It’s a hallmark of the American tradition that somewhere around preschool or kindergarten we’re all taught we’re unique. The North American Menopause Society (NAMS) is trying to reintroduce women and their doctors to that concept in the specific area of hormone replacement therapy.
With its position statement titled “The North American Menopause Society Statement on Continuing Use of Systemic Hormone Therapy After Age 65,” NAMS hoped to get the word out in 2012 that the approach to women’s use of hormones needs to be as unique as each woman. NAMS Founder and Executive Director Wulf Utian, M.D., says the findings published in July 2002 by the National Heart, Lung & Blood Institute (NHLBI) of the National Institutes of Health (NIH) following its Women’s Health Initiative (WHI) Estrogen-Plus-Progestin Trial did a grave disservice to women.
The Estrogen-Plus-Progestin Trial was stopped in July 2002 when investigators found the associated risks of the combination hormone therapy outweighed the benefits. Specifically, an increased risk of heart disease, stroke, blood clots, and breast cancer were reported.
“It was such a misdirection in science it was unbelievable,” said Utian, who was working at the Cleveland Clinic at the time. “Women were terrified. They were calling up their doctors’ offices.”
Somehow, the abrupt end to the trial and the results of the study led to “the impression that it’s not really appropriate for women to be on hormone therapy after their sixth decade,” said Marla Shapiro, M.D., a member of the NAMS board of trustees and a menopause-credentialed physician serving as associate professor at the Department of Family and Community Medicine at the University of Toronto.
She explained the 26 percent increase in risk of breast cancer attributed to estrogen-plus-progestin was relative risk. How that plays out is like this: For every 10,000 postmenopausal women with a uterus, 30 are at risk for breast cancer. Give those 10,000 women estrogen plus progestin and an additional eight would develop breast cancer.
“If you understand that relative risk is eight of 10,000 it looks a lot smaller,” Shapiro said of the 26 percent, adding that two-thirds of the women in the study were over age 60. “The age of the participant, it really mattered,” Shapiro added, explaining that women in their 50s have half the risk of breast cancer as those in their 60s, and the risk continues to double with each decade.
Three months after the early end of the WHI trial, NAMS published its first position statement on hormone therapy after age 65 and has been updating it ever since. “Use of HT should be individualized and not discontinued solely based on a woman’s age,” the paper continues, concluding, “The decision to continue or discontinue HT should be made jointly by the woman and her health care provider.”
Utian said there’s an agreed-upon list of patients the medical community will not treat with hormone therapy. They include: those with active liver disease, those with a major history of recurrent, previous blood clots from embolism, and current cancer patients. Debate ensues, however, when discussion turns to whether or not a woman who was formerly treated for cancer but is currently cancer-free should receive hormone therapy.
While the NAMS statement says to maximize safety, hormone therapy should be initiated in healthy, symptomatic women, within 10 years of menopause or younger than 60 who don’t suffer any contraindications, it also acknowledges moderate to severe symptoms documented in 42 percent of women 60 to 65. “I’ve had patients who have come in in tears,” said Utian, now Professor Emeritus of Reproductive Biology at Case Western University in Cleveland, Ohio. “’My life is an absolute, thorough mess! I cannot live like this!’ She’ll say, ‘I’d rather be dead than go on living like this’ and I’ll say, ‘Fine.’ And those are some of the most grateful [patients].”
“That blanket statement of no hormone use after age 60 has to be abandoned,” said Shapiro. She hopes the NAMS statement serves as a call-out to insurance companies which often will not cover the cost of hormone therapy for patients over age 60 since estrogens, with or without progestins, have made it onto Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
“I think an educated patient is a really empowered patient,” Shapiro said. She encourages women to visit www.menopause.org to read up on the subject further and find a list of NAMS-certified practitioners who hold the designation of North American Certified Menopause Practitioner (NCMP).
Wulf Utian, M.D., via phone conversation August 5, 2015.
Marla Shapiro, M.D., via phone conversation August 5, 2015.
The North American Menopause Society Statement on Continuing Use of Systemic Hormone Therapy After Age 65. The North American Menopause Society (NAMS). Retrieved August 5, 2015. http://www.menopause.org/docs/default-source/2015/2015-nams-hormone-therapy-after-age-65.pdf
Hormone Replacement Therapy: New Facts. Healthday News. Retrieved August 13, 2015. http://consumer.healthday.com/encyclopedia/breast-cancer-7/breast-cancer-news-94/hormone-replacement-therapy-new-facts-646066.html
Reviewed August 13, 2015
By Michele Blacksberg RN