Quite a number of clinical research reports (patient studies) have sprouted from the Nurses' Health Study. This study was initiated in 1976 when 121,700 female registered nurses of ages 30 to 55 years initially completed a questionnaire concerning their medical history. This included information on menopause7 cardiovascular disease, cancer and other important items. The follow up consisted of biennial questionnaires which were evaluated periodically. Thus, there is a very large cohort of women followed over a period of about 20 years. The different reports that have come out of it have involved analyses for the first 16 year period of time. A great deal of information was gleaned from these reports - who developed heats attacks, cancer, and mortality studies. The follow up on death studies was quite complete and more than 98% of those who died were studied with detailed medical information: For example, for all deaths death certificates were obtained and, when appropriate, information from next of kin was obtained and usually review of medical records was available. Over the years, heart attacks, strokes and other disorders have been evaluated from this study. For this study the question involved the value of hormonal therapy in women who have had menopause - be it a natural menopause or one following a surgical procedure (hysterectomy). This particular study evaluated the results of estrogen therapy after the menopause in terms of heart attacks, cancer and, particularly, mortality.
Those who continued to take hormone therapy (estrogen and estrogen/progesterone) had a definite reduction in all cause mortality This major reduction in mortality was mainly due to the reduced occurrence of coronary artery disease. There was a 37% decrease in the risk of death for hormone users as compared to those who had never used hormones. The major reduction in death was due to lowered mortality from coronary heart disease. After ten years of treatment there was an increased incidence of breast cancer of smaller magnitude.
The reduction in coronary heart disease was greatest in women who were positive for coronary risk; factors (smoking, high cholesterol levels, high blood pressure, diabetes, a parental history of premature heart attacks' and obesity). The decrease in deaths from all causes was mainly the result of the decreased deaths Born coronary heart disease. The authors also found that there was substantially less benefit among women who were at a low risk for coronary heart disease in the first place (that is, those having fewer or none of the coronary risk factors). There appeared to be no increased benefit after ten years of treatment and after ten years is when the incidence of breast cancers increased. However, the major reduction in all cause mortality was due to the fact that there was a great decrease in coronary heart disease death which far overshadowed the much smaller increase in breast cancer. The actual decrease in mortality due to heart disease was 53%. The authors' conclusion was that the survival benefits appeared to outweigh the risks but the risks and benefits vary depending upon existing risk factors in patients. This article is entitled, "Post Menopausal Hormone Therapy and Mortality," by F. Grodstein, et al, and was published in The New England Journal of Medicine, Vol. 336, No. 257 pp. 1769-1775 (June 19, 1997).
The companion editorial in the same issue commented that the "cumulative absolute risk of death from the ages 50 to 94 years has been estimated to be 31% from coronary heart disease, 2.8% from breast cancer, and 2.8% from hip fracture - thus the benefits from estrogen use appear to far outweigh the risks '' It also should be noted that estrogen therapy is of considerable value in preventing osteoporosis and thus there is, therefore, an added benefit as well. However, in such complex situations the patient should discuss the situation in detail with her own physician before important decisions are made. Once estrogen therapy is initiated it is continued for a long period of tune. In snaking such a decision, one must consider such factors as family history of cancer of the breast and. on the other hand. premature heats disease death in members of the family, coupled with the other risk factors mentioned above such as smoking, high blood pressure, diabetes, and high cholesterol. As a general proposition, it would appear that the risks are worth the gain, but certainly there is some increase in breast cancer if hormonal therapy has been used for ten years. A positive family history of breast cancer might well deter estrogen use. Further studies are in the offing and hopefully will shed more light on the situation of post-menopausal estrogen use.
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