Menopausal hormone therapy in a health maintenance organization before and after women's health initiative hormone trials termination

The risk of stroke after bilateral salpingo-oophorectomy at hysterectomy for benign diseases: A nationwide cohort study

OBJECTIVE

To assess the risk of stroke (and subtypes of stroke) in women after elective bilateral salpingo-oophorectomy at hysterectomy for benign diseases.

STUDY DESIGN

We conducted a nationwide population-based, retrospective cohort study using claims data from Taiwan's National Health Insurance program between 1997 and 2013. Women aged 20 years or more who underwent bilateral salpingo-oophorectomy at hysterectomy for benign diseases (n = 1083) were compared with women who did not undergo bilateral salpingo-oophorectomy at hysterectomy for benign diseases (n = 3903). The follow-up period ranged from 10 to 16 years. Age-adjusted (or unadjusted) and multivariate Cox proportional hazards regression models were used to estimate the risk of stroke between the two groups.

MAIN OUTCOME MEASURES

A diagnosis of stroke (and subtypes of stroke).

RESULTS

We did not find a significant association between bilateral salpingo-oophorectomy and the risk of incident stroke (or subtypes of stroke) over an average follow-up of 13 years. Among women aged 50 years or more who used estrogen therapy, the risk of developing stroke was 64% lower in those who had undergone bilateral salpingo-oophorectomy (hazard ratio, 0.36; 95% confidence interval, 0.16-0.79) than in those who had undergone hysterectomy only.

CONCLUSION

This study suggests that the use of estrogen after bilateral salpingo-oophorectomy at hysterectomy for benign diseases reduces the risk of stroke in women aged 50 years or more.

Effect of prior oophorectomy on changes in bone mineral density and carotid artery intima-media thickness in postmenopausal women

OBJECTIVE

To determine the effect of prior oophorectomy in healthy postmenopausal women on the rate of loss of bone mineral density (BMD) and rate of increase in carotid artery intima-media thickness (CIMT).

DESIGN

Secondary analysis from a randomized controlled trial.

SETTING

University-based research clinic.

PATIENT(S)

Two hundred twenty-two healthy postmenopausal women in the Greater Los Angeles area.

INTERVENTION(S)

Baseline and annual screening of BMD and assessment of CIMT every 6 months for a total of 3 years.

MAIN OUTCOME MEASURE(S)

Changes in BMD and CIMT during postmenopausal years.

RESULT(S)

Among women who were menopausal for more than 10 years, the rate of CIMT progression was statistically significantly less in women with intact ovaries compared with those in women with prior oophorectomy. In women 5-10 years postmenopause, there was a trend toward a slower loss of BMD in those who retained their ovaries, and in women more than 10 years postmenopause there was significantly less BMD loss in those who retained their ovaries.

CONCLUSION(S)

As time from menopausal transition increases, retained ovaries are associated with a slower rate of bone loss and a slower rate of thickening of the carotid artery wall compared with rates in menopausal women with oophorectomy.

Postmenopausal hormone therapy initiation before and after the Women's Health Initiative in two French cohorts

OBJECTIVES

The aim of this study was to describe the evolution of hormone therapy (HT) initiation among newly postmenopausal women after the release of the first results from the Women's Health Initiative trial (July 2002).

METHODS

We used data from two French prospective cohorts, E3N and GAZEL. We identified 3,364 women with natural menopause onset occurring before 2002 and 1,880 women with menopause onset occurring after 2002.

RESULTS

After 2002, the age-standardized rate of HT initiation (no later than 1 y after menopause onset) in newly postmenopausal women fell by 69.9% (67.9% and 74.8% in the E3N and GAZEL cohorts, respectively). There were also changes in the distribution of both the route of administration of estrogen and the type of associated progestogen, which made transdermal estrogen plus progesterone the predominant HT type initiated after 2002 (43.6% of the initiated HT, 44.0% and 42.2% in the Étude Épidémiologique auprès de femmes de l'Éducation Nationale and GAZEL cohorts, respectively).

CONCLUSIONS

The evolution of HT initiation was similar in these two French cohorts, with a substantial drop in HT initiation rate accompanied by changes in the types of HT used.

Self-reported changes in providers' hormone therapy prescribing and counseling practices after the Women's Health Initiative

BACKGROUND

Prescribing and counseling practices in hormone therapy (HT) since publication of the Women's Health Initiative (WHI) trials have changed. Our objective was to compare changes by practice field and region.

