HRT : Facts women should know

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Hormone Replacement Therapy (HRT) for postmenopausal women was in the news the past several weeks following the release of a study by the Women's Health Initiative. The confusion that ensued and the anguish it brought countless concerned women around the world highlighted the fundamental need to revisit the issue and present the findings and data in their proper perspective and clinical significance.

To enlighten the public and allay some unjustified fears created, we have invited a respected colleague, one of our very own, Imelda Abesamis Layno, M.D., a Diplomate of the Philippine Board of Obstetrics and Gynecology and Professor, Cebu Doctors' College of Medicine, to address this particular issue for the benefit of our readers, their family and friends.

We are indebted to Dr. Layno for contributing the following piece on HRT:

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One month ago, newspapers and magazines seemed to herald the death of hormone replacement therapy (HRT) with the publication of the Women's Health Initiative (WHI) Study on 16,608 healthy postmenopausal women aged 50-79 with an intact uterus, receiving either a fixed dose combination of conjugated equine estrogen (CEE) 0.625 mg. plus medroxyprogesterone (MPA) 2.5 mg. or a placebo (not taking hormones) . The study was halted at 5.2 years primarily because of an increased risk of invasive breast cancer.

What did the data show?

HRT NO HORMONES per 10,000 women

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Breast cancer 38 30 +8 /10,000 0.08%

Heart attacks 37 30 +7 /10,000 0.07%

Stroke 29 21 +6 /10,000 0.06%

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The actual risks were very small, all less than 1/10 of 1% per year of use. The increased risk for breast cancer did not appear in the first 4 years of use nor was it found in another WHI study group of patients taking CEE 0.625 mg only ( so that the WHI trial on estrogen use alone is continuing). Compared to the placebo group, those receiving combination HRT would have 6 fewer colorectal cancers, and 5 fewer hip fractures.

The study confirmed previous reports that HRT increases the risk for breast cancer and stroke. It does not offer protection against heart attacks. Overall , the harm outweighed the benefits derived from HRT .

It did not address the issue of symptoms and quality of life of postmenopausal women.

Is there still a role for HRT?

We have to distinguish between the asymptomatic perimenopausal woman and the woman who is suffering from vasomotor symptoms (hot flushes, nights sweats, insomnia) and urogenital problems of vaginal atrophy and dryness, frequent urinary tract infections. These are most common in the early years of menopause (average age 51)

No other therapy has been shown to be better for relief of menopausal symptoms. The vasomotor problems are temporary, lasting 2-3 years in most women. Short-term HRT therapy offers marked relief of symptoms. Women have to be individualized as to hormone dose, preparation, duration of use. There is no "standard dose" for all women and not all women need HRT. "Hormone therapy, if indicated, if individualized, if monitored, is safe." (Notelovitz, MD, PhD)

The American College of Obstetricians and Gynecologists (ACOG) continues to recommend that the use of combination hormone therapy be a personal individualized decision, made after consultation between a woman and her physician, taking into account a woman's individual benefits and risks from such use.

When should an abdominal aneurysm be repaired?

An abdominal aortic aneurysm is an outpouching of the belly portion of the aorta, the large central arterial pipeline that carries blood from the heart to all parts of the body. The ballooning out of the aorta is caused by hardening of the artery and high blood pressure, leading to stretching and thinning of the aortic wall over the years. Many abdominal aneurysms grow slowly, causing no problem, and remain undetected, only to be diagnosed incidentally when imaging study of the abdomen is done for an unrelated condition or when the physician discovers its presence by physical examination. Some of these aneurysms burst, leading to massive internal bleeding that is usually fatal. To prevent a rupture, surgery can be performed by resecting the ballooned out artery and replacing it with an artificial arterial tube graft made of Dacron. The timing of the operation depends on the size of the abdominal aortic aneurysm. A study sponsored by the National Institute of Health on nearly 5000 older men and women, who underwent ultrasound for diagnosis and "sizing" of the aneurysm, confirms the recommendation of most experts in cardiovascular surgery that surgical repair be performed when an abdominal aortic aneurysm is at least 5 centimeters (about 2 inches) in diameter (cross section) or when the aneurysm is growing rapidly. Smaller aneurysms should be monitored closely with the use of ultrasound every year. Surgery is not indicated in small uncomplicated aneurysm.

Why is eating food high in fiber good for us?

Having a diet high in fiber lowers serum cholesterol, relieves some problems with diverticulosis, hemorrhoids, constipation and irritable bowel syndrome. It may also help lower the risk for heart disease, diabetes and certain forms of cancer, like colon cancer. It is recommended that one should have at least five servings of fruits and vegetables daily. High in fibers are: Broccoli, berries, brussel sprouts, apples, cauliflower, potatoes, pears, orange, figs, carrots, beans, green peas and prunes, oatmeal, brown rice, whole-wheat bread, bran cereals, popcorn. Some people might get cramping, gas or bloating when eating a lot of high fiber foods. Going slow, starting with small changes in the diet, spread over several days, usually gives the body enough time to adjust and have a comfortable transition.into this very healthy diet. Drinking more fluids, at least 8 glasses of water a day, is essential.

Can a simple urine test detect heart disease?

An article in Circulation, a journal of the American Heart Association, reports of a Dutch research that measured the level of albumin in urine samples obtained from more than 12,000 healthy older women (who were seen for breast cancer screening). Albumin is not normally found in urine. The women were followed up for 20 years. Those with the highest level or albumin in the urine were found to have 4 times greater risk of dying of heart disease compared to those whose urine did not show albumin. The implication was that poor kidney function was due to diseased kidney arteries (from hardening of the arteries), which allowed albumin to leak thru the filtering arteries into the urine. It seems logical then to interpolate this finding of albumin in the urine into a much wider problem affecting other arteries in the body, like the coronary arteries of the heart, which are likewise frequently affected by hardening of the arteries. Albumin in the urine could be one of the earliest clues to signal the onset of obstructive plaques of cholesterol in the arteries of the heart. The findings are preliminary and investigations are ongoing. Hopefully, someday soon, physicians will be able to "detect" asymptomatic coronary heart disease sooner with a simple urine test.

©2003Raoul R. Diez, M.A.O.D.