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Microsoft word - hormone replacement therapy1.doc
Michael P. Osborne, MD
HORMONE REPLACEMENT THERAPY (HRT) AND HEART DISEASE
The Heart and Estrogen/progestin Replacement Study (HERS) found no overall
reduction in the risk of coronary heart disease (CHD) in postmenopausal women who had
a prior diagnosis of CHD. The trial randomized 2763 postmenopausal women with CHD
to ~4 years of HRT or placebo. There were no significant overall decreases in further
CHD events in women assigned to HRT. However, it was observed that women on HRT
had an increased
rate of CHD events in the first year and decreased
risk during years 3-
5; these lower rates did not persist after stopping HRT in the further 2.7 years of follow-
Adverse effects of HRT included an increased rate of deep vein thrombosis and
pulmonary embolism, as well as biliary tract surgery for gallstones. Overall, there were
261 deaths in those on HRT and 239 among those on placebo.
On July 17th, the Journal of the American Medical Association reported the results
of the Women’s Health Initiative. The study had enrolled 16,000 healthy
postmenopausal women who were randomly assigned to HRT with either estrogen and
progesterone or placebo. After 5 years, it was found that those on HRT had an additional
increased rate of breast cancer of (8/10,000 women), stroke (8/10,000 women), blood
clots to the lung (18/10,000 women) and heart attack (7/10,000 women) when compared
to placebo. HRT reduced the rate of colon cancer (6/10,000 women) and hip fractures
(5/10,000 women). These risks and benefits work out unfavorably for HRT. The study
was therefore stopped and the participants were told to stop taking their medication.
Another study is ongoing evaluating the safety of estrogen alone in women who have had
a hysterectomy. To date, no increase in breast cancer has been observed but the study has
It is important to note that the only effective treatment for menopausal symptoms
is estrogen. It is reasonable to take estrogen for symptoms that interfere with the quality
of life for about five years. After five years, consideration should be given to tapering off
estrogen in consultation with your physician.
Prevention of osteoporosis can be accomplished with dietary supplementation of
calcium and Vitamin D, weight bearing exercises and bisphosphonates Fosamax,
Aredia or Evista. The prevention of heart disease can be accomplished by aerobic
exercise, diet, weight and blood pressure control, and, if necessary, control of cholesterol
and lipoproteins using statins (Lipitor, Prevacid, Proscar, Pravachol). It has
recently been reported that raloxifene (Evista) can also reduce the chances if heart
attack in women who are at increased risk.
References: Barrett-Connor E et al. Raloxifene and cardiovascular events in osteoporotic postmenopausal women: four year results from the MORE (Multiple Outcomes of Raloxifene Evaluation) randomized trial. JAMA 2002; 287:847-857. Grady D et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy. JAMA 2002;288:49-59. Hulley S et al. Noncardiovascular disease outcomes during 6.8 years of hormone therapy. JAMA 2002;288:58-66.
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