Hormone replacement therapy: The right choice for your patient?
Hormone replacement therapy (HRT) has generated fear and confusion among many women. While the absolute risk for diseases associated with hormone use is low, the diseases are devastating. Breast cancer and stroke are 2 of the most feared illnesses, yet research studies often provided conflicting results on the risk of hormone replacement associated with these conditions.
Individualize every decision
The calculation of risks/benefits ratio has changed with the WHI data. All patients on HRT must be counseled on the new data, ideally in a face-to-face visit. Phone calls for medication refill, annual exam, and regular office visits are opportunities to revisit the subject of hormone therapy (HT). Given the mixed benefits and risks associated with HT, every decision should be individualized. A patient-centered counseling approach would allow a shared decision: the patient expresses her needs, goals, and preferences, and the physician applies medical knowledge to his and her values. In this dynamic approach, the physician can shift from a directive to a nondirective posture, taking the lead vs giving the patient full autonomy. The point in the continuum where the physician chooses to participate is determined by the patient, the physician, and the medical evidence.
The patient’s personal and family histories (breast/colon cancer, stroke, MI, osteoporosis) and risk factors (lipid profile, diet, exercise, body-mass index) play major roles in the decision. However, the patient’s philosophical approach to health often is the determining factor. The physician must provide the facts and ensure a patient is not taking HRT for reasons no longer valid. Questions such as, “What benefits do you hope to gain from HRT?” and “What are your major fears of HRT?” can help facilitate the discussion.
The patient’s philosophy
Patients often will select treatments most consistent with their philosophical approach to health. Patients with a holistic view of healthcare and an uneasiness with HRT are unlikely to have many questions. The patients who could benefit from your counsel are those who stopped HRT due to the findings of the WHI studies and those still on HRT who would like to continue. A recalculation of their individual risk/benefit ratio will help determine if HRT is still the right decision for them.
Considering symptoms
Menopausal symptoms are common and bothersome, often adversely impacting patients’ quality of life. Symptoms should be considered in calculating the risks/benefits ratio, but unfortunately, they are seldom included in research studies. In a UK qualitative study using a “time trade-off” method, participants were asked to make trade-offs between a shorter life span in “perfect health” compared with a longer life span with the condition under study.23 Women reported they might give up 3 months of their life to live the rest of the year without menopausal symptoms, underscoring the importance of menopausal symptoms.
Unanswered questions remain
Though national organizations such as ACOG, NAMS (The North American Menopause Society), and USPSTF (US Preventive Services Task Force) generally agree that estrogen and progestin should not be used routinely to prevent chronic conditions of menopause, such as CHD, there remain many unanswered questions. What are the risks associated with progestin? Is topical estrogen truly safe? Does the type of estrogen and delivery system have an impact on the safety profile? A recent systematic review and meta-analysis of the commonly used estrogen preparations showed that CEE and oral and transdermal 17 B-estradiol have consistent and comparable efficacy in the treatment of hot flashes and may have similar short-term adverse effects.24 But current clinical trials have many limitations, and further testing is needed to answer many remaining questions. Until clear strategies become available for HRT, the role of the physician continues to be that of a medical advisor helping patients make well-informed, personal, and thoughtful decisions.
—Shou Ling Leong, MD