METHODS

Between December 2005 and May 2006, we mailed surveys to 938 practitioners from two large integrated health systems in the Northeastern and Northwestern United States. We received 736 responses and excluded 144 who do not prescribe/counsel about HT, leaving 592. Data included prescriber characteristics, knowledge about HT trials, and self-reported HT counseling and prescribing changes. We compared provider characteristics and HT counseling and prescribing by region and practice field (obstetrician/gynecology [OB/GYN] or primary care).

RESULTS

Respondents included 79 OB/GYNs and 513 primary care providers. OB/GYNs were more likely, than primary care providers to consider themselves experts regarding the Heart and Estrogen/progestin Replacement Study (HERS) and WHI trials (30.4% vs. 8.2%, p < 0.001). The majority (87%) were cautious about HT use, especially primary care providers (p < 0.01 compared to OB/GYNs). Respondents reported prescribing less oral unopposed estrogen (64%) and combination estrogen/progestin (81%) post-WHI. OB/GYNs were less likely to report decreases in oral unopposed estrogen use (p = 0.006). Use of lower-dose and transdermal products (low-dose estrogen, vaginal estrogen, estradiol vaginal ring) increased, especially by OB/GYNs.

CONCLUSIONS

Our study highlights numerous HT prescribing and counseling differences between primary care and OB/GYN providers. Reasons for these differences are unknown but may be related to self-reported WHI/HERS knowledge. HT formulations used in the WHI trials are being replaced by low-dose and alternate formulations. Studies to support this practice are needed.

Effect of bilateral oophorectomy on women's long-term health

Bilateral oophorectomy at the time of hysterectomy for benign disease is commonly practiced in order to prevent the subsequent development of ovarian cancer or other ovarian pathology that might require additional surgery. At present, bilateral oophorectomy is performed in 78% of women aged between 45 and 64 years having a hysterectomy, and a total of approximately 300,000 prophylactic oophorectomies are performed in the USA every year. Estrogen deficiency resulting from pre- and post-menopausal oophorectomies has been associated with higher risks of coronary heart disease, stroke, hip fracture, Parkinsonism, dementia, cognitive impairment, depression and anxiety in many studies. While ovarian cancer accounts for 14,800 deaths per year in the USA, coronary heart disease accounts for 350,000 deaths per year. In addition, 100,000 cases of dementia may be attributable annually to prior bilateral oophorectomy. At present, observational studies suggest that bilateral oophorectomy may do more harm than good. In women who are not at high risk of developing ovarian or breast cancer, removing the ovaries at the time of hysterectomy should be approached with caution.

Bilateral oophorectomy versus ovarian conservation: effects on long-term women's health

Bilateral oophorectomy at the time of hysterectomy for benign disease is commonly practiced to prevent the subsequent development of ovarian cancer. Currently, bilateral oophorectomy is performed in 55% of all U.S. women having a hysterectomy, with approximately 300,000 prophylactic oophorectomies performed every year. Observational studies show that estrogen deficiency, resulting from premenopausal or postmenopausal oophorectomy, is associated with higher risks of coronary artery disease, stroke, hip fracture, Parkinsonism, dementia, cognitive impairment, depression, and anxiety. These studies suggest that bilateral oophorectomy may do more harm than good. In women not at high risk for development of ovarian or breast cancer, removing the ovaries at the time of hysterectomy should be approached with caution.

Changes of menopausal hormone therapy use pattern since 2000: results of the Berlin Spandau Longitudinal Health Study

BACKGROUND

There are virtually no prospective cohort studies in Germany regarding the changes of menopausal hormone therapy (HT) use pattern and factors associated with HT discontinuation after the release of the Women's Health Initiative (WHI) trial results.

METHODS

We assessed HT prevalence and use pattern as well as factors associated with HT discontinuation in a cohort of 903 women 40 years of age and older, who participated in two consecutive follow-up visits in a 20-year prospective health study from July 2000 to February and from August 2002 to December 2004.

