09 October 2012

International Menopause Society comments on BMJ paper on HRT and menopause

The British Medical Journal (BMJ) is publishing the results of a long-term randomised trial, which followed 1006 Danish women, half of whom started taking HRT at the time of the menopause.
The study authors conclude that “After 10-years of randomised treatment and 16 years of total follow-up, women treated with HRT early after menopause had significantly reduced risk of mortality, heart failure, or MI, without any increase of cancer including breast cancer, VTEs or stroke”.
The IMS believes that the study adds significantly to our understanding of HRT use at the time of the menopause. The last 15 years have seen the publication of several studies on HRT use, with the differing interpretations giving the impression of conflicting results. This has made it difficult for women to understand the real risks and benefits, but in fact, if you compare the studies like for like, there is remarkable consistency. This present study supports the idea that HRT use is associated with a “window of opportunity”, meaning that starting HRT at around the time of the menopause, as well as giving the best relief of menopausal symptoms, is generally beneficial.  The idea that the timing of HRT use is important has become increasingly accepted over the last 10 years. In addition, this study also suggests that HRT use may confer some significant long-term benefits, and the IMS calls for a much larger study to assess these possible benefits. 
 IMS president, Dr Tobie de Villiers (Cape Town, South Africa, ) commented:
“This study is of great importance as it reflects what happens in real life where women start taking HRT at the time of the menopause. In this study HRT did not cause any major harm, and indeed resulted in significant benefits. Of great importance to women is the fact that women who took HRT had fewer cases of breast cancer compared to non-users over a 16 year follow-up period  The results are different to the results of the Women’s Health Initiative (WHI) study,  reported 10 years ago, but that’s because they were looking at very different groups of women. The WHI was a large study, but it looked at much older women, with an average age of 63 when they started HRT. In contrast, this Danish study looks at women who start taking HRT at the time of the menopause, around 50 years of age. The Danish study also followed up these women for 16 years, which is significantly longer than the follow-up of WHI. This new work supports the safety of HRT taken at the time of the menopause”.
Professor Howard Hodis (University of Southern California, Los Angeles, ) said:
“This Danish study is the only long-term prospective randomised HRT trial to consider women at or near the menopause when starting HRT. It provides direct and compelling evidence that the benefits of prevention of chronic diseases outweigh the risks, even when HRT is used for more than 15 years. This trial confirms the consistent data that has accumulated over the last 50 years, that HRT reduces CVD and total mortality when started in women at or near the time of menopause, and does so safely.  This new trial provides further evidence-based data to contradict the “lowest dose for the shortest period of time” statement which never had any scientific basis, and in fact, such limited use may prevent women from realising the total benefits associated with longer-term HRT use such as the reduction of CVD, bone fractures and total mortality”. 
Dr John Stevenson (Royal Brompton Hospital, London, ) said;
“There are several things to note here. The trial, including follow-up, lasted 16 years, with no significant adverse events. Indeed, there is evidence for HRT providing long-term benefits to women who start HRT around the menopause, consistent with what other studies have shown. The strength of the study is its long duration, and this shows that HRT, started around the menopause, is really pretty safe indeed, even for longer-term use. Each woman need to discuss HRT use with her doctor, and then decide if it’s right for her. But if taken in the appropriate way, with regard for individual circumstances, then women should really no longer be worried about using HRT”.
The IMS believes that women who start HRT use near the time of the menopause need have few worries about safety, and that the benefits of HRT use outweigh any risks. The IMS recommends that any decision to take or not to take HRT should be made according to a woman’s individual circumstances, in consultation with her clinician.

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