CENTRAL  SOUTH  DAKOTA  MEDICAL CENTER
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
30  AUGUST  2001

Hormone Replacement Therapy - A Dilemma

Between the ages of 45 and 55, the amount of estrogen in women and testosterone in men drops to a certain low level at which "menopausal" symptoms occur. For women, the symptoms include sleep disturbance, headaches, hot flushes, and their husbands seem to be harder to get along with. These same symptoms occur in men, and if he and she are about the same age and going through the same problems together things can get kind of owly.

It was learned in the 1960s teat giving women estrogen or men testosterone to supplement their falling natural hormone production corrected these symptoms and made the individual feel better. By 1980, there were suggestions in the medical literature that estrogen replacement treatment resulted in an increased incidence of carcinoma of the uterus in women. By 1995, it had been established that there was a slight increase in the incidence of carcinoma of the breast in woman using estrogen replacement treatment. The word cancer is so scary that many women do not even consider using estrogen.

Then why is there a dilemma in regard to the use of hormone replacement? The dilemma rests upon the observation that as many women die from broken hips as die from breast cancer. In the 1980s and early 1990s, large groups of women were studied and it became the impression that estrogen replacement treatment resulted in a major decrease in the incidence of heart attacks. Now, the problem became major. There are approximately 300,000 deaths per year from heart disease in women but only 15,000 deaths per year from breast cancer. If hormone replacement therapy with estrogen significantly decreased the rate of heart attacks but increased the rate of breast cancer by just a little bit, the lifesaving effect would be huge. Thus, through the decade of the 1990s, hormone replacement therapy was strongly recommended as having an overall lifesaving and beneficial effect for women. Had medical researchers left well enough alone, there would be no dilemma at this point.

Medical researchers are just a very busy group of people. They are always asking questions and reanalyzing the information they have to be sure that the advice that doctors offer is correct. A group of medical researchers noted that all of the studies on estrogen replacement treatment were done in what is called a retrospective manner. It seemed to be a valid approach to take a group of women and see how well the group taking estrogen did as compared to the group of women not taking estrogen. This type of study is only suggestive of the correct answer.

Decisive and reliable medical information comes from something called a prospective trial in which a group of women are matched and then split into two groups. One group is given estrogen replacement treatment and the other group not. Then these two groups are followed over the next several years to see if there is a difference in the rate of heart attacks in the two groups. This type of study was first done for a group of women who had all already had their first heart attack. It was hoped that starting estrogen in the treated group would prevent heart attacks from recurring. However, after several years of observation, the rate of heart attacks in the estrogen-treated group of women as compared to the group of women who had no estrogen was exactly the same. This was a very surprising and unexpected result.

Since that first study was done, there have been three more that addressed the same or a similar question. One of the subsequent three studies was addressed to women who have never had a heart attack and had no known heart disease. It was felt that perhaps starting estrogen treatment in this group of women before they ever had a heart problem would prevent it from occurring in the future. Again, when the study results were tabulated, there appeared to be no heart benefit.

Thus the major reason for recommending estrogen replacement therapy in women now was in serious doubt. The medical researchers have analyzed the data, reanalyzed the data and argued about the conclusions but at this time the American Heart Association has concluded that the use of estrogen replacement therapy to prevent either a first heart attack or a recurrent heart attack has no demonstrated merit.

Where does that leave estrogen replacement treatment and is it still a useful consideration? Its use to prevent menopausal symptoms is still an accepted and useful application of the drug. Its use to prevent a fracture of the hip, arm and spine has also clearly demonstrated benefits. For women who have had a hysterectomy especially at a young age, estrogen replacement therapy probably has greater benefits than risks. For women who have not had a hysterectomy or have a substantial family history of carcinoma of the breast, estrogen replacement therapy needs to be carefully considered in each individual case.

For men, hormone replacement treatment has not been nearly as extensively or well studied as has estrogen replacement therapy for women. One of the problems for the male hormone is that there is no safe pill such as women have for estrogen. Instead, men need to use a testosterone skin patch which is somewhat expensive or injections of testosterone given about every 10 days. The injections are not particularly expensive if self-given at home.

There are few data demonstrating the longevity or disease prevention effect of testosterone replacement in men. Rather the injections or patches are used to help maintain appetite, muscle mass and sensation of well being. Contrary to a common belief, testosterone treatment in men has very little effect on sexual function or erectile dysfunction.  While testosterone replacement in men is not shown to cause prostate cancer, it generally does make a prostate cancer that the man may already have grow faster. Frequent monitoring of the prostatic specific antigen blood test is important if a man is to use testosterone replacement therapy.

As mentioned in the title, hormone replacement treatment presents a dilemma in both men and women. Individual consideration is important. The nurse practitioners, physician's assistants and physicians at your local clinic are aware of the various considerations and can help individuals make decisions regarding hormone replacement treatment.

For  an  update  of  this  topic  see  the  column  of  August 1, 2002.