RESULTS

Overall, the prevalence of HT users in the cohort declined significantly from 35.4% in 2000-2002 to 22.5% in 2002-2004. Adjusting for aging of the population, a statistically significant decrease in HT user prevalence was consistently observed across subgroups of HT users defined by type and duration of HT use. The decline was most pronounced with respect to women using combined estrogen-progestin regimens (-10.5%), higher-dose estrogens (-11.6%), oral preparations (-11.1%), as well as long-term HT users (-8.4%). The prevalence of women indicating HT use for climacteric symptoms decreased significantly (-12.4%), whereas the prevalence of women reporting use of HT for the prevention of osteoporosis increased (+1.8%) significantly. Irrespective of hysterectomy status, half of the women who continued HT changed their HT preparations and switched to lower estrogen doses (11.5%), topical estrogens (8.2%), or phytohormones (3.8%). We did not observe any significant differences between women who continued and discontinued HT regarding health-related characteristics of the study population as of 2000-2002. However, women seeing a gynecologist in the 12 months preceding the 2002-2004 visit were significantly less likely to discontinue HT use in bivariate and multivariate analyses.

CONCLUSIONS

Substantial declines in HT user prevalence as well as changes in HT use patterns to lower-dose estrogen preparations and non-oral routes of administration are likely to reflect effects of the publication of the WHI results. Consulting a gynecologist appeared to be relevant for a woman's decision to continue HT.

Managing menopausal symptoms after gynecological cancer

PURPOSE OF REVIEW

As the length of survival in patients with gynecological malignancies increases due to advances in early diagnosis and therapy, quality of life becomes a major issue for the survivors. These women frequently suffer symptoms following an iatrogenically induced menopause. Many gynecologists advise these patients against hormonal replacement therapy. This review attempts to provide the clinician with information based on current evidence.

RECENT FINDINGS

The most recent two prospective studies did not find an increase in the recurrence rates in endometrial cancer patients who used hormonal replacement therapy. To date, there are few studies on hormonal replacement therapy in patients with ovarian cancer but the available data suggest that there is no detriment to overall or disease-free survival. There are no data showing an association between poorer outcome and hormonal replacement therapy use in patients with cervical or vulvar cancers.

SUMMARY

There is no evidence showing hormones negatively influence survival after treatment for epithelial ovarian, squamous cervical or vulvar cancer. Their use can be considered in symptomatic patients with endometrial cancer, after weighing the benefits against the risk of recurrence. Gynecologic cancer survivors suffering from menopausal symptoms should be supported by advice about the alternatives to hormonal replacement therapy and by giving them nonbiased information on the present knowledge on the effects of hormonal use in women with a previous cancer. It is reasonable to prescribe hormonal replacement therapy to symptomatic, well informed patients.

Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses' health study

OBJECTIVE

To report long-term health outcomes and mortality after oophorectomy or ovarian conservation.

METHODS

We conducted a prospective, observational study of 29,380 women participants of the Nurses' Health Study who had a hysterectomy for benign disease; 16,345 (55.6%) had hysterectomy with bilateral oophorectomy, and 13,035 (44.4%) had hysterectomy with ovarian conservation. We evaluated incident events or death due to coronary heart disease (CHD), stroke, breast cancer, ovarian cancer, lung cancer, colorectal cancer, total cancers, hip fracture, pulmonary embolus, and death from all causes.

RESULTS

Over 24 years of follow-up, for women with hysterectomy and bilateral oophorectomy compared with ovarian conservation, the multivariable hazard ratios (HRs) were 1.12 (95% confidence interval [CI] 1.03-1.21) for total mortality, 1.17 (95% CI 1.02-1.35) for fatal plus nonfatal CHD, and 1.14 (95% CI 0.98-1.33) for stroke. Although the risks of breast (HR 0.75, 95% CI 0.68-0.84), ovarian (HR 0.04, 95% CI 0.01-0.09, number needed to treat=220), and total cancers (HR 0.90, 95% CI 0.84-0.96) decreased after oophorectomy, lung cancer incidence (HR=1.26, 95% CI 1.02-1.56, number needed to harm=190), and total cancer mortality (HR=1.17, 95% CI 1.04-1.32) increased. For those never having used estrogen therapy, bilateral oophorectomy before age 50 years was associated with an increased risk of all-cause mortality, CHD, and stroke. With an approximate 35-year life span after surgery, one additional death would be expected for every nine oophorectomies performed.

CONCLUSION

Compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer. In no analysis or age group was oophorectomy associated with increased survival.

Use of hormone replacement therapy, 1998-2007: sustained impact of the Women's Health Initiative findings

BACKGROUND

Trials of hormone replacement therapy (HRT) for prevention of chronic disease in postmenopausal women have suggested that the risks of treatment outweigh the benefits. The publication in 2002 of the Women's Health Initiative (WHI) study sparked a rapid decline in HRT purchases among American women.

