Hormone Replacement Therapy
This feedback report was written in January 2001
Authors
Dr Peter Mansfield
General Practioner (Aldinga Beach, South
Australia)
Director of HealthySkepticism.org
Professor Paul Glasziou
Head of Department
Department of Social and Preventative Medicine, University of Queensland
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?”
Responses to case study
Deep venous thrombosis and pulmonary embolism
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