Invited papers: individualizing therapy

It is now nearly four years since the publication of the original Women’s Health Initiative (WHI) trials and the huge amount of data continue to be analysed and published. The most recent publications indicate that there was actually a significant reduction in the number of breast cancers observed in estrogen-only users compared with placebo. At worst this implies that estrogen-only hormone therapy (HT) does not increase breast cancer risk and at best it suggests it may actually be protective. This is potentially excellent news for menopausal women, particularly those who have been hysterectomized. Yet, where are the media reports to get this message across to the public? Where are the reassuring statements from the regulatory authorities? At the time of going to press these latest reports have largely gone unnoticed and unreported. One of the key driving forces for the WHI trial was to identify whether or not there was a case for estrogen being ‘cardioprotective’. The initial results and accompanying headlines indicated that it was not and indeed suggested that estrogens may even be disadvantageous. Unfortunately, the media, many medical societies and the regulatory authorities all over the world subsequently took the message from the study that estrogens were not good for cardiovascular disease risk and extrapolated it to all age groups, even though the increase in adverse events was largely confined to the over70s. Reanalyses of the data now indicate an actual reduction in cardiovascular events in the younger age groups (50–59 years), the ages when most women are likely to consider HT. This is further supported by the latest Nurses’ Health Study publication showing a significant reduction in coronary heart disease in women who started HT around the time of menopause. Thus, it appears that estrogens started around the time of menopause may have a protective effect after all! Away from the WHI, the adverse publicity about HT has focused attention on non-hormonal treatments and their potential role in treating menopausal symptoms. Some alternative treatments have been the subject of appropriate scientific assessment, with varying results, but the debate about the role of alternative medicines in the management of the menopause continues.