OBJECTIVE

To examine the impact of the WHI findings on patterns of HRT use in Israeli women.

METHODS

We linked purchases of estrogen preparations from 1998 to 2007 by female Israeli health maintenance organization members aged 45 years and older to membership data. For each year, we calculated total annual purchases and rate of HRT utilization, characterized new users by age and mode of therapy, and examined rates of switching between modes of therapy.

RESULTS

Twenty percent of women aged 45 years and older purchased estrogen products in 2001, versus 10% in 2007 (p < 0.001; chi(2)). Vaginally administered products accounted for a rising percentage of purchases, from 5% in 1999 to 18% in 2007. An increasing percentage of new users aged 55 years and older started with a vaginal product (62% in 1999, 82% in 2007). After 2002, new users of oral therapy discontinued use more quickly than those who started oral therapy before 2002. Tibolone accounted for an increasing percentage of oral drugs purchased (12% in 2003, 29% in 2007).

CONCLUSIONS

The WHI findings had a rapid and sustained impact on HRT utilization in a large population of Israeli women, including a sharp decrease in the rate of use, particularly of oral preparations, as well as reduced duration of therapy and increased use of vaginal preparations and tibolone as first choices for treatment.

Hormone replacement therapy to maintain cognitive function in women with dementia

BACKGROUND

As estrogens have been shown to have several potentially beneficial effects on the central nervous system, it is biologically plausible that maintaining high levels of estrogens in postmenopausal women by means of estrogen replacement therapy (ERT) could be protective against cognitive decline in women with Alzheimer's disease (AD) or other dementia syndromes.

OBJECTIVES

To investigate the effects of ERT (estrogens only) or HRT (estrogens combined with a progestagen) compared with placebo in randomized controlled trials (RCTs) on cognitive function of postmenopausal women with dementia.

SEARCH STRATEGY

The Cochrane Dementia and Cognitive Improvement Group Specialized Register, which contains records from many medical databases, The Cochrane Library, EMBASE, MEDLINE, CINAHL, PsycINFO and LILACS were searched on 7 November 2007 using the terms ORT, PORT, ERT, HRT, estrogen*, oestrogen* and progesterone*.

SELECTION CRITERIA

All double-blind randomized controlled trials (RCTs) into the effect of ERT or HRT for cognitive function with a treatment period of at least two weeks in postmenopausal women with AD or other types of dementia.

DATA COLLECTION AND ANALYSIS

Abstracts of the references retrieved by the searches were read by two reviewers (EH and KY) independently in order to discard those that were clearly not eligible for inclusion. The two reviewers studied the full text of the remaining references and independently selected studies for inclusion. Any disparity in the ensuing lists was resolved by discussion with all reviewers in order to arrive at the final list of included studies. The selection criteria ensured that the blinding and randomization of the included studies was adequate. The two reviewers also assessed the quality of other aspects of the included trials. One reviewer (EH) extracted the data from the studies, but was aided and checked by JB from Cochrane.

MAIN RESULTS

A total of seven trials including 351 women with AD were analysed. Because different drugs were used at different studies it was not possible to combine more than two studies in any analysis.On a clinical global rating, clinicians scored patients taking CEE as significantly worse compared with the placebo group on the Clinical Dementia Rating scale after 12 months (overall WMD = 0.35, 95% CI = 0.01 to 0.69, z = 1.99, P < 0.05).Patients taking CEE had a worse performance on the delayed recall of the Paragraph Test (overall WMD = -0.45, 95% CI = -0.79 to -0.11, z = 2.60, P < 0.01) after one month than those taking placebo. They had a worse performance on Finger Tapping after 12 months (WMD = -3.90, 95% CI = -7.85 to 0.05, z = 1.93, P < 0.05).Limited positive effects were found for the lower dosage of CEE (0.625 mg/day) which showed a significant improvement in MMSE score only when assessed at two months, and disappeared after correction for multiple testing. No significant effects for MMSE were found at longer end points (3, 6 and 12 months of treatment). With a dosage of 1.25 mg/d CEE, short-term significant effects were found for Trial-Making test B at one month and Digit Span backward at four months. After two months of transdermal diestradiol (E2) treatment, a highly significant effect was observed for the word recall test (WMD = 6.50, 95% CI = 4.04 to 8.96, z = 5.19, P < 0.0001). No other significant effects were found for other outcomes measured.

AUTHORS' CONCLUSIONS

Currently, HRT or ERT for cognitive improvement or maintenance is not indicated for women with AD.