HRT after hysterectomy - new data show risks in the balance

Menopause News May 10th 2011

The question of whether to take HRT after hysterectomy, especially in younger women, is complex and requires a careful individual assessment by a qualified physician. Many factors come into play: a woman's age, her individual risk profile, symptoms, weight, and her own attitude to risk, all need weighing up.

New results from the Women's Health Initiative (WHI), have recently been published in a leading medical journal, and add some further insights(1).

The WHI was a large study of the possible effects of hormone therapy in preventing a number of chronic diseases. The study took place between 1993 and 2004, and was stopped early because a higher stroke risk was seen in hormone users compared with women taking a placebo.

The recently published findings are an analysis of long term, follow-up (post-intervention) data, on the women who reported having had a hysterectomy at the start of the study, and who had therefore been allocated to the estrogen-alone trial. On March 1st 2004, study participants were instructed to stop taking the study pills. Since then, the investigators have followed up these women to assess the long term effects of hormone therapy.

Although some women decided to drop out, over 7500 women (78% of the original sample) agreed to the follow-up study, which included annual questionnaires and mammography. The women were followed up for a mean of 10.7 years from the start of the study, and had taken conjugated equine estrogens (CEE) for a median of 5.9 years.

Investigators LaCroix and colleagues, report that once the estrogen therapy was stopped, the increased risk of stroke disappeared, and a reduction in hip fractures that had been noted while on hormones, was also no longer apparent. There were no changes over this time period, in the risks of coronary heart disease, deep vein thrombosis, colorectal cancer or total mortality. Interestingly, the decreased risk of breast cancer, noted in the earlier analyses, was maintained during the follow-up period.

As JAMA editorialists, Jungheim and Colditz point out, these findings are inconsistent with many other studies, which have shown that unopposed estrogen therapy increases breast cancer risk (2). It seems that hysterectomy status and length of treatment, as well as age at starting and stopping hormone therapy all play a role - short-term use of hrt after hysterectomy in younger women, possibly being safer.

Clearly the whole story has yet to be unravelled, and both women and their physicians, making decisions about the use of hormones for menopausal symptoms, need to be cautious in how they interpret these findings.

As the editorialists conclude:

"There may still be a role for short-term use of unopposed estrogen for treating some women with menopausal symptoms, but this role may be vanishing as existing and emerging data continue to be better understood in terms of application to patients."(2)

Menopause hot flushes can make some women feel miserable. And while careful reflection on long-term risks versus short-term benefits of hormones is necessary, other treatment options and an emphasis on a holistic approach to a healthy lifestyle, can also help them through this period.


References

  1. LaCroix AZ, Chlebowski RT, Manson JE, et al., Health Outcomes After Stopping Conjugated Equine Estrogens Among Postmenopausal Women with Prior Hysterectomy. JAMA 2011; 305: 1305-14.
  2. Jungheim ES and Colditz GA. Short-term Use of Unopposed Estrogen. A Balance of Inferred Risks and Benefits. JAMA 2011; 305: 1354-5.


Published May 10th 2011.

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