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Hormone Therapy To Prevent Disease and Prolong Life in Postmenopausal Women
- Deborah Grady, MD, MPH;
- Susan M. Rubin, MPH;
- Diana B. Petitti, MD, MPH;
- Cary S. Fox, MS;
- Dennis Black, PhD;
- Bruce Ettinger, MD;
- Virginia L. Ernster, PhD; and
- Steven R. Cummings, MD
Abstract
▪ Purpose: To critically review the risks and benefits of hormone therapy for asymptomatic postmenopausal women who are considering long-term hormone therapy to prevent disease or to prolong life.
▪ Data Sources: Review of the English-language literature since 1970 on the effect of estrogen therapy and estrogen plus progestin therapy on endometrial cancer, breast cancer, coronary heart disease, osteoporosis, and stroke. We used standard meta-analytic statistical methods to pool estimates from studies to determine summary relative risks for these diseases in hormone users and modified lifetable methods to estimate changes in lifetime probability and life expectancy due to use of hormone regimens.
▪ Results: There is evidence that estrogen therapy decreases risk for coronary heart disease and for hip fracture, but long-term estrogen therapy increases risk for endometrial cancer and may be associated with a small increase in risk for breast cancer. The increase in endometrial cancer risk can probably be avoided by adding a progestin to the estrogen regimen for women who have a uterus, but the effects of combination hormones on risk for other diseases has not been adequately studied.
We present estimates for changes in lifethne probabilities of disease and life expectancy due to hormone therapy in women who have had a hysterectomy; with coronary heart disease; and at increased risk for coronary heart disease, hip fracture, and breast cancer.
▪ Conclusions: Hormone therapy should probably be recommended for women who have had a hysterectomy and for those with coronary heart disease or at high risk for coronary heart disease. For other women, the best course of action is unclear.
[Note that sections in this review are numbered so that they can be identified with cross-references as supporting evidence for the Clinical Guideline, (Guidelines for Counseling Postmenopausal Women about Preventive Hormone Therapy), which also appears in this issue of Annals; see pages 1038-1041—The Editors]
Article and Author Information
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From the University of California, San Francisco; San Francisco Department of Veterans Affairs Medical Center; and the San Francisco Kaiser Permanente Medical Center, San Francisco, California. For current author addresses and affiliations, see end of text.
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This paper was commissioned by the Clinical Efficacy Assessment Subcommittee. The authors, Deborah Grady, MD, and her colleagues submitted their first draft to CEAS for its review. A revised draft was then submitted to outside peer review to 18 reviewers, including internists, gynecologists, endocrinologists, geriatricians, cardiologists, oncologists, family physicians, and to their respective specialty societies. The manuscript was reviewed by Dr. Grady and her colleagues to address the comments of these reviewers and was resubmitted to CEAS. The final version was approved by the subcommittee, the Health and Public Policy Committee, and the Board of Regents, and submitted to the Annals of Internal Medicine for publication.
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Grant Support: In part, by a Merck/Society for Epidemiologic Research Clinical Epidemiology Fellowship Program (Dr. Grady) and the Henry J. Kaiser Family Foundation Faculty Fellowship in General Internal Medicine (Dr. Cummings).
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Requests for Reprints: Linda Johnson White, Director, Scientific Policy, American College of Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572.
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Current Author Addresses: Drs. Grady, Black, and Cummings, and Ms. Rubin, and Mr. Fox: University of California at San Francisco, Prevention Sciences Group, 74 New Montgomery, Suite 600, San Francisco, CA 94105.
Dr. Petitti: University of California at San Francisco, Box 0900, AC-9, San Francisco, CA 94143.
Dr. Ettinger: 2200 O'Farrell Street, San Francisco, CA 94115.
Dr. Ernster: Department of Epidemiology and Biostatistics, University of California at San Francisco, Box 0560, San Francisco, CA 94143.
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