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Chapter: Obstetrics and Gynecology: Menopause

Cautions in Hormone Therapy

The results of the WHI in 2002 revealed epidemiologic findings that have modified the contemporary use of hormone therapy.



The results of the WHI in 2002 revealed epidemiologic findings that have modified the contemporary use of hor-mone therapy. This large, multicenter, randomized clinical trial (approximately 17,000 women) studied the effects of hormone therapy, dietary modification, and calcium and vitamin D supplementation as related to heart disease, frac-tures, breast cancer, and colorectal cancer. Although thereare features of this study that are not applicable to many younger menopause patients, the overall results suggested that when com-pared to placebo, a combination of conjugated equine estrogens and continuous low-dose medroxyprogesterone acetate resulted in an increased risk of heart attack, stroke, thromboembolic disease, and breast cancer, with a reduced risk of colorectal cancer and hip frac-tures. Some of the data contradicted prior large-scale obser-vational studies, and thus many physicians have changed their practice regarding hormone therapy to center more on the relief of short-term symptoms of estrogen depriva-tion, including hot flushes, sleeplessness, and vaginal atro-phy. Although reappraisals of the study have focused on its flaws, current opinion suggests that initiation early in menopause is associated with a good risk-benefit ratio, with preference for the transdermal route. Nonetheless, the current recommendations from numerous organizations, including ACOG, is that hormone therapy should only be used for the short-term relief of menopausal symptoms and should be individually tailored to a woman’s need for treat-ment (Box 37.2).


Hormone therapy in women with prior history of breast and endometrial cancer is controversial. Currently, prospective studies are underway using low-dose hormone therapy in women with a prior history of limited-lesion, successfully treated breast cancer. Similar studies in women with prior treated limited-lesion endometrial cancer have been completed and show no increased risk of recurrence for estrogen users.


Box 37.2

Contraindications to Hormone Therapy

Undiagnosed abnormal genital bleeding

Known or suspected estrogen-dependent neo-plasia except in appropriately selected patients

Active deep vein thrombosis, pulmonary embolism, or a history of these conditions

Active or recent arterial thromboembolic disease (stroke, myocardial infarction)

Liver dysfunction or liver disease

Known or suspected pregnancy

Hypersensitivity to hormone therapy preparations


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