The data on lung cancer are particularly contradictory in that, overall, it appears that starting estrogen-progestogen therapy in older women with a history of smoking may promote the growth of existing lung cancers, while “evidence from the WHI and some case-control and cohort studies of hormone therapy in a younger population [less than 60 years] shows some protection against lung cancer,” the authors stated. Although confusing, the findings “reinforce the need to encourage prevention or cessation of smoking and possibly to increase surveillance in older smokers who are current or past users of hormone therapy,” they wrote.
The revised statement also addresses the issues of cognitive impairment and coronary heart disease. It recommends against the use of HT at any age “for the sole or primary indication of preventing cognitive aging or dementia,” noting that it may increase the incidence of dementia when initiated in women who are 65 years or older.
Additionally, HT is not recommended as a sole or main indication for coronary protection in women of any age. When HT is started in recently menopausal women for the treatment of menopause symptoms, there does not appear to be an increased risk for coronary heart disease; however, women who initiate HT more than 10 years beyond menopause are at increased CHD risk, the authors noted.
In all cases, because each woman is unique with her own risk profile and preferences, “individualization of [hormone] therapy is key to providing health benefits with minimal risks, thereby enhancing quality of life,” the authors wrote. Women should be informed of known risks, with the understanding that “a woman's willingness to accept risks of [HT] will vary depending on her individual situation.” okOverall, “NAMS continues
Overall, “NAMS continues to refine our recommendations and approach to hormone therapy as data from the WHI and other studies continue to emerge,” NAMS president Cynthia A. Stuenkel said in an interview. “While we support the use of hormone therapy for symptomatic women [younger than age 60 years], close to the time of menopause, we remind our readers that there are some risks, though small, and there are some uncertainties remaining regarding short-term and long-term effects of hormone therapy.”
In general, “we strongly advocate for the lowest dose for the shortest time for the individual woman who has been carefully counseled about risks and benefits,” said Dr. Stuenkel, clinical professor of medicine at the University of California, San Diego.
The advisory panel members' financial disclosures are listed on the position statement, which can be found at www.menopause.org/PSht10.pdf
There are new sections on ovarian cancer and lung cancer, Dr. Margery L.S. Gass said.
My Take
Hormone Therapy Still Plays a Role
In general, the 2010 NAMS position statement on postmenopausal hormone therapy is in line with clinical practice; however, many doctors are not prescribing hormones, even when supported by the science, because of bad publicity and a lack of interest combined with fear of litigation.
It is pretty clear that hormone therapy should be used for patients with a clear indication, and the statement outlines what the relevant indications are. The data coming from the Women's Health Initiative] seem to be a reversal on the cardiovascular issue. Some of the subanalyses suggest that hormone therapy is associated with a cardiovascular benefit in women close to the age of menopause, while other studies from the same group suggest that this isn't so. Obviously, the science is evolving, and we are only beginning to understand the mechanism of cardiovascular risks and benefits. Overall, however, the statement is pretty clear that we should not use hormones to prevent cardiovascular disease.
In all cases, the decision to initiate hormone therapy has to be individualized to each patient. There is not a one-size-fits-all solution. The main issue is determining what is the safest drug for a woman at a particular time in her life.
MICHELLE P. WARREN, M.D., is director of the Center for Menopause, Hormonal Disorders, and Women's Health at Columbia University Medical Center in New York.