IMPORTANCE OF PERSONALIZING HORMONE REPLACEMENT THERAPY

Angela Missaggia RNNP, CV-CNS, MSN

Good day. Today we’re talking about HRT, Hormone Replacement Therapy, and the importance of considering, on an individual basis, whether HRT is appropriate for a post-menopausal woman or not. Here’s a bit of background… Recently there has been a lot of conflicting information in the press regarding the risks and benefits of Hormone Replacement Therapy (hereby referred to as HRT).

Some benefits of taking HRT after the onset of menopause are: relieving such problems as hot flashes,, mood swings, vaginal dryness; and improving a sense of wellbeing. Additionally, health care providers have advocated the use of HRT for heart health, preventing the complications of osteoporosis (such as vertebral and hip fractures), maintaining colon health, and improved cognition. This July, surprising information has come to light from two recent studies. This information is now challenging both patients and their health care providers regarding the decision to take HRT post menopause.

The first study, called HERS II, published in the July 3 issue of the Journal of the American Medical Association (know as JAMA) looked at whether women post menopausal, with pre-existing cardiovascular disease, received protection and improvement in their disease by taking HRT. ( By cardiovascular disease I mean illnesses like stroke, angina, or heart attacks ) The data showed that taking combined Estrogen/Progestin HRT did NOT provide cardiac protection in these women. In fact, the data showed that HRT actually increased the incidence of cardiac events during the first year of use.

The second study, published July 17th in JAMA, called the Women's Health Initiative, addressed the risks and benefits of HRT. In examining the risks and benefits of HRT, the conditions considered were coronary heart disease (like angina or heart attacks), strokes, breast cancer, colon cancer, and fractures. The study examined both combined Estrogen/Progestin, and Estrogen alone. I need to mention here that estrogen alone can be taken after menopause if the women as undergone prior hysterectomy, and doesn’t have an intact uterus. For women with a uterus, both estrogen and progestin have to be taken together.

This particular study was to run for a total of 8.5 years, yet part of it was halted after only 5 years. After 5 years of study the predetermined boundary for invasive breast cancer was exceeded in the group of women taking HRT. Also, the indicators looking at the risk for coronary heart disease and stroke outweighed the benefits. The data from the Women’s Health Initiative showed the actual numbers of “increased events” per 10,000 women is: 7 more Cardiac events , 8 more strokes, and 18 more blood clots. Concerning breast cancer there were 8 more cases. However, the data strongly suggested that HRT promotes the growth of EXISTING breast cancer, RATHER THAN CAUSES breast cancer. Now, on the flip side… for colorectal cancer and hip fracture, there were FEWER cases: 6 fewer per 10,000 women for colorectal cancer, and 5 fewer hip fractures. For the first time for any therapy, this study demonstrated HRT reduces hip fractures and colon cancer!!!

WHAT DOES IT ALL MEAN???

HEART PROTECTION: Women taking HRT solely for the prevention of cardiovascular disease (like heart attack and stroke) should consider other treatment options. Lifestyle modification to reduce your risk of cardiovascular disease is always important. By lifestyle modification I mean improving diet and getting regular exercise. Also, it is important to improve the status of diseases that increase the risk of heart disease: for example making sure if your diabetic your maintaining good control of your blook sugar. If you have high blood pressure and are on medication that you take your medications correctly, and have your blood pressure checked regularly. Lastly, things like smoking cessation, controlling your weight, limiting your alcohol consumption, and promoting stress reduction are all important.

OSTEOPOROSIS PREVENTION: For women taking HRT only for the prevention of Osteoporosis, the recommendation is to first assess your actual risk for osteoporosis: do you have a positive family history for example. If you are at risk, consider alternative treatments such as medications called biphosphonates, raloxifene, and calcitonin. Also, simple measures like having an adequate intake of Calcium and vitamin D shouldn’t be overlooked.

SHORT TERM RELIEF OF HOT FLASHES: The benefits for short term use of HRT, meaning 1-4 years, are likely to outweigh the risks.

LONG TERM RELIEF OF HOT FLASHES: Long term HRT needs to be discussed again on an individual basis, considering that woman’s underlying risk for breast cancer, heart disease, colon cancer, or osteoporosis. Things that are a concern for breast cancer risk are a positive family history (meaning a sister, aunt, mother has been diagnosed with breast cancer).. If you have underlying heart disease, or illness that can increase your chances for heart disease, long term HRT may not be a good idea. However, if you have diagnosed osteoporosis, or a family history of that, (and no underlying heart disease, or family history of heart disease, or breast cancer), then long term HRT for hot flashes may be a good idea. Overall, one situation can’t be applied to every woman. We as health care providers need to take the time to review each woman’s health concerns, past medical history, risk factors for heart disease/breast cancer/colon cancer/ osteoporosis, and then come up with a plan to use, or not use, HRT.

INDIVIDUALIZED CARE

The National Association of Nurse Practitioners in Women’s Health views women as unique, with different health issues, different family medical histories, different emotional needs, different values, and different belief systems. No two individual needs are alike! Regardless of their choice for HRT, women should be encouraged to see their health care provider for regular breast, cervical, colon, and skin cancer screening. Additionally, regular screening for diabetes, thyroid, cholesterol, blood pressure, height and weight, and overall health care maintenance should be encouraged.

ADDITIONAL INFORMATION

For additional information, or comments, please feel free to contact me at the Sante Wellness Centre, Day Spa and Retreat, located at Marina Point in Parrot Tree Plantation.