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No Evidence For Routine Use Of HRT

No Evidence For Routine Use Of Hormone Replacement Therapy

A New Zealand guideline launched on 10 May shows that Hormone Replacement Therapy (HRT) is not recommended for routine use in postmenopausal women. Indeed, the guideline team reports that many women do not require or seek treatment at menopause or later in life.

The guideline updates and extends a consensus document developed in 1993. Studies since then have provided new evidence and there has been a trend towards using HRT for new indications. The guideline says that the new evidence does not appear to have bolstered arguments in favour of the benefits of HRT, while there is now greater clarity about risks.

The guideline team found that the main benefits of HRT were for women with troubling menopausal symptoms such as hot flushes and vaginal dryness and as prevention of fractures for women at high risk.

The guideline clarifies the risks of HRT. International and New Zealand evidence indicates that HRT should not be prescribed for women with coronary heart disease or a personal history of venous thromboembolism. These findings represent a significant change in previous advice to practitioners.

The team also found that there was little evidence to justify the use of HRT for conditions such as incontinence, depression, Alzheimer’s and memory loss, loss of libido, aches and pains and skin ageing.

Dr Helen Roberts, chair of the guideline team, said that “the team also found strong evidence of the effectiveness of HRT treatments for disruptive menopausal symptoms (hot flushes, vaginal atrophy and disturbed sleep), premature menopause and where women are at high risk of osteoporotic fracture.”

Helen, a Senior Lecturer of Women’s Health, University of Auckland and Research Manager of New Zealand Family Planning Association, said “it was a unique experience working with such a broad based multi-disciplinary guideline team. We had Maori and Pacific Island representatives, health professionals with an interest in specific conditions associated with the menopause, general practitioners, evidence based researchers, an epidemiologist, information specialist and consumer representative.”

The multi-disciplinary team worked together over a period of two years to evaluate the evidence for hormone-based treatments currently prescribed for some New Zealand women during the perimenopause and postmenopause, including pharmaceutical preparations, herbal preparations and dietary supplements. The guideline team’s objective was to provide an evidence based summary of the benefits, risks and contraindications to the use of unopposed estrogen therapy and combined estrogen-progestogen hormone replacement therapy (HRT) for the treatment and/or prevention of symptoms and conditions associated with the menopause, based on the best evidence currently available.

There is wide support for this guideline. It has received endorsement from the New Zealand Guidelines Group, the Royal College of General Practitioners, the Royal Australasian College of Obstetricians and Gynaecologists, The College of Nurses Aotearoa New Zealand, Women’s Health Action, the Family Planning Association, the Cardiac Society, the National Heart Foundation, the Australasian Menopause Society and Osteoporosis New Zealand.

Sandra Coney was the team’s consumer representative. Sandra said “I was very pleased to be involved in the collaboration of this guideline. We now have clear, up to date, evidence-based information that will help older women and their doctors find out more about their health options and the benefits, risks and uncertainties of HRT.”

The guideline is aimed at primary health care providers, women’s health information services and specialists. Plans for a special resource for women and their families are being developed for launch later this year.

Helen Roberts said that HRT usage has increased significantly in NZ during the last decade. PHARMAC data shows that subsidised hormone replacement units doubled from 1993 to 1999 (from 15,000,000 units to 31,700,000 units). They also found a significant increase in women being prescribed HRT between 1992 and 1999.

“We hope that this new evidence-based guideline will improve prescriber’s access to the latest international information on the risks and benefits of HRT in a helpful and useful way”, said Dr Roberts.

Summaries of the guideline as well as copies of the full guideline will be available from the New Zealand Guidelines Group from 10 May 2001 on their website NZGG is also planning a education programme aimed at getting the guideline messages to practitioners through seminars, videos and CME meetings.

“We are aware of the need to keep tabs on new evidence as it emerges. We are planning to review the guideline in the light of new research, at least every four or five years” said Helen Roberts. The updated guideline has been able to clarify some potential harms of HRT but there is still contradictory and inconsistent evidence in some areas. Two large international multi-centre trials are currently in progress. The WISDOM trial of 34,000 women will have follow-up for at least 10 years and results will be reported in 2010. The Women’s Health Initiative trial, including 161,000 women aged 50-79 will provide answers in 2005.


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