HRT has many benefits, but further studies are necessary
Despite mounting evidence of the health benefits of hormone replacement therapy for peri- and postmenopausal women, the therapy remains controversial. Robert D. Langer, MD, shed some light on those risks and benefits in a clinical seminar on HRT at the Assembly.
Dr. Langer has been involved with several national clinical trials on the effects of HRT on heart disease, breast and endometrial cancers, cognitive function, and osteoporosis. He is associate professor of family and preventive medicine at the University of California, San Diego.
He noted that 82 percent of all cardiologists, internists, family physicians, and general practitioners prescribe HRT for women with symptoms of menopause, and to treat or prevent osteoporosis, coronary heart disease, and high blood cholesterol. "The fact that we have HRT is not remarkable," Dr. Langer said, "but it is remarkable that we have so many women we have to consider for HRT."
From 1988 to 2010, it is expected that the number of postmenopausal women will increase by 50 percent. "This is a dramatically increasing portion of our population," he noted. "And with the increasing life expectancy of women, some 30-40 percent of the average woman's life will be spent after menopause."
A common thread among these women, ages 50-79, is that they are at increased risk for health problems, especially cardiovascular disease. "Most women don't think that cardiovascular disease is a threat to their health," Dr. Langer said. "Yet statistics show that CVD is the major health problem facing older women."
He noted that in more than 50 studies, all but one observational, HRT has been shown to reduce by about half the rate of CVD among post-menopausal women. "While these observations support the idea that HRT offers some protection, more relevant clinical data is needed," he said.
Evidence also has mounted for an increased association between long-term use of HRT and breast cancer, but as yet there is no hard data to prove this association, Dr. Langer said. And recent reports also have reintroduced concerns about thromboembolic events, which Dr. Langer called "the dark side of HRT."
"While a 1996 study showed a greater risk for thromboembolism for women using HRT, a new clinical trial showed the absolute risk to be low," he said. "Clearly, we need more data in this area."
Endometrial disease is another concern for HRT users. "The baseline incidence for a 50-year-old woman is 1 in 1,000 with HRT," he said. "The relative risk increases by about 1 each year after 50."
HRT also has been shown to decrease bone density loss among postmenopausal women, and preliminary studies have shown some evidence that HRT may protect against dementia, Alzheimer's disease, and loss of cognitive functioning.
"Rational approaches to pretreatment evaluation and on-treatment monitoring have evolved with the introduction of newer screening techniques and the changing perspectives on possible associations with cancers and subtypes of metabolic diseases," Dr. Langer said. "Available formulations, delivery systems, and dosing regimens for HRT have also changed in the past few years. Physicians now have a much larger number of options to consider in individualizing therapy."
He described the initiation and management of HRT in the primary care setting and covered the benefits of the various treatment regimens.
"We tend to think of HRT as a silver bullet," Dr. Langer said. "While it is an important therapy to prevent many major diseases that women get after menopause, we need to remember that here are alternatives such as diet, exercise, and other treatments like biophosphonates and lipid-lowering agents."
- FP Report is published by the AAFP News Department.