Hormone Therapy: Timing is Everything!

In building a house, if you don't use proper materials and end up with an unsafe structure, can you blame the local construction codes?  What if you don't put the parts of the house together in proper sequence.  Can you blame the construction materials?  Obviously, I've overblown this situation in order to develop an analogy for our current understanding regarding the use of hormone therapy in menopausal women.

First, we've used non-bio-identical hormones, such as medroxyprogesterone acetate which is sold as Provera, rather than bio-identical progesterone, commonly available as Prometrium.  When you study these two medications, you'll see that their physiologic effects are not at all similar.  And when you think of when we normally consider offering hormone therapy to women, it's when they're symptomatic at menopause, not 10 years later post-menopause.

And yet, this is exactly what we did in designing the Women's Health Initiative, using the wrong materials at the wrong time.  Not surprisingly, in retrospect, we found harm rather than the benefit typically demonstrated in observational studies of hormone therapy.  So we've been arguing among ourselves for the past 10+years.

Not that it will stop all the vehement discussions, a randomized study was published in the BMJ just 3 days ago in which 1,006 women were randomized to estradiol +/- norethisterone at the time of menopause for 10 years. Of course, everyone stopped their regimens when WHI was announced but the participants were followed for several more years thereafter.

The authors noted that starting estrogen within 7 months of going through menopause was associated with lower risk of death, heart failure & heart attack.  Even better, they found no increase risk of cancer, blood clots or stroke.

It would appear that timing is everything!

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