Actualités sur la ménopause. Données de la médecine factuelle (« evidence based medecine »)

Following several recent epidemiological studies - including in particular the interventional study of the Women’s Health Initiative (WHI) - the risk-benefit balance of hormone replacement therapy (HRT), as well as its instructions for use and prescription procedures, has been reconsidered. Unlike previously published observational studies, the WHI underlines the absence of preventive effects in terms of cardiovascular disorders. Therefore, despite the awareness of the difference between the WHI studied population and molecules and the French population and steroids used in France, and since we lack equivalent European epidemiological work, we should no longer prescribe HRT for cardiovascular disease prevention. On the other hand, some data from the WHI study do agree with the results of previous observational studies: a slight increase in the risk of venous thrombo-embolism, at least with the use of orally-administered estrogens; a decreased risk of colon cancer with the use of estrogen-progestogens; a protective effect against the risk of osteoporotic fractures in all areas studied. However, the main problem presented by the recent studies concerns the risk of breast cancer: outside data sources support the slight increase in the risk of breast cancer observed during the WHI study with the use of estrogen-progestogens. Besides, the same study did not observe any increased risk with the use of estrogen alone, which constitutes a new datum requiring confirmation. As for the widely-publicised results of the MWS study, which led the European Medicines Agency (EMEA) to revise its position on HRT, these appear too erroneous to be accepted without caution. In terms of medical practice, it is henceforward recommended to prescribe HRT in the lowest possible effective dosage, and to continue treatment only as long as symptoms persist, with temporary suspensions to verify signs of estrogen deficiency. Finally, some recent studies seem to indicate a greater risk of breast cancer in patients undergoing combined continuous - as opposed to sequential - hormone treatment, but this essential difference deserves further study.