Editor—Two contrasting leading articles followed publication of the randomised trial of the women's health initiative study of hormone replacement therapy.1,2
Stevenson and Whitehead in the BMJ said that the increased risk of breast cancer in the study was small, but they did not mention that during the study 42% of women taking active drug and 38% receiving placebo stopped the assigned treatment.1
In contrast, Fletcher and Colditz reported in JAMA that the intention to treat analysis may have underestimated the true effects. In addition, if the duration of treatment is important as seems to be the case with breast cancer and if compliance decreases over time, then five year results may have underestimated the long term treatment effects.2
Stevenson and Whitehead deduced that because the risk of breast cancer was not appreciably increased in the first few years of taking hormone replacement therapy, women wishing to take short courses of this form of hormone replacement should be reassured. There must, however, be an interval between applying an agent that increases breast cancer development and the cancer manifesting clinically, so the validity of their deduction is open to question.
According to the BMJ editorial, long term hormone replacement therapy could still be considered for prevention of osteoporosis, whereas the JAMA editorial finishes with the definitive statement not to use oestrogen or progestogen to prevent chronic disease.
Stevenson and Whitehead in the BMJ say that the preliminary data of the effects of hormone replacement in preventing dementia are encouraging, but this is in marked contrast to a review in the New England Journal of Medicine last year. Although several early observational studies show that cognitive dysfunction or Alzheimer's disease is less likely to develop in women who take oestrogen after the menopause, more recent observational studies have not supported this hypothesis.3 Furthermore, a recent randomised trial did not show any benefit of oestrogen as treatment for mild to moderate Alzheimer's disease,4 and the HERS study did not show any benefit of hormone replacement on cognitive function.5
Stevenson and Whitehead reported that in the women's health initiative study overall mortality was not increased with treatment, but the authors of the study make it clear that as yet there are no meaningful data from this study relating to use of hormone replacement and mortality.
Conflicting and confusing views expressed in major journals make it very difficult for those of us who deal with patients to put forward a coherent and consistent message.
References
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