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June 1, 2006 -- When is menopausal hormone therapy appropriate? An expert panel of doctors tries to cut through the confusion.
Endocrinologist Bruce Ettinger, MD, and colleagues boldly go where none has gone before. Their mission: to determine, specifically, what is an "acceptable" use of hormone therapy, and what is "unacceptable."
"We felt that guidance we were getting from major medical societies was too vague -- it leaves too much unsaid, and there is not enough information to help people make decisions," Ettinger tells WebMD. "Even though our panel never gets to perfect agreement, we can say, "This is mainstream activity, and this is not."
Ettinger, a Kaiser Permanente researcher and a clinical professor of medicine at the University of California, San Francisco, and colleagues report their finding in the current issue of the journal Menopause.
Looking for Menopausal Hormone Therapy Consensus
Doctors agree that hormone therapy can help women whose lives are disrupted by menopausal symptoms. Doctors agree the treatment -- estrogen plus progestin for women with a uterus, and estrogen alone for women who have had a hysterectomy -- carries risks. Doctors agree that for some women, the risks of hormone therapy outweigh the benefits.
And that's where the agreement ends. Doctors disagree over which women need hormone therapy, and why they might need it. They disagree over when it's best to start hormone therapy. And they disagree over when to stop hormone therapy.
Some doctors are very quick to recommend hormone therapy as soon as a woman enters menopause. Others try everything else first -- and then offer only short-term hormone therapy as a treatment of last resort for devastating menopausal symptoms.
Some doctors see hormone therapy as a way to maintain a woman's bone and sexual function as natural estrogen levels wane. Others see hormone therapy -- especially long-term hormone therapy -- as an unwarranted risk for heart diseaseheart disease, strokestroke, and cancercancer.
So far, official advice has been cautious. The word from the National Institutes of Health and the American College of Gynecology is brief: Use hormone therapy only when necessary, in as small a dose as possible, for the shortest time possible.
Finding the Bottom Line
But what, exactly does this mean for specific groups of women? To try to get consensus, Ettinger worked with a panel of eight other experts. The panel started by concluding that the only menopausal women who need hormone therapy are those whose lives are disrupted by severe hot flasheshot flashes.
The panel then found that, in specific circumstances, hormone therapy was acceptable, unacceptable, or uncertain. Uncertain means that most panelists had "midlevel enthusiasm for hormone therapy in a particular setting."
For women with a uterus, the panel found that:
For women without a uterus -- that is, women who have had a hysterectomy -- the panel found that:
"You want to relieve a woman's intolerable symptoms, but you don't want to create other health problems at the same time," Ettinger says. "There is a certain level of comfort we have in prescribing any form of hormone therapy for a woman who is healthy. And there is a high level of discomfort in prescribing hormone therapy for a woman at risk of stroke or heart attackheart attack -- even if she has intolerable symptoms."
The panel strongly recommends that after a woman has been on hormone therapy for a year, she should try to stop or at least take a lower dose. At every annual checkup, the panel advises, doctors should revisit this issue and urge women to stop or taper off their hormone therapy.
Consensus: Not
Will the Ettinger panel's recommendations calm the roiled waters of opinion over menopausal hormone therapy? Another metaphor may better apply -- the stirred hornet's nest.
WebMD showed the panel's recommendations to two experts. Both served as researchers in the Women's Health Initiative study. Lawrence Phillips, MD, is professor of endocrinology at the Emory University School of Medicine in Atlanta. Mary Jo O'Sullivan, MD, is professor of obstetrics and gynecology at the University of Miami Miller School of Medicine.
"This is not at all helpful. It is false," Phillips tells WebMD. "Hormone therapy is beneficial for younger women -- that is, women who begin at menopausemenopause. It is not good for women to start after menopause."
Phillips says the Ettinger panel is packed with people opposed to hormone therapy. He says there is strong evidence that hormone therapy, begun during menopause, actually cuts a woman's risk of heart diseaseheart disease. And while he certainly says he thinks doctors and patients should discuss whether to continue hormone therapy at every visit, he sees no reason to urge women to stop.
"I think a woman who has been using hormone therapy, and who has done well with it, should probably stay on it," Phillips says. "On balance, that will be beneficial to her health. I do believe the long-term risks will prove to be less with estrogen given as a patch than as a pill. But the evidence to support that is only indirect at present."
O'Sullivan, too, is unhappy with the panel's conclusions -- but for far different reasons than Phillips. She says the panel underestimates the risks of hormone therapy.
"I truly understand how these women feel," O'Sullivan tells WebMD. "But there are other things besides hormone therapy to do for severe menopausal symptoms. I do feel there is a role for hormone therapy for women who cannot get their symptoms relieved -- but for a short period of time; just enough to give them a break. I say not to give it for a year, but for three or four months -- then start weaning them off."
For women who choose to remain on hormone therapy, O'Sullivan would check back with them in two or three months -- not a year -- and urge them to try stopping.
SOURCES: Ettinger, B. Menopause, May/June 2006; vol: 13 pp 404-410. Bruce Ettinger MD, adjunct research scientist, division of research, Kaiser Permanente Northern California; and clinical professor of medicine and radiology, University of California, San Francisco. Lawrence Phillips, MD, professor of endocrinology, Emory University School of Medicine, Atlanta. Mary Jo O'Sullivan, MD, professor of obstetrics and gynecology, University of Miami Miller School of Medicine.