September 2002 • Volume 8 • Number 9 |
Hormone replacement therapy garnered blistering headlines recently when a major study comparing estrogen/progestin with placebo was halted early because the therapy's risks outweighed and outnumbered its benefits.
Principal findings for this portion of the Women's Health Initiative appeared in the July 17 Journal of the American Medical Association. Immediately, media coverage created a gigantic hot flash for HRT. FPs couldn't help but notice.
What was your experience like that day?
"It must have been on one of the morning talk shows today," wrote Michael Sevilla, M.D., of Salem, Ohio, in a July 16 e-mail to an Academy online discussion group. "I had about five people ask to be taken off of their HRT 'because that stuff kills people.'"
In a follow-up phone interview, Sevilla said he and his office staff always know when the press picks up a health-related story because the patient phone calls start rolling in. "I appreciate the fact that the media create enough interest in a topic to get people into the office to ask questions," said Sevilla. "But it's difficult for physicians to know what patients have seen and heard. Sometimes the media don't report the full story -- or the public picks up on the negative aspect and runs with it."
How is he handling the latest bombardment? The five FPs in Sevilla's medical group concentrate on patient education. "We directed staff to schedule appointments for patients calling in with HRT questions," said Sevilla. "Then we can discuss the issue in depth during the office visit."
FP Mary Elizabeth Roth, M.D., is in a management and teaching position at Sacred Heart Hospital in Allentown, Pa. She said colleagues have asked her opinion about the WHI results. "It's really the physicians who need the reassurance right now," said Roth. "They need to feel secure and knowledgeable about this topic."
| Women should consider which health risks concern them the most. |
In addition, said Roth, FPs are spending more time on HRT during patient visits, time for which they may -- or may not -- receive reimbursement. "You've got to stop in your tracks and try to explain what the headlines mean to your patient," she said.
"FPs are stymied," she added. "All of a sudden, women who automatically renewed their prescriptions every year are hesitating."
How does Roth respond to her colleagues' inquiries? Roth said she emphasizes separating "her" from the "herd."
"A family doc has to focus on the woman sitting in the office," she said, "but the physician also has to know the data about the herd" -- the large population upon which the study was based.
FP Melissa Behringer, M.D., of Huntsville, Ala., agrees. "This new study is important, and it probably should change our way of addressing this issue," Behringer said, "but it is clearly not an all-or-nothing decision."
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Behringer illustrated the importance of considering a patient's family history and unique risk factors. "One of my patients called in a panic, wanting off her estradiol patch," she said. Behringer and the patient went over the patient's history: six breast-fed children, a total abdominal hysterectomy and bilateral salpingo-oophorectomy, a favorable lipid profile, and no family history of vascular disease. However, the patient did have a strong family history of Alzheimer's dementia, colon cancer and osteoporosis. After discussing her options, the woman decided to stay on the patch.
"The increase in deaths in the WHI study were all in areas in which this patient had significant protective factors to begin with," said Behringer.
Sensational headlines can misconstrue the evidence in a study, she continued. "Yes, this kind of patient education is our job, but I don't like having to defend myself and my clinical advice from screaming headlines."
Several FPs said they use absolute numbers when explaining the risks and benefits to patients. "I've told my patients that with the new study, there's an increased risk of about 10 to 20 significant health problems developing in every 10,000 women taking the drugs for a year," said AAFP Director Daniel Van Durme, M.D., of Tampa, Fla. "Keep these risks in perspective."
AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., counsels women to consider which health risks concern them the most. "If she has seen many close relatives endure colon cancers and colostomies, she may fear that more than she fears the risk of breast cancer," said Roberts.
Editor's note: At press time, two new reviews of research on HRT supported the findings of the halted WHI clinical trial. Go to http://www.ahrq.gov/clinic/3rduspstf/hrt/ to read the reviews on the AHRQ Web site.
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Copyright © 2002 by
American Academy of Family Physicians.