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Healthy Skepticism International News

July 2001

Hormone Replacement Therapy

July / August 2001 Vol 19 No 7/8

This report was written in January 2001 regarding feedback from Australian GPs about National Prescribing Service Case Study 11 released October 2000.

Authors

Dr Peter Mansfield
General Practioner (Aldinga Beach, South Australia)
Director of Healthy Skepticism

Professor Paul Glasziou
Head of Department
Department of Social and Preventative Medicine, University of Queensland

Scenario

Ann McDonnald is a successful 55 year old business executive.  She starts her first consult with you by saying.  “I’m getting hot flushes.  It’s only a hormone transition and I’m strong, I got through puberty so I can get through the menopause.  But a friend has suggested I take HRT for prevention.  I had a small heart attack last year but my angina is Ok now.  My mother aged 80 is making a good recovery from a fractured hip.  My father died of a heart attack at 45.  One of my cousins aged 50 has just been diagnosed with breast cancer which has deeply upset the whole family.  I have read conflicting reports that HRT may do good or harm.  Doctor what do you think?  How sure are you?”

Contents

Summary
Introduction
Responses to case study
Fractures
Cardiovascular events
Deep venous thrombosis and pulmonary embolism
Breast cancer
Gallbladder disease
Options recommended for Ann

Summary

Ann is a 55 year old woman with a past history of a myocardial infarct who has hot flushes but does not want treatment for them.  She requested information about whether HRT is beneficial or harmful for life threatening events such as fractures, heart attacks and breast cancer.

The evidence currently available suggests that the impact of HRT on:

  • fracture rates is probably known and may be mildly beneficial.
  • cardiovascular event rates is very uncertain but may be very harmful, in the short term but neutral for survivors in the medium term.
  • thromboembolim is probably known and is very harmful
  • breast cancer is very uncertain but could be very harmful.
  • gallbladder disease is very uncertain but may be very harmful.

There is stronger evidence that supports recommending a Mediterranean diet, physical activity, aspirin, and a beta-blocker for Ann.  If Ann’s total cholesterol level was >5 we would also recommend a “statin”.

For women who have had a myocardial infarct, HRT has been shown to be potentially harmful in RCTs of up to 4.1 years duration.  The possibility that longer-term use may do more good than harm has not been excluded but any excess benefit would have to be very large to make up for the early harm.

On balance, for Ann, the risks of harm from HRT outweighs the uncertain benefits.  We are also concerned that use of HRT may also be harmful by diverting attention from more beneficial interventions.

Next: Introduction

 

 

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