22nd
Annual Meeting of NAMS
WASHINGTON, D.C. — During an academic debate held here, two
physicians argued the issue of whether the use of hormone therapy is ever
warranted in asymptomatic postmenopausal women.
David F. Archer, MD, professor of obstetrics and gynecology,
Jones Institute for Reproductive Medicine, Eastern Virginia Medical School,
took the “pro” side, arguing that menopause is an endocrinopathy. He
pointed out that, as women age, ovarian function declines, follicle-stimulating
hormone levels rise and other changes occur.
“If we measured a woman’s thyroid-stimulating hormone and it
was elevated and her thyroxine level was falling, we would assume that this
woman has
hypothyroidism and we would have no qualms treating it, even
though only 12% of women have clinical hypothyroidism. On the other hand,
menopause affects 100% of women globally.”
Archer also explained that some human and rodent data suggest that
estrogen retards the development of atherosclerosis, has a slightly beneficial
effect on lipid profiles and, most importantly for an aging woman, helps
maintain vascular reactivity. In addition, estrogen has positive ramifications
for bone endpoints. Evidence shows that bone mineral density rapidly increases
with estrogen use and rapidly decreases after discontinuation of treatment.
Moreover, therapy has been shown to reduce fracture risk, he said, and even
among asymptomatic women has the potential to boost muscle strength when added
to an exercise regime. Subtle improvements in quality of life, such as
increased libido, are also significant.
Archer acknowledged the potential adverse effects of estrogen use as
well. He noted, however, that the link to venous thromboembolism associated
with HT disappears after 2 years. The risk for neoplasia is also
slight, he said. Data from the Women’s Health Initiative (WHI) and
Women’s Health Study conflict as to the relationship between duration of
use and development of neoplastic breast cells.
In response, James A. Simon, MD, clinical professor at George
Washington University School of Medicine and medical director of Women’s
Health & Research Consultants, said data from the WHI and other randomized
clinical trials denote considerable increases in incidence of stroke and
pulmonary embolism with estrogen therapy, as well as higher risk for venous
thromboembolism with HT.
Simon pointed out that information from the WHI does not indicate
benefit for prevention of cardiovascular disease, and maintenance of vascular
reactivity is only evident if a woman has healthy arterial vessels (i.e. coronary arteries). Moreover,
physicians cannot reliably identify women at risk for coronary artery disease
and therefore cannot determine whether HT will be helpful for certain patients.
In terms of bone density, Simon agreed that estrogen can increase
BMD
and may reduce the risk for fracture, but he cited other treatments, such as fluoride, increase BMD but subsequently were found to increase fracture risk. Furthermore, he noted that WHO lists
estrogen as a carcinogen.
He recommended that physicians “be careful about recommending any treatment for
every asymptomatic woman. For primary prevention, we should instead recommend
exercise, stress and weight reduction or some other interventions that have been
documented to be beneficial, such as statins or aspirin.”
After the presentations, the audience favored pro argument by a narrow
margin of 52% to 48%.
For more information:
- Goldstein SR. Debate — Is there ever an indication for hormone
therapy in an asymptomatic postmenopausal woman? Presented at: the 22nd Annual
Meeting of the North American Menopause Society; Sept. 21-24, 2011; Washington,
D.C.
Disclosure: Dr. Archer is an advisory board member of, consultant/speaker for or has received research grants from Bayer, Chemo, Corcept, Merck, Pfizer, Warner Chilcott, Watson and Duramed/Barr. Dr. Simon is an advisory board member of,
consultant/speaker for or has received research grants from Abbott, Agile,
Amgen, Ascend, Azur, BioSante, Boehringer Ingelheim, Depomed, Fabre-Kramer, Laboratoire HRA Pharma, Meditrina, Merck, Merrion, NDA Partners, Novo Nordisk, Novogyne, Pfizer, Shionogi, Slate, Teva, Trovis, Warner Chilcott, Watson, EndoCeutics, Palatin Technologies and Bayer.
We've been having a very exciting meeting this year at the 22nd Annual Meeting of the North American Menopause Society in Washington, D.C., and perhaps one of the most fun sessions was a debate between two very talented speakers - Dr. David Archer and Dr. James Simon - on the controversial topic of whether there is ever a reason to use hormone therapy in the asymptomatic woman. We know that the indications that the FDA has given us are for treating symptomatic women, so these two men were given the challenge of debating the pro or the con side. They did not know before they arrived to which side they would be assigned. So they put out their best efforts, and in the end, it was pretty close to a tie as to whether or not we should consider giving women without symptoms treatment or not. One could make an argument for using HT in the asymptomatic woman, and a perfect case would be to prevent significant bone loss for someone at high risk for osteoporosis but is not symptomatic at the time. Another less well-proven area would be to prevent vaginal atrophy in a person who is headed in that direction. So there are some caveats like that to HT and we'll just have to stay tuned about how well they're received.
– Margery Gass, MD, NCMP
Executive Director of the North American Menopause Society
Consultant, Cleveland Clinic
Disclosure:Dr. Gass reports no relevant financial disclosures.