Controversial Analysis of Landmark Study Information Questions Avoiding Hormone Replacement Therapy After Hysterectomy

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In 2002, results from the Women’s Health Initiative (WHI) Study were released showing that women who took combination hormone replacement therapy (HRT) had a higher risk of breast cancer than women who didn’t take HRT. In the years after the WHI study was published, use of HRT dropped dramatically. At the same time, rates of breast cancer dropped and other studies, including the Million Women Study, found a link between HRT use and breast cancer risk.

In 2004 and 2011, two analyses done on specific groups of women in the WHI (called subgroup analysis) suggested that women who had had a hysterectomy (surgically removing the uterus) had a lower risk of dying if they took estrogen-only HRT after the hysterectomy.

Now a group of scientists has done a new analysis of information collected by the WHI. The new study looked only at younger women (ages 50 to 59) who had a hysterectomy. The findings suggest that younger women who have a hysterectomy and don’t take estrogen-only HRT after the hysterectomy are more likely to die earlier than younger women who take estrogen-only HRT after hysterectomy.

The study was published online on July 18, 2013 by the American Journal of Public Health. Read the abstract of “The Mortality Toll of Estrogen Avoidance: An Analysis of Excess Deaths Among Hysterectomized Women Aged 50 to 59 Years.”

To figure out how many younger women who had had a hysterectomy were dying earlier than expected because they didn’t take estrogen-only HRT after hysterectomy, the researchers used information from the 2011 subgroup analysis published in the Journal of the American Medical Association (JAMA) that showed that 13 fewer women out of 10,000 would die per year if they took estrogen-only HRT after hysterectomy. Then the researchers used a math formula and census data to estimate that between 18,601 and 91,610 women were dying early over a 10-year period starting in 2002.

While these numbers are large and seem troubling, many other researchers are questioning the study’s results, including researchers who did the WHI study. The big range in the estimate of the number of women who died illustrates the amount of uncertainty involved in the study results.

“They [the researchers who did the new study] took one statistic from the JAMA paper and put it into a formula and calculated the expected number of deaths under a set of assumptions that may or may not be reasonable,” said Andrea LaCroix, M.D. of the Fred Hutchinson Cancer Research Center in Seattle and a WHI researcher. “These data from the WHI were first reported in 2004, and there were declines in estrogen use in 2002. My first question is, where is the real evidence that death rates have increased in women 50 to 59 in the United States in those communities where the greatest decreases in hormone therapy have occurred?”

“As a result of the methodology, the findings are unreliable projections, which are, at best, hypothesis-generating and should not inform clinical practice,” said Rowan Chlebowski, M.D. of the University of California-Los Angeles and a WHI researcher.

It’s also VERY important to know that this study didn’t consider whether the younger women who had hysterectomy had been diagnosed with breast cancer. This likely would have dramatically changed the results.

Menopausal side effects can dramatically reduce quality of life for some women. These women have to weigh the benefits of HRT against the risks. While all the results of studies on HRT and breast cancer risk don’t perfectly agree, there is good evidence that:

  • HRT increases the risk of being diagnosed with invasive breast cancer.
  • HRT increases the risk of recurrence (the breast cancer coming back) in women who’ve been diagnosed.
  • Risk increases within the first several years of HRT use; the risk appears to be greater the longer a woman uses HRT.
  • Combination HRT increases breast cancer risk more than estrogen-only HRT.
  • High-dose HRT increases risk more than low-dose HRT.

Here are the important things to keep in mind:

  • If you’ve ever been diagnosed with breast cancer, HRT is NOT RECOMMENDED for you. Even if you’ve had a hysterectomy.
  • HRT is known to increase the risk of blood clots and stroke; these risks go down when you stop taking HRT.
  • Using bioidentical hormones is not recommended. "Bioidentical" means the hormones in the product are identical to the hormones your body produces. Bioidentical hormones are said to be "natural" -- derived from plants.
  • If you’re having severe hot flashes or other menopausal symptoms, talk to your doctor about ALL of your options. Be sure to discuss the pros and cons of different types and doses of HRT, as well as any other health problems you may have.
  • If vaginal dryness or discomfort during intercourse is your only menopausal symptom, you may want to ask your doctor if low-dose topical estrogen is a good idea for you.
  • Some complementary and holistic medicine techniques have been shown to ease hot flashes, including exercise, yoga, cognitive behavioral therapy, and acupuncture.
  • If you decide to take HRT, try to take it for the shortest time possible. You also may want to ask your doctor about vaginal or transdermal HRT.

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