Cautions in Hormone Therapy

CAUTIONS IN 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