General - risks, definition | Which OHT? | Deciding on it | Getting off it | "Natural" hormones | Long term considerations |
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
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." http://www.obgyn.net/english/pubs/features/tfp/kaunitz-2_tfp.htm
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.
The extract below is an extract
from a longer file which used to reside at
How
to Use a Clinical Practice Guideline
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
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.
http://www.acponline.org/journals/annals/06apr99/hrtedit.htm
"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?"
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General - risks, definition | Which OHT? | Deciding on it | Getting off it | "Natural" hormones | Long term considerations |