The recent stampede against HRT seems to have swept across the UK following
the strongly negative reaction from the USA. The RCP statement and now the
CMO statement have a consistent message that short term use of HRT is
acceptable for symptom relief but in the long term HRT is to be avoided.
This is unfortunate for those women who may benefit from long term
treatment with HRT and ignores all the data supplied (or not supplied) in
the WHI and Million Women studies. It should be noted that the oestrogen
only limb of the WHI study (a randomised placebo controlled study) is still
progressing and the independent review board did not ask for this limb of
the study to be stopped. The CMO recommendation on oestrogen alone therapy
is presumably based on the Million Women study which is not randomised
placebo controlled.
The average age of entry into the WHI study was well in to the sixties but
this was not a study looking at patients with proven osteoporosis. The
significant reduction in hip and vertebral fractures is therefore of
greater significance than may at first be appreciated from a glance at the
WHI study. Use of HRT in a high risk group with reduced bone mass may
result in greater benefits. The current licensed osteoporosis treatments
were all tested using patients with proven fracture and significant
reductions in bone mass (a high risk group) which may have helped them
obtain a beneficial outcome. It is interesting that in one study where the
BMD measurements were re-aligned following the study according to NHANES
data there was no significant difference in fracture efficacy between the
bisphosphonate (alendronate)and Ca+vit D in patients with osteopenia on BMD
(a large group in the WHI study).
I can fully appreciate the concerns that the recent studies have raised
regarding thrombotic events, myocardial infarction and breast cancer but
the outright condemnation of all forms of long term HRT seems misplaced.
The MI and vascular events in WHI were mainly in the early years of the
study suggesting a subset of women exist who are sensitive to these
effects, overall mortality was not significantly different between the two
groups so does HRT actually have a cardiovascular benefit in a subset of
women?
There is a lot more that could be discussed and although I was never a
major advocate for HRT I am surprised by the current reaction. The recent
data should have helped to promote a better understanding about HRT and
define those who would benefit from such treatment and those who should
avoid this treatment. Alas I very much doubt if Ethics Committees will be
prepared to condone any future research into the value of HRT.
Bill Fraser
--On 04 December 2003 15:23 +0000 "Iversen, Andrew (Dr.)"
<[log in to unmask]> wrote:
> Is everyone convinced that HRT is such a bad thing? Admittedly the
> short-term prothrombotic effect in patients with CHD is adverse, but the
> curves in HERS do tend to converge after a few years. Gallstones are a
> nuisance. The million women study was not randomised and I'd be surprised
> if HRT can cause cancer so quickly (i.e. was it there before in a denser
> breast). The lipid results are still appealing, and the QALY score for
> some (non-CHD) patients might be quite good. Are the alternatives for
> osteoporosis as palatable and effective? Or are we now against HRT?
>
> Andrew
> -----Original Message-----
> From: Mainwaring-Burton Richard (RGZ)
> [mailto:[log in to unmask]]
> Sent: 04 December 2003 11:17
> To: [log in to unmask]
> Subject: Re: CMO Advice on HRT in the over 50s with osteoporosis
>
> It is a bit like the reccomendation "Employ a teenager NOW while he still
> knows everything"
>
> with best wishes
>
> Richard
>
> Richard Mainwaring-Burton
> Consultant Biochemist
> Queen Mary's Hospital
> Sidcup, Kent
> DA14 6LT
> 020-8308-3084
>
>
> -----Original Message-----
> From: ablumsohn [mailto:[log in to unmask]]
> Sent: 04 December 2003 08:27
> To: [log in to unmask]
> Subject: Re: CMO Advice on HRT in the over 50s with osteoporosis
>
>
> As they say:
>
> "Use a new drug while it's still effective"
>
> Aubrey
>
>
> GMA> This document became available at 15:00
> GMA> today relating to the use of HRT in women over 50
> GMA> years old.
>
> GMA> Malcolm Gray
>
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Professor W D Fraser
Department of Clinical Chemistry
The University of Liverpool
4th Floor, Duncan Building
Daulby Street
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L69 3GA
Tel: 0151 706 4247/4257
Fax: 0151 706 5813
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