The Hormone Dilemma
The latest flip-flop on hormone therapy gives new hope to younger women
After Janet Smith had a hysterectomy at the age of 48 in 2001, her doctor suggested she take hormones. "I'd already experienced some night sweats and hot flashes, and they're not a lot of fun," says Smith, who lives in Boulder, Colo. She did her own research but was baffled by the reams of conflicting studies. "The more I read, the more confused I got," says Smith, who decided to give hormone therapy a try. But just two years later, she quit. "There always seemed to be something scary in the news about it."
Smith had plenty of company in her hormone jitters. After the federal Women's Health Initiative halted one hormone study in 2002 and another in 2004 after concluding that the risks--including breast cancer and stroke--outweighed the possible heart benefits, women all over the country threw out their pills. Estrogen prescriptions dropped dramatically.
But now it seems some of those women may not have needed to give up their hormone regimens. Two new studies suggest that women like Smith who take hormones when they're relatively young and closer to menopause may actually be protected against heart disease--not at higher risk. "There's mounting evidence that age and time since menopause may make a difference," says JoAnn Manson, chief of preventive medicine at Harvard's Brigham and Women's Hospital and one of the authors of the two new papers as well as the original WHI studies. "These are important pieces of the puzzle."
Hormones started to look like a fountain of youth in the 1980s and 1990s, after several observational studies suggested a myriad of benefits, from preventing heart disease and osteoporosis to improving memory. "The perception that these hormones protect the heart was so strong that many doctors were prescribing it to prevent heart disease," says Manson. The assumption was that hormones were like vitamins, something you would take for the rest of your life.
Yet no large clinical trials supported the grand claims of hormone enthusiasts. So the WHI set out in 1992 to answer the question once and for all: Should hormones be prescribed for all older women to prevent heart disease?
The answer was--and remains--a resounding no.
The WHI studies looked at two types of hormone treatments. One trial randomly assigned 16,608 women to take estrogen plus progestin or a placebo. This combination is prescribed for women who have not had hysterectomies because estrogen alone increases the risk of cancer of the uterus. In the other trial, 10,739 women who had undergone hysterectomies were randomly assigned to take estrogen alone or a placebo.
Stunned. The results of the trials shocked the medical community. Not only did the studies find no benefit for heart disease, but the estrogen-plus-progestin trial also showed an increase in heart disease, as well as significant risks for breast cancer, stroke, and embolism. It also showed a decrease in colorectal cancer and hip fracture, but not enough to outweigh the risks. In 2002, the estrogen-plus-progestin trial was called off. Two years later, the WHI halted the other trial because of the increased risk for stroke with no benefits in stopping heart disease.