Revised post-WHI hrt use guidelines gradually getting wider press

We've spoken elsewhere about the more realistic stance that hrt use guidelines have taken as the initial Women's Health Initiative Study cancellation panic has waned and the data is more responsibly re-examined. The North American Menopause Society, the International Menopause Society (both of these are medical groups of significant professional standing) and the American Association of Clinical Endocrinologists (free signup required to read) have all in recent years published revised consensus documents that emphasize that a balanced, patient-centric view that includes quality of life issues must be taken of hrt use.

But those guidelines have been easy to miss unless a doctor is already following the issue. Now, however, the major medical journal in the field, Obstetrics & Gynecology (the journal of The American College of Obstetricians and Gynecologists), has published a clinical review. Sadly, the article, in the April issue, is behind a paywall. A medscape news summary is available, however, and only requires a free signup to read.

There isn't breaking news here: what they say is pretty much covering the same things that the other specialty groups have already stated: there are benefits that rival (or in the case of younger women, outweigh) the risks of using hrt. There are a couple gaps where they miss some elements of interest to many of our readers, notably any mention that route-related effects play into their "risk of causing cardiovascular disease" or any mention of the whole range of SSRIs as alternative symptom-relieving drugs. Since SSRIs are the firstline alternative in oncology, this only goes to show how very insular the medical specialties are. And of course there is not a word about surgical meno (*sigh*). While "smallest amount/shortest time" as a metric seems sort of silly for us, remember: it is actually just the same as saying "as much as we need (but no more) for as long as we need it." This will of course be different in length for us than for women in natural perimenopause, but we can still use this concept to support meeting our needs.

One thing we found interesting and perhaps of use to those of you who are still struggling to have your doctors accept that symptoms other than hot flashes are indeed hormone-related is this statement that talks about the effects of menopause:
Major health concerns of menopausal women include vasomotor symptoms, urogenital atrophy, osteoporosis, cardiovascular disease, cancer, cognition, and mood...


Okay, so if the content isn't new, what's so exciting here?


What is novel in this version is that just about every medical professional in this field subscribes to this journal. That doesn't mean they read it, but it's a professional credential so they do make an effort to at least scan the table of contents while sitting on the...ahem...in their library. And so this puts the topic back in front of them in a way that hasn't happened since WHI made headlines on CNN. The fact that their professional journal changed its mind makes it supportable that they might, just might, consider at least reading the newer guidelines. And it means that when we cite this journal back to them, they have a harder time claiming we're just bringing them garbage off the internet and blahblahblahdismiss.

Or maybe your doctor is reading the New York Times


It's rare for a helpful and unalarming topic to get much media coverage since media is a business of selling, not informing or educating. While the WHI cancellation and subsequent anti-hrt backlash got plenty of Great Big Scary Headlines, nobody much has paid attention to the reappraisals and gradual resumption of hrt by many women who just couldn't live a life of hormone deprivation.

But the Times Magazine is known for more in-depth treatments of less dramatic topics, and this past week looked at The Estrogen Dilemma from the standpoint of the women trying to cope with the effects of hormone disruption. While the piece ultimately focuses on the scientific efforts in the field, it is frank about how hormonal fluctuation disrupts the brain and how hrt can alleviate those effects to a marked extent.

It also goes into the so-called "timing effect," something at the heart of many of the WHI results. According to this premise, maintaining adequate hormone levels protects from a number of the negative impacts of menopause. That this kind of early hrt conveys a level of wellness that is not seen in research using hrt to treat existing illness is at the crux of research design and interpretation following on the WHI, and is foreshadowed by things like the startling increase in all-causes mortality (another article, free signup required to read) seen in women of younger age following oophorectomy without hormonal resupply.

This isn't an article to carry in to your doctor in support of convincing him to change his opinion. Things in the popular press are routinely brushed off as not representing scientific accuracy. Still, your doctor may stumble across it on his own, and when it's his own choice to read it, he'll be more open to what it contains.

Beyond that, though, this article stands as another element in a growing trend that he may well notice: gradual rehabilitation of hrt in general. The more times he reads about it, even in the deprecated popular press, the more likely he is to begin internalizing that attitude just the way all that pop coverage of WHI poisoned all notion of hrt.

So, no revolution here. But little step by little step, rationality is slowly creeping back into the foundations of menopausal medical practice. Fewer doctors have grounds to offhandedly dismiss women's requests for hrts. And that can only be a good thing.