Collins_edit.qxp 2/1/09 02:57 Page 58
Menopause
estrogen–progestogen trial reported a modest significant increase in risk preparations, with use of lower dosages, or with different routes of
for any stroke (relative rate 1.31, 95% CI 1.08–1.68).
22
In the combined administration.
39
Relative risks of less than two-fold are classified as
WHI analysis of both hormone trials, the number of strokes due to moderate breast cancer risk factors. Other risk factors in this range include
hormone use over and above the number that would be experienced by alcohol consumption, obesity, and nulliparity.
40
non-users was 9.3 cases (95% CI 3.4–15.13).
22
Endometrial Cancer
Venous Thromboembolism The incidence of endometrial cancer in post-menopausal women is less than
Venous thromboembolism is a term that includes thrombophlebitis in deep one case per 1,000 women per year.
12
Epidemiological studies since 1975
veins and pulmonary embolism. The incidence among post-menopausal have consistently shown that unopposed estrogen use in women with a
women is about one per 1,000 women per year.
12,13
Data from uterus increases the risk for endometrial cancer by approximately 2.8-fold
epidemiological studies and RCTs consistently demonstrate an increased risk (95% CI 2.6–3) compared with those who have never taken estrogen.
41
for thromboembolism associated with post-menopausal hormone use.
32,33
Combining estrogen with progestogen appears to minimize the effect of
The increased risk declines from approximately four-fold in the first year unopposed estrogen on endometrial cancer risk.
42
In the WHI
of use to less than two-fold after the third year of use.
32,33
The estrogen–progestogen trial, the risk was similar to that seen in the placebo
WHI studies confirmed the venous thromboembolism risk estimates group (relative rate 0.83, 95% CI 0.29–2.32).
12
from the epidemiological studies. In the estrogen-alone trial, the risk increase
was not significant (relative rate 1.32, 95% CI 0.99–1.75), and it was highest Epithelial Ovarian Cancer
in the first two years.
32
There were two more cases of venous thrombosis per Invasive ovarian cancer incidence in post-menopausal women is
1,000 women per year in the estrogen group than in the placebo group. The approximately 0.3 cases per 1,000 women per year.
9,43
The use of hormones
WHI estrogen–progestogen trial reported a two-fold increase in venous during the menopause has been associated with higher ovarian cancer
thromboembolism risk (relative rate 2.11, 95% CI 1.26–3.55).
12
incidence, but social class is a predisposing factor for ovarian cancer and
women in the highest social classes are most able to pay for hormones.
44
Breast Cancer Combined data from five epidemiological studies involving 2,501 women
Breast cancer incidence in post-menopausal women is approximately three showed that the ovarian cancer risk was 1.28-fold higher (95% CI
cases per 1,000 women per year.
12
An association between breast cancer 1.05–1.56) for hormone users compared with non-users.
45
In the WHI trial
and hormone use is plausible because breast cancer incidence is increased of estrogen–progestogen the ovarian cancer risk was not significantly
by hormonal factors such as early menarche and late menopause.
34
The increased (relative rate 1.58, 95% CI 0.77–3.24).
9
combined results of 51 epidemiological studies showed that breast cancer
risk increased by 2.3% per year of hormone use. This was similar to the Conclusions
increased risk of 2.8% per year of natural delay in the onset of the Hot flashes occur in over 50% of women entering the menopause and their
menopause.
35
Data from four RCTs involving 12,643 women indicate that frequency declines to 30% after three years. Estrogen with or without
the use of estrogen alone may not affect breast cancer risk.
25,36–38
The progestogen is the most effective treatment for hot flashes and for
average risk for invasive breast cancer in the trials was 0.81 (95% CI symptoms due to vulvar and vaginal atrophy. The average patient is a woman
0.63–1.03).
39
In a further four randomized trials involving 19,756 women aged between 45 and 60 years who takes hormones for less than three
who used estrogen–progestogen, the average breast cancer risk was 1.24 years. Long-term hormone use is not indicated to prevent CHD, hip fractures,
(95% CI 1.03–1.50).
39
In 19 recent epidemiological studies, the hormone- or senile dementia. The impact of side effects can be diminished by
associated breast cancer risk diminished soon after discontinuing appropriate counseling. Venous thromboembolism may occur during the first
hormones, and normalized within five years.
39
Breast cancer risk does not year of treatment, but adverse effects on cancer and stroke incidence are
vary significantly with different types of estrogen or progestogen mainly associated with using hormones for more than three years. ■
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58 US OBSTETRICS & GYNECOLOGY
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