Estrogen therapy shouldn t give women pause

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For women suffering from the unpleasant side effects of menopause, hormone replacement therapy (HRT) was once a much sought-after remedy. That is, until 2002, when a large study called the Women s Health Initiative (WHI) was halted abruptly after researchers seemed to have discovered a link between combined estrogen-progestin therapy (EPT) and an increased risk of breast cancer and adverse cardiovascular events. Although these findings would later be largely contested, the damage had already been done: There was a large drop in HRT use, and a whole generation of women suffered through menopause without these medications.

Now, however, the North American Menopause Society is abandoning this overly cautious practice and is instead adopting a more flexible approach to HRT, one that takes into account the type and timing of therapy as well as individual patient history.

No one size fits all approach is acceptable anymore, announced the society s president, Dr. JoAnn E. Manson, an epidemiology professor at the Harvard School of Public Health. Interestingly, Dr. Manson was also a principal investigator for the WHI study. The latest approach, she hopes, will be reassuring to many women.

One of the main problems with the WHI results was that researchers studied older women who had begun HRT long after undergoing menopause. But according to the latest society guidelines, absolute risks are low for women who start HRT in their 50s. And for younger women with no history of breast cancer, HRT can be used until they reach the more typical age of menopause and even longer if symptoms persist.

Though the latest recommendation may be startling for some, the thinking is not new. Last summer, the Endocrine Society issued similar guidelines, stating that the risks and benefits of HRT vary with age and time since onset of menopause. According to the menopause society advisory, estrogen-only (ET) therapy may be used for seven years without increasing the risk of breast cancer; for EPT, the recommended duration is three to five years of use.

Some may be confused by this latest flip-flop, says ACSH s Dr. Elizabeth Whelan, yet we ve previously noted that the WHI study was beset with confounders, and the scares emanating from it have been, one by one, transformed into science-based recommendations about the duration of HRT that will provide the most effective treatment of menopausal symptoms with minimal (if any) increased risk of heart or breast ailments.