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Hormone therapy guide issued by ACOG task force

Although much is known about the risks and benefits associated with HT, its effects on younger women are still not clear.

By Susan J. Landers, amednews staff. Nov. 15, 2004.

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Washington -- Findings from the Women's Health Initiative released more than two years ago set in motion a broad swing away from use of hormone therapy that is just now settling down to a more moderate approach, and this is good, says a new guide.

A task force of the American College of Obstetricians and Gynecologists scrutinized the evidence surrounding the use of estrogen and estrogen/progestin products and found the hormones can still play an important treatment role, particularly to alleviate hot flashes. The task force advised physicians to consider prescribing hormones for women with persistent hot flashes for longer than the average four years it takes most vasomotor symptoms to disappear.

A guide produced by the task force and published as a supplement to the October issue of ACOG's Obstetrics and Gynecology also found it appropriate to use the controversial therapy to treat women who say they "feel better on hormone therapy or who feel it improves sexuality," said the group's chair, Isaac Schiff, MD, chief of Obstetrics and Gynecology at Massachusetts General Hospital.

Findings from the WHI released in July 2002 generated numerous calls to physicians from women struggling to understand whether they should continue taking hormone therapies. One arm of the large study was halted early because of the finding that estrogen/progestin caused a small increased risk for breast cancer.

A second arm was terminated earlier this year when it was determined that estrogen alone provided no protection from heart disease and might increase a woman's risk of stroke.

While the WHI helped foster an understanding of the risks and benefits of hormone therapy, "it's only an early step in the continuing quest to understand how women's hormones affect their health," said ACOG President Vivian Dickerson, MD.

The main message from the task force's evaluation is that "hormones are a very effective way to treat symptoms such as hot flashes and vaginal dryness," said Dr. Schiff. However, he added, "Estrogen therapy should be offered to women only after a full briefing on the risks and benefits of the treatment."

But the task force agreed that hormones should not be used to prevent cardiovascular disease, nor should they be thought to protect against Alzheimer's disease or arthritis, said Dr. Schiff. The task force also concluded that there is indeed a small increased risk of breast cancer.

"We're moving back to an appropriate balance -- accepting that HT has risks, but recognizing that it can be appropriate for conditions like hot flashes so long as women are informed about the risks and weigh their decisions with their doctor," said Dr. Schiff.

The task force also confirmed earlier recommendations made by ACOG and the AMA, including that estrogens should be used in the smallest effective dose and for the shortest amount of time to achieve therapeutic goal.

But the take-home messages when prescribing low-dose estrogen should include the need for patience, since it might take as long as two months until hot flashes are relieved or diminished on the lower doses, said James Liu, MD, a member of the task force.

Still a balancing act

Julia Johnson, MD, professor of obstetrics and gynecology at the University of Vermont, praised the new guide. "This is the kind of information that patients want," she said.

The first question many patients still ask about hormone replacement therapy is "Should I ever use it?" said Dr. Johnson. The answer remains: It depends on why a woman is taking hormones. There is still no better treatment for hot flashes, and recent studies found that one in four women who stopped hormone therapy after the release of the initial findings of the WHI has gone back on them.

Among the additional messages in the guide:

• The jury is still out on sex drive, as there have been too few studies to prove that taking estrogen or testosterone -- either orally or topically -- can improve a woman's sexual libido. However there is ample evidence that estrogen given topically or orally can improve the quality of a woman's sex life by relieving vaginal dryness and related symptoms that make sexual intercourse uncomfortable for many menopausal women.
• Selective serotonin reuptake inhibitors can be effective alternatives to hormone therapy for the relief of menopausal vasomotor symptoms. However, some physicians questioned whether the 60% effectiveness rate of SSRIs is worth the risk of side effects which can include altered sleep patterns in patients who take SSRIs for reasons other than depression. Hormone therapy has an effectiveness rate of 90%. "Why would I want to use a drug with potentially more side effects versus low-dose estrogen with known side effects which are fairly uncommon?" asked Dr. Liu.
• The guide also noted that herbal remedies such as wild yam extracts, black cohosh or dietary phytoestrogen supplements derived from the isoflavone red clover have no significant effects on vasomotor symptoms. The guide cautions that since soy and dietary isoflavones appear to affect estrogen receptors, they may not be safe for women with estrogen-dependent cancers such as breast cancer.
• Estrogen appears to have mood-elevating effects in some perimenopausal women who may be more vulnerable to depression than pre- or postmenopausal women. However, the guide cautions that because of its risks, estrogen should not be a first-choice treatment for depression.
• It's not hormone therapy but the normal aging process that accounts for weight gain during middle age. "No matter how many studies are conducted about weight, we can't avoid the inevitable," said Deborah Smith, MD, adviser to ACOG's Managing Menopause consumer magazine. "If we want to lose, we've got to move."

Despite its exhaustive review of the large amount of literature being amassed on hormone therapy, the task force would like to see additional research that examines whether hormones taken during perimenopause or early in menopause might yield a benefit.

"In the future, we may find that for younger women, if hormones are started right at the time of menopause, they may prevent heart disease," said Dr. Schiff.

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