HRT should not be prescribed for disease prevention, guidelines say

By Jenny Manzer

TORONTO – Women experiencing serious menopausal symptoms can benefit from short-term combined hormone replacement therapy (HRT), but it should not be prescribed for disease prevention, say new Canadian guidelines.
   The Society of Obstetricians and Gynecologists of Canada (SOGC) recently released updated guidelines in response to results of the Women's Health Initiative trial, made public in July.
   The WHI trial included 16,000 postmenopausal women with a uterus, average age 63 years.
   The women were randomly assigned to an estrogen-progestin combination (conjugated equine estrogen and medroxyprogesterone acetate) or placebo.
   The study was halted after findings suggested the slightly increased risk of breast cancer, cardiovascular disease, stroke and venous thromboembolism associated with long-term HRT outweighed the potential benefits.
   The WHI team concluded combined continuous HRT was not effective for prevention of heart disease.
   On the other hand, the findings showed HRT was associated with a slightly decreased risk of osteoporotic fractures and colorectal cancer.
   In light of the findings from the large, high-quality study, the SOGC struck an expert panel including gynecologists, pharmacists and family doctors to revamp their guidelines, last changed in 2001.
   The new SOGC guidelines support use of combined HRT for up to four years in healthy perimenopausal women experiencing distressing menopausal symptoms, such as hot flashes, night sweats and vaginal dryness.
   After four years, doctor and patient should re-evaluate whether to continue HRT, say the guidelines.
   Dr. Donna Fedorkow, SOGC president, said the four-year marker reflects the WHI study findings that breast cancer risk was not significantly increased for up to four years of treatment.
   The SOGC also recommended that after four years, a patient's treatment should be reviewed each year she continues on HRT.
   "When balancing the risks and benefits, women may choose to stay on HRT with an annual review," said Dr. Fedorkow, speaking at a Toronto news conference.
   The new guidelines say combined HRT should not be prescribed as a primary treatment to prevent coronary heart disease, stroke, osteoporosis or colorectal cancer in women free of meno-pausal symptoms.
   Women who take combined HRT for relief of menopausal symptoms may experience osteoporosis and colorectal cancer prevention as a secondary benefit, according to the guidelines.
   "We have to be very circumspect about what we put in the prevention column," said Dr. Jennifer Blake, head of women's health at Toronto's Sunnybrook and Women's College Health Sciences Centre.
   Dr. Fedorkow said the SOGC guidelines have not changed radically, but noted modifications such as suggesting a review after four years of treatment, instead of five.
   Dr. Blake suggested physicians do a yearly review of all patients with menopause concerns.
   "The field is changing rapidly, and whatever is right this year may be changing next year." The WHI arm of estrogen-only treatment for women who have undergone hysterectomies is still ongoing, and no findings on risks or benefits have been released, noted the SOGC in a statement.
   "Women who plan to take estrogen-only therapy should undergo standard breast health monitoring. In the absence of data, it is prudent to use the lowest effective dose and duration of estrogen for the treatment objectives," the SOGC recommended.