporosis
  • HERS (Heart and Estrogen/Progestin Replacement
    Study) no decrease in hip, wrist, spine or total
    fractures with hormone therapy
  • WHI (Womens Health Initiative) significant
    decrease in total fracture decrease in spine and
    hip fracture

8
Osteoporosis (cont)
  • Meta-analysis of 22 trials of estrogen reported
    an overall 27 decrease in non-spine fractures
  • There was variation in study quality
  • overall there appears to be potential benefit
    with increased bone density and decreased
    fracture risk

9
Colorectal Cancer
  • HERS reduced incidence of colon cancer
  • Meta-analysis of 18 trials of postmenopausal
    women showed a 20 decrease in colon cancer 19
    decrease in rectal cancer
  • Similar results in WHI with women taking CEE/MPA
  • probable reduced colorectal cancer risk

10
Mental Status
  • Variation in assessment outcomes of studies with
    some indication of decreased risk for dementia in
    postmenopausal women on HRT
  • WHI estrogenprogestin therapy increased the
    risk for probable dementia in postmenopausal
    women 65 it did not prevent mild cognitive
    impairment

11
Mental Status (cont)
  • Insufficient evidence to be certain about
    effects of HRT on dementia and cognitive function

12
Breast Cancer
  • WHI increased breast cancer incidence no effect
    on breast cancer mortality
  • HERS comparable increase in breast cancer in
    women on estrogen/ MPA over 6.8 years
  • Conflicting evidence in several cohort studies
  • WHI no increase risk on estrogen alone after 5
    years of follow-up so far

13
Breast Cancer
  • good evidence for increased risk for breast
    cancer, but equivocal data regarding mortality
    from breast cancer

14
Heart Disease (CHD)
  • WHI increased risk for fatal and nonfatal MI for
    those on daily CEE/MPA
  • Mortality was not significantly increased
  • Meta-analysis of observational studies showed
    significant reduction in CHD among current HRT
    users
  • Selection bias (tendency for healthier women to
    use HRT) may account for protective effect in
    observational studies

15
Heart Disease (cont)
  • HRT does not decrease and may in fact increase
    the incidence of CHD no definitive effect on
    mortality, however

16
Stroke
  • WHI increased incidence of stroke in women
    taking daily CEE/MPA
  • fair evidence for increased risk of stroke with
    HRT

17
Blood Clots (DVT/ PE)
  • WHI 2-fold increased rate of venous
    thromboembolic disease for those on CEE/MPA
  • Risk highest in first year in 5 of 6 studies
    reporting use over time
  • good evidence for increase risk of venous
    thromboembolism

18
Uterine/ Ovarian Cancer
  • Uterine cancer increased with unopposed estrogen
    decreased with combined therapy
  • Inconsistent correlation between HRT and ovarian
    cancer 2 good cohort studies report increased
    risk
  • Insufficient evidence to determine effect of
    HRT on ovarian cancer

19
Gallbladder Disease
  • Nurses Health Study reported increased risk of
    cholecystitis for those on HRT
  • HERS increase in biliary surgery for those on
    HRT
  • Fair evidence for increase risk of cholecystitis

20
Summary
21
US Preventive Task Force
  • Recommendations
  • Against routine use of estrogen/ progestin for
    the prevention of chronic conditions in
    postmenopausal women
  • Did not evaluate use of HRT to treat
    postmenopausal symptoms
  • Insufficient evidence regarding estrogen alone to
    prevent chronic conditions

22
Clinical Considerations
  • Absolute risk increase from HRT is modest for
    women aged 50-79, 10,000 taking estrogen/
    progestin for 1 yr might have
  • 7 additional CHD events
  • 8 more strokes 8 more blood clots
  • 8 more invasive breast cancers
  • 6 fewer cases of colorectal cancer
  • 5 fewer hip fractures

23
Clinical Considerations (cont)
  • We lack information on variations in dose,
    duration and type of estrogen/ progestin for HRT
  • We need to use a shared-decision making model,
    reviewing individual risk factors and preferences
  • Might natural estrogens/ progestins be more
    protective?

24
Conjugated Equine Estrogen
  • Premarin (CEE)
  • Derived from horse urine, which contains a dozen
    different estrogen compounds, only one of which
    is an exact replica of a human estrogen compound
    (estradiol)
  • Most pills, patches, creams also only contain
    this one human estrogen compound

25
Natural Estrogens
  • Exact chemical replica of what our body produces
  • Estradiol aggressive estrogen about 10 of body
    make-up
  • Estrone also more aggressive estrogen about 10
    of body make-up
  • Estriol more benign estrogen about 80 of body
    make-up thought to be protective

26
Progestins
  • Also a differentiation between chemical hormonal
    substitutes such as medroxyprogesterone (Provera)
    (MPA) and natural, hormone replicas such as
    progesterone
  • Chemical substitutes cannot exactly match our
    bodys hormone communication pathways
  • Little research on natural hormones

27
Are There Other Options?
  • Bone?
  • Hot flashes?
  • Natural estrogens/ progestins?
  • Soy?

28
Resources
  • www.preventiveservices.ahrq.gov
  • www.womenshealth.com
  • National Womens Health Hotline 1.800.222.4767
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