July 31, 2013
Rejection of Estrogen Therapy Linked to Thousands of Unnecessary Deaths in Last Decade

New Haven, CT—Thousands of women may have died unnecessarily in the last decade because of the widespread rejection of estrogen therapy, even for those aged 50 to 69 who have had a hysterectomy, according to a new study.

For the analysis, published in the American Journal of Public Health, Yale School of Medicine researchers analyzed United States census data, hysterectomy rates, and estimates of decline in hormone use in women aged 50 to 59 between 2002 and 2011.

They found that over a 10-year period starting in 2002, as few as 18,601 or as many as 91,610 postmenopausal women died prematurely because of the avoidance of estrogen therapy (ET).

Before 2002, when the influential Women’s Health Initiative (WHI) study on hormone replacement was released, physicians routinely prescribed estrogen therapy for older women who had hysterectomies. In fact, more than 90% of those women supplemented with estrogen to treat symptoms such as hot flashes, and to prevent osteoporosis and other diseases related to menopausal hormone deficiency, according to the study. Now, estrogen is used in only about 10% of women in that category.

The WHI study created widespread fear about the dangers of postmenopausal hormones, but the authors of the Yale study suggest some of those concerns were misplaced. That study concerned women with a uterus, who took pills that combined estrogen and a progestin, they point out, and not women with no uterus who use estrogen-only therapy.

“Sadly, the media, women, and health care providers did not appreciate the difference between the two kinds of hormone therapy,” said lead author Philip Sarrel, MD, emeritus professor in the Departments of Obstetrics, Gynecology & Reproductive Sciences, and Psychiatry. “As a result, the use of all forms of FDA-approved menopausal hormone therapy declined precipitously.”

Sarrel noted that avoiding combined hormone therapy, or at least Prempro, the conjugated estrogens/medroxyprogesterone acetate compound used in the study, may have been a good decision because of the documented increases in breast cancer, heart disease, stroke, and blood clots compared to placebo. For women taking estrogen-only therapy, however, avoiding treatment does not appear to have been a good decision, he argued.

A second part of the WHI study followed women who had no uterus and who took either estrogen-only pills or placebo and had very different results from the part that was highly publicized. The Yale study notes that, in a series of papers published by the WHI between 2004 and 2012, those using estrogen-only therapy had mostly positive health outcomes. In 2011 and 2012, for example, the WHI reported that women who received estrogen compared to those who received placebo had fewer deaths each year for 10 years and were less likely to develop breast cancer and heart disease. On the other hand, over a 10-year period among those not taking estrogen, 13 additional women per 10,000 died, mostly from heart disease, with breast cancer accounting for almost all of the other deaths.

“Estrogen avoidance has resulted in a real cost in women’s lives every year for the last 10 years—and the deaths continue,” Sarrel said. “We hope this article will stir an overdue debate and raise consciousness about the health benefits of estrogen-only therapy for women in their 50s with no uterus.”

Estrogen therapy “in younger postmenopausal women is associated with a decisive reduction in all-cause mortality, but estrogen use in this population is low and continuing to fall,” according to the authors. “Our data indicate an associated annual mortality toll in the thousands of women aged 50 to 59 years. Informed discussion between these women and their health care providers about the effects of ET is a matter of considerable urgency.”

U.S. Pharmacist Social Connect