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The Honolulu Advertiser
Posted on: Tuesday, July 16, 2002

Short-term hormone use still deemed safe

By Daniel Q. Haney
Associated Press Medical Editor

Stopping HRT? Here's how
The Physician's Committee for Responsible Medicine, a nonprofit organization that promotes preventive medicine, has issued a set of guidelines for those who want to discontinue hormone replacement therapy.

The six steps:
• First, consult your doctor.
• Ask your physician to taper you gradually to the lowest possible dose for a smooth transition.
• Hot flashes may recur, but they will go away with time, and may be reduced by exercise.
• The best protection against heart disease comes from a low-fat vegetable-rich diet, regular exercise and no smoking. Vegetarians, particularly vegans, should supplement their diets with vitamin B-12.
• To protect bones, get plenty of exercise, along with vitamin D from sunshine or supplements, vitamin C from fruits and vegetables, and calcium from green vegetables, beans or fortified juices. Note: Excess animal proteins and salt can deplete calcium.
• Doctor-prescribed drugs are available to lower cholesterol and to prevent osteoporosis, if these are risk factors.

Experts say short-term estrogen is still a valuable treatment for many with menopause symptoms.

A year or two on hormones may still make sense for millions of women beset with hot flashes and other miseries of menopause, despite worrisome new findings about long-term use of the pills.

Even though soy foods or simply avoiding caffeine may help some women, many rely on the estrogen-progestin combination to make menopausal life bearable by easing hot flashes, night sweats and sleeplessness.

A large study last week seemed to call this use into question, but several doctors said Wednesday that the benefits of hormone replacement therapy almost certainly outweigh the risks, especially if women stop taking the pills as soon as they can.

"We should not go into a panic and stop using estrogens altogether. They are very effective," said Dr. Isaac Schiff of Massachusetts General Hospital.

Schiff heads a task force of the American College of Obstetricians and Gynecologists that will draw up new guidelines for hormone use following the landmark study, sponsored by the National Institutes of Health.

The new research clearly shows that doctors should not prescribe the hormone combination for more than five years as a way of preventing heart disease and bone loss, something that was once routine.

Instead, it now is clear that the treatment actually begins to increase the chance of a heart attack after a year of use, even though the extra hazard is small. After four years, it begins to increase the risk of breast cancer, as well.

However, doctors say that most women entering menopause in their late 40s and early 50s have healthy hearts, so the risk of a year or two of hormone treatment for them is slight.

Unless women have unusually high risk of heart disease, "nothing much changes for the short-term use of hormones," said Dr. Wulf Utian, head of the North American Menopause Society.

Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women's Hospital in Boston, noted that for severe hot flashes, estrogen is undoubtedly the most effective treatment.

"The duration of use is really the key factor," she said. "Women should not be panicked by these findings. Short-term use may still be a viable option for many women."

For those reluctant to take the hormones, however, there are other approaches. The simplest, said Schiff, is to wear loose clothing and avoid caffeine and alcohol, which can make hot flashes worse.

Among others:

• Low doses of anti-depressant drugs, such as Prozac and Effexor, can relieve hot flashes, even if women are not depressed.

However, they do not work as well as estrogen.

• Clonidine, a drug prescribed for high blood pressure, also can be effective, although some women complain of feeling tired.

• Soy-rich foods may also help some, as does vitamin E.

While there is evidence of varying degrees of scientific rigor supporting all of these, many other concoctions have been promoted, and some swear by them. Almost certainly the new fears about estrogen will give these alternatives a boost.

"All the snake oil salesmen selling cures for menopause will be out there advertising," Utian said. "There is virtually nothing that is much better than a placebo," he cautions, "unless it is a prescription drug."

Dr. Richard Hodes, head of the National Institute on Aging, recommended that women deciding to take hormones for menopause be watched especially carefully for signs of heart disease and breast cancer.

In the end, he said, the decision about whether even a slightly increased risk of these diseases is worth taking remains a personal balancing act, and many will probably opt to avoid it entirely.

"The overall equation is changed in an important way," he said. "For many women, this will make a difference and lead to a decision not to use estrogen therapy."

• On the Web:
Study: jama.ama-assn.org