Table II-12-5. Critique of Women’s Health Initiative Study
Excludes patients with vasomotor symptoms
Primary indication for hormone replacement
Mean patient age was 63 years
Missed the 10-year “window of opportunity”
Same dose of hormone for all ages
Older women don’t need as a high dose as do younger women
Patients were not all healthy
Hypertension (40%), ↑ cholesterol (15%), diabetes mellitus (7%), myocardial infarction (3%)
• Benefits: Both HT and ET groups in WHI had decreased osteoporotic fractures andlower rates of colorectal cancer.
• Risks: Both HT and ET groups in WHI were found to have small increases in deepvein thrombosis (DVT). The HT group also had increased heart attacks and breast cancer, but these were not increased in the ET group.
Table II-12-6. WHI–Benefit and Risk (Mean Age of 63 Years)
| E + P | E Only | |
| Vaginal dryness | Benefit | Benefit |
| Hot flashes | Benefit | Benefit |
| Vasomotor symptoms | Benefit | Benefit |
| Osteoporosis | Benefit | Benefit |
| Breast cancer | Risk | No change |
| Heart disease | Risk | No change |
| Stroke | Risk | Risk |
Definition of abbreviations: E, estrogen; E + P, estrogen and progestin.
Contraindications. A personal history of an estrogen-sensitive cancer (breast or endometrium),active liver disease, active thrombosis, unexplained vaginal bleeding.
Modalities. Estrogen can be administered by oral, transdermal, vaginal, or parenteral routes.
All routes will yield the benefits described. Women without a uterus can be given continuous estrogen. All women with a uterus should also be given progestin therapy to prevent endometrial hyperplasia. The most common current regimen is oral estrogen and progestin given continuously.
Recommendations. The Global Consensus Statement on Menopausal Hormonal Therapy (MHT) by the International Menopause Society (2013) says the following:
Proven Benefits of MHT and Only Indicatlons For Use
• Vasomotor symptoms. MHT is the most effective treatment for vasomotor symptomsassociated with menopause at any age, but benefits are more likely to outweigh risks for symptomatic women age <60 or within 10 years after menopause.
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GYN Triad
Limitations of WHI
• Women with prominent vasomotor symptoms, the most common reason for initiating HT, were excluded from the study.
• The mean age of 63 is 10 years past the age that most women begin HT, thus missing the “window of opportunity” immediately after menopause.
• The same hormone dose was used in both older and younger women.
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• Vaginal dryness. Local low-dose estrogen therapy is preferred for women whosesymptoms are limited to vaginal dryness or associated discomfort with intercourse.
• Premature menopause. In women with premature ovarian insufficiency, systemicMHT is recommended at least until the average age of the natural menopause.
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