Department of Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, New York, New York 10461
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Introduction |
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The classic, preventive approach to HRT can be summed up in a few phrases: 1, estrogen is good for you; 2, start taking it now; 3, take it for the rest of your life. These tenets come under fire in the present series of articles, and the time is right for a re-evaluation of these principles.
Preventive medicine is difficult. Women, by and large, are voting with their feet about this approach to HRT, and only a small minority of women take it, although benefits of HRT are likely to accrue to a majority of women. Our authors do not dispute that HRT will help to prevent osteoporosis and fracture. All anticipate some benefit, though it may be smaller than expected, in cardioprotection from HRT (Dr. Roussow excepted). All authors express great concern that individualization of the treatment decision ought to be considered, and this is the first salient feature that marks a change in the thinking about HRT over the past two years. Dr. Col and colleagues lead off with a specific set of directives aimed at providing individualized estimates of the benefit-to-risk ratio for HRT (1). Their risk and benefit estimates are primarily based on data from the Nurses Health Study (2, 3). These studies have tended to provide a better-than-average estimate of cardiovascular disease risk reduction and a worse-than-average estimate of breast cancer risk associated with HRT, effects which may cancel each other out. Nonetheless, I find this approach valuable, because it models the behavior of a physician in the office, who must discuss and come up with a recommendation for his or her patients without the benefit of the results of randomized, clinical trials. Dr. Cauleys presentation also discusses the need to consider the individuals risk and hormonal profile before concluding that HRT is or is not a wise recommendation. This paradigm shift now leads us to a targeted approach to HRT. I believe that this approach is helpful for several reasons. It articulates which risk factors are modifiable for our patients and may lead them to engage in behaviors that will reduce disease risk. It sends the message to a patient that she is an individual who is not representative of the "everywoman" who will probably benefit from HRT, a message especially welcome by our highly individualistic aging baby boomers. It demystifies the process of decision making and welcomes the patient as a partner in the process, a feature that will probably enhance the ability to stick with the program.
A second paradigm shift that is detectable in all of the pieces is an appreciation that nonhormonal therapies are available to treat postmenopausal women. The impact of the "statins" probably contributed to the negative outcome of the HERS study, in which a substantial percentage of the women were being concomitantly treated with additional cardioprotective agents (4). The statins, in particular, have been demonstrated to save lives, something that cannot now be said about HRT, despite the implications of the many observational studies (5, 6). The notion that HRT is a global risk-reduction strategy is being re-evaluated. In a world that is now turning out statins, SERMs, and orally active bisphosphonates, pharmacologic methods to reduce cardiovascular and bone risk that do not involve the use of HRT are available, and there is every reason to believe that the choices will continue to proliferate. As the pharmacologic choices for risk reduction expand, we will be better able to appreciate the real and perceived barriers to long-term preventive treatment of postmenopausal women.
Finally, I think that the authors herein reflect a third, significant evolution of thought in this field. The "feminine forever" sentiment has led us to the unnecessarily heavy proposition that women must commit to HRT for the rest of their lifetime. This, in my opinion, presents an impediment to women contemplating its use. In a world of doubt, and in a world of choice, many women and their physicians may modify their program as they age, using HRT in varying regimens and adding or subtracting other medications for risk reduction, comfort, and diminution of side effects.
All of these paradigms are welcome. As knowledge accrues, we will have better information to assist the decision-making process, but as Dr. Col points out, it will never be definitive enough to cover each and every individual. On his 65th birthday, my father delivered his toast with the opening line, "If I knew I was going to live this long, I would have taken better care of myself!" Our goal as physicians should be to show patients the way to both live longer and take better care of themselves. We can do this by keeping abreast of the latest knowledge and evaluating its quality carefully, individualizing treatment decisions for our patients, and providing a full range of effective choices, including behavioral and pharmacologic approaches.
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Footnotes |
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Accepted March 11, 1999.
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References |
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