Hormone Therapy Still Viable Treatment

By Sharon Kirkey, Canwest News Service

January 22, 2009

Canada

With unprecedented numbers of Canadian women about to enter menopause, Canadian doctors are telling women it's safe to go back on hormones.

An expert panel convened by the Society of Obstetricians and Gynaecologists of Canada has concluded that no treatment is as effective as hormone therapy for hot flushes and other symptoms of menopause.

The group says an "extensive" review of new data — along with a re-analysis of a massive study that led women to abandon their hormones in droves seven years ago — shows hormones are a safe option for moderate to severe symptoms, if started early and used over the short term.

The group is recommending using the lowest effective dose. And while there is no fixed timeline, "we suggest that taking it for four to five years is a good starting point," says Dr. Robert Reid, lead author of the updated guidelines and chair of the division of reproductive endocrinology and infertility at Queen's University in Kingston.

The new advice to doctors says:

- Hormones do not increase the risk of heart attack in younger women, and they have little appreciable effect on the risk of breast cancer if taken for less than five years.

- Hormones can prevent bone loss and fractures.

- Herbal remedies such as black cohosh and soy are no more effective than placebos, or sugar pills for hot flushes, and doctors should not recommend complementary medicines.

"A lot of women were told point-blank, stop your hormones. Suck it up. And they're in my office with terrible hot flushes and irritability and depression and other mood things and they're saying, 'My doctor won't prescribe (hormones) for me', " says Reid. "What we're trying to do is ensure people who have symptoms that may benefit aren't afraid to put (hormones) on the list of options."

This year, the largest demographic from the "baby boomer" generation turns 50. In Canada, there are now 2.5 million women between 45 and 54. Women are expecting treatments will be provided to them, Reid says.

"Now what I'm seeing is people who have gone past that initial scare — first-time users who are coming in saying, 'Look, I'm a busy professional woman, I've got presentations to do at corporate meetings. I don't want to be standing there, flushing my face and soaking my clothes'. "

Women and their doctors were frightened off hormones after a run of troubling news from one of the largest and most expensive studies ever conducted by the U.S. National Institutes of Health.

The Women's Health Initiative Trial, which involved nearly 17,000 women, was prematurely halted in 2002 after researchers discovered an increased risk of heart disease, strokes, breast cancer and blood clots in women using an estrogen-progestin combination.

In Canada, hormone prescriptions plummeted, from 11.6 million in 2002 to five million in 2007, and 4.8 million in 2008, according to IMS Health Canada, a prescription drug tracking firm.

Many doctors told women to go off hormones, and to try losing weight. They were advised to use fans or cold face cloths for hot flushes. The hormone backlash helped fuel a multibillion-dollar market for herbal and alternative products, with scant safety data or evidence of benefit, doctors say.

But a second look at the data found no increases in risk for coronary heart disease in younger women aged 50 to 59.

The average age in the women's health initiative study was 63; many women were in their 70s. The oldest was 84 when the trial stopped. A "substantial proportion" of the women might have had undetected heart disease, according to the report by the Canadian panel.

Dr. Michel Fortier, professor of obstetrics and gynecology at the University of Laval, says the number 1 fear of using hormones is breast cancer. But he says, "women take a much greater risk by getting into a car to (drive to) my office than taking HT (hormone therapy)."

The Canadian update says longer-term use (more than five years) increases the risk of breast cancer, but the risk is similar to the risk a woman runs by being overweight, drinking alcohol every day or not exercising.

The risk returns to normal after hormones are stopped.

A chief complaint is hot flushes, which affect 60 to 80 per cent of women in menopause and can cause sweating, heart palpitations, anxiety and poor sleep.

Reid says lifestyle changes — avoiding triggers such as alcohol and hot drinks, dressing in layers and exercise — can help ease mild hot flushes. For severe or moderate hot flushes, "lifestyle choices often fall short."

Reid says herbal and natural health products can interact with prescription drugs and anesthetics.

"We are now telling our members not to be sending a woman to the drugstore to find a herbal remedy for her hot flushes," Reid says.

The panel says doctors can consider using non-hormonal drugs, including antidepressants, blood pressure drugs and gabapentin — an anti-epileptic drug that has been linked with an increased risk of suicidal thinking and behaviour.

Five of the six authors of the new guidelines have been consultants or speakers for drug companies, including makers of hormones.

Reid says the menopause and osteoporosis update was done "completely at arm's length; there was no pharmaceutical involvement whatsoever."

Anne Rochon Ford, of Women and Health Protection, says she was disappointed the doctors' group "isn't more active around promotion of alternatives other than pharmaceuticals."

"I certainly have concerns about promoting the use of antidepressants and gabapentin, whose history we know about" for hot flushes, she says.

Women would be further ahead "if we were putting as much energy into promoting healthy responses to difficult menopausal symptoms than promoting pharmaceutical responses”.

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