IMPORTANT NOTICE
This site was archived on December 31, 2002 (Why? click HERE)
It is not maintained and cannot be relied upon for up to date medical information.
Despite this, there is much useful information which is not time sensitive
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OVARIAN HORMONE THERAPY
General - risks, definition Which OHT?  Deciding on it  Getting off it  "Natural" hormones Long term considerations
Should I, shouldn't I?
Women talking
Advice to physicians
A summary of the May 2001 updated HRT Guidelines for New Zealand can be read at
http://www.medsafe.govt.nz/profs/PUarticles/HRTguideline.htm
item #1: HRT is not recommended for routine use in the menopause.
The full (and extremely long) 
Best Practice Evidence-Based Guideline to the Appropriate Prescribing of HRTmay be downloaded from http://www.nzgg.org.nz//library/gl_complete/gynae_hrt/

This document is a treasure trove of information and contains 400+ references to high quality studies.


Despite being the result of a grant from hormone-producing company (Solvay), a  June 2001 CME article breaks new ground by admitting that not all women need hormones, but doesn't go so far as to abandon the concept of estrogen "deficiency". It's overall theme is that one size doesn't fit all

http://www.medscape.com/Medscape/WomensHealth/ClinicalMgmt/CM.v02/public/index-CM.v02.html
Women's Health Clinical Management - Volume 2 Individualizing Hormone Therapy: Principles and Practice  CME
Prescribing Hormone Therapy

Although all menopausal women are estrogen deficient, not all menopausal women need hormone therapy. Appropriate clinical evaluation will identify symptomatic women who will indeed benefit from this therapy. However, it is the judicious use of selective tests that will determine the presence of asymptomatic risk factors or latent disease that would otherwise be missed. In addition to quantifying the presence and degree of a given abnormality, these tests, when repeated over time, will confirm the desired efficacy of the prescribed hormone therapy. This, in turn, will encourage long-term compliance. Often forgotten by patients -- and frequently by their physicians -- is this simple fact: Hormone therapy is beneficial as long as it is used; once stopped, the advantages of therapy are soon lost.


For an overview of the physicians role in counselling women about HRT see http://www.macmcm.com/pcp/pcp2000_06.htm
Successfully Individualizing HRT: Delivering Benefits and Minimizing Risks
Individualizing Treatment Options for Menopausal Women

     "The physician's role should be to facilitate the menopausal patient's wishes for symptom control and long-term disease prevention," said Nanette F. Santoro, MD, Pro-fessor and Director, Division of Reproductive Endocrinology, Albert Einstein College of Medicine, Bronx, NY. "Frequently, these discussions are best held sequentially, since a woman will often present first with symptoms, requesting relief, and secondarily with questions concerning the long-term safety and effectiveness of hormone replacement therapy (HRT) in disease prevention." 


How do doctors decide about OHT recommendations?
Note: Of the three URLs below, only the first is still freely available on line, but I have left the extracts from the others and the old URLs for reference.

http://www.obgyn.net/english/pubs/features/tfp/kaunitz-2_tfp.htm
Tailoring HRT to Your Patients: 
An Expert Roundtable Discussion on the Issue

      For anybody who has definitely decided to take hormones (after carefully researching the risks and benefits) I think the site will be of interest as it covers many of the problems that often occur. It is written from the viewpoint of how to get patients to "comply" and come what may, do as the doctors want - i.e. not only take hormones (or other drugs), but continue to do so. This is a viewpoint which offends me personally, as it implies that any woman who doesn't use HRT is a fool and cannot possibly be making a rational decision. Nevertheless it does address the issues of tailoring the dosage etc so that a woman will stay on the drugs thus ensuring a more tailor made prescription - something which has to be a Good Thing. 

      The content is far reaching and of general interest, addressing as it does the reasons why women *don't* take HRT (and what can be done to eliminate that reason), drugs other than hormones (Raloxifene etc) and the problems with FSH tests. For a woman who has made the decision, this should make her more aware of possible variations, one of which should fit *her* needs well.

      I was surprised by the uncritical acceptance of the "fact" of estrogen's cardioprotective function, especially as I looked at the creation date. The file was last updated in May of this year so I would have expected some reference to the HERS study which raised questions about the wiseness of starting its use in women with established heart disease. Maybe the "see editor's note" was supposed to deal with this - but I was unable to *find* the Editor's Note....[This was written in 1999 - in 2001 nothing has changed]

As I said before, I am recommending this NOT as an aid in the decision of whether to take HRT or not, as it is far too biassed in favour, but as additional info for somebody who has already made the decision to accept the risks.



Want to know what criteria your doctor is likely using when making recommendations about HRT (or anything else)? S/he is very likely following (at least in part) a clinical guideline. 

The extract below is an extract from a longer file which used to reside at 
http://hiru.mcmaster.ca/ebm/userguid/8_cpg.htm but which has lately gone missing. This forms the introduction to a lesson for physicians, and will alert you to the possible pitfalls of such guidelines. Be aware of these when a doctor tells you that such and so is the "regular" or "standard" procedure.

How to Use a Clinical Practice Guideline
Robert S.A. Hayward, Mark C. Wilson, Sean R. Tunis, Eric B. Bass, Gordon Guyatt for the
Evidence Based Medicine Working Group
      Clinicians serve patients by addressing each individual's health care needs. This includesrecognizing important health problems, considering sensible options for  managing each problem, interpreting evidence about the outcomes of each option, and ascertaining patient preferences for each outcome. Increasingly, clinicians  must also consider the resource implications of their decisions. This involves detecting, treating, palliating and preventing health problems in a way that maximizes  the public good achieved with available resources.To meet patients' expectations, individually and in aggregate, clinicians face intimidating tasks of information management. Overviews can help by systematically  gathering, selecting and combining evidence that links options to outcomes. Clinical decision analyses can help by refining questions and exploring the trade-offs  between competing benefits and harms. Economic analyses can help by tallying the costs associated with different options. While useful, these approaches do not always synthesize information in a way that directly supports specific clinical recommendations.

       Clinical practice guidelines, which have been defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances," represent an attempt to distill a large body of medical knowledge into a convenient, readily useable format. Like overviews, they gather, appraise and combine evidence. Guidelines, however, go beyond most overviews in attempting to address all the issues relevant to a clinical decision and all the values that might sway a clinical recommendation. Like decision analyses, guidelines refine clinical questions and balance trade-offs.  Guidelines differ from decision analyses in relying more on qualitative reasoning and in emphasizing a particular clinical context.

      Guidelines make explicit recommendations, often on behalf of health organizations, with a definite intent to influence what clinicians do. These suggestions about what should be done go beyond a simple presentation of evidence, costs, or decision models. They reflect value judgments about the relative importance of  various health and economic outcomes in specific clinical situations. As a result, they should be required to pass unique tests about how matters of opinion, in  addition to matters of science, are handled.

      When appraising a consultant's counsel, we are impressed if she states and explains her
suggestions clearly, discusses alternatives, and acknowledges possible biases and extenuating circumstances. We can use this common sense approach to assess the validity, importance and applicability of clinical practice guidelines.  In this article, we offer suggestions for deciding whether to use a clinical practice guideline in formulating one's own clinical policies (Table 1). Our focus is on evaluation of interventions, including prevention, diagnosis, and therapy, that are designed to improve important patient outcomes. For prevention and diagnosis, this involves looking beyond the accuracy of the test to the ultimate consequences of choosing a diagnostic strategy on patients' morbidity, mortality, and health-related quality of life.

      We use the same basic questions as the users' guides for original research articles, overviews, and decision analyses. Are the recommendations valid? If they are, what are the recommendations and will they be helpful in patient care? To answer these questions, we draw upon an emerging literature about practice guideline development and evaluation while emphasizing the perspective of practitioners who must adopt, adapt, or reject recommendations. Busy clinicians might hope that criteria for appraising practice guidelines would obviate the need for reviewing how the guideline developers have brought together the evidence, and how they have chosen the values reflected in their recommendations. Unfortunately, any shortcuts that bypass at least a cursory look at evidence and values will leave the clinician open to being misled by guidelines that may be based on a biased selection of evidence, a skewed interpretation of that evidence, or an idiosyncratic set of values. Shortcuts that do not highlight health conditions and interventions, patients and  practitioners, benefits and harms will leave the clinician open to misapplication of guidelines in clinical practice.



The editorial at the URL below is commentary on a survey in the same issue of the Annals of Internal Medicine which documented the use or nonuse of HRT by postmenopausal women. Finding a relatively small proportion of women were in fact doing so, the author compares this uncertainty to her own as she too approaches menopause. The extract below is a small part of the article which is a good description of what needs to be considered.

http://www.acponline.org/journals/annals/06apr99/hrtedit.htm
EDITORIALS
Medical Uncertainty and Practice Variation Get Personal:
What Should I Do about Hormone Replacement Therapy?
 Annals of Internal Medicine, 6 April 1999. 130:602-604.

"What should I do?" Now, in my late forties, I face the same decision. Should I embark on a course of HRT as I navigate through menopause? I am healthy and (so far) have not experienced the troublesome symptoms of menopause. I exercise with both strengthening and weight-bearing exercise almost as often as I should, and take calcium supplements in the correct doses as often as I remember. My mother had breast cancer at 51 years of age, suffered through a disfiguring but curative modified radical mastectomy, and died 5 years ago (at 75 years of age) of cardiac and cerebrovascular disease, much accelerated by her smoking. Three years ago I asked my gynecologist, a thoughtful man, what I should do. He gave me a surprisingly epidemiologic answer....snip

.... I asked my internist, also a superb physician, who replied that it was my decision. "Have you tried one of the HRT decision-making tools provided by your HMO?" he asked. Yes, but somehow it didn't help. ..... snip

.... To be honest, I have a hard time finishing a 10-day course of antibiotics for bronchitis, let alone 5 to 30 years of HRT. My friends and colleagues, even their spouses, want to discuss the merits and risks of HRT at work, at social gatherings, and in quiet, late-evening telephone calls. They ask, "What should I (she) do?" 
 

OVARIAN HORMONE THERAPY
General - risks, definition Which OHT?  Deciding on it  Getting off it  "Natural" hormones Long term considerations
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