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'No need to panic'
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R. KRITHIKA speaks to some doctors about the current debate over hormone replacement therapy. The bottom line remains that women should consult their doctor and weigh pros and cons before deciding on treatment.
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"I AM a great believer in a good quality of life and if anything that I do today can make it easier for me in my old age, I am all for it," states Dr. Duru Shah, a Mumbai-based gynaecologist as emphatically as one can over the faceless, voiceless e-mail. Given the current debate over the use of Hormone Replacement Therapy (HRT), doctors in India seem to be quite calm about something that has scared many women all over the world.
HRT was a godsend to those suffering from the terrors of menopause. Not only did it help deal with menopausal symptoms; it was also said to reduce risk of osteoporosis and cardiovascular diseases. And to those who worried about growing old; it helped reduce signs of ageing. But as the therapy came under scrutiny, signs emerged that all was not well. There were side effects but more frightening were reports of increased risk of breast cancer and, in the light of the Heart and Estrogen Replacement Study (HERS) trial, of cardiac events in patients known to have cardiac problems.
And now comes the clincher. The Women's Health Initiative (WHI) in the United States stopped its study of the HRT early because it found that the therapy's risks outweighed the benefits. Said Jacques Rossouw, M.D., acting director of the WHI-National Heart, Lung and Blood Institute Communications office, "These findings are the first confirmation from a rigorous clinical trial that taking estrogen plus progestin increases the risk of breast cancer ... The findings also show a 22 per cent increase in total cardiovascular disease ... For heart attack, the risk began to increase in the first year of ... use."
But short-term use of HRT to manage peri-menopausal symptoms is likely to continue, say doctors. "There is no need to panic," says Dr. Usha Sriram, a Chennai-based endocrinologist and physician. "The best option is to go back to the physician who prescribed it." Already the media glare has led to much concern. Dr. Jaya Narendra, a gynaecologist from Bangalore, says that there are many questions from patients on HRT and worries that others may have stopped treatment on their own. The emphasis should be that HRT is not dangerous in the short-term and that risks to individual patients are small, provided each case is individualised and appropriate pre-screening, counselling, and follow up is done, says Dr. Radha Reddy, an endocrinologist in Bangalore. "Many women ... are stopping all HRT regimen and other treatments because some are not sure if they are on HRT or not. This is a difficult period for us, because as specialists, it took many years to convince our primary care providers about benefits of HRT and to advocate it to their patients Now, it gives them a chance to say `I told you so'."
Dr. Lakshmi Seshadri, from the Christian Medical College, Vellore, feels that the WHI report has received too much publicity. "The patient selection, the inclusion criteria and the statistical analysis leave a lot to be desired. Sixty three per cent of women are above 60 years; we do not prescribe HRT for such women. Several have taken HRT for five to 10 years in the past."
Dr. Uma Ram, a gynaecologist and obstetrician in Chennai, says that while the study confirms increased risk of breast cancer and cardiovascular problems in otherwise healthy women, the absolute number of adverse outcomes was eight more breast cancers per 10,000 and seven more cardiovascular events and eight more strokes per 10,000.
Doctors have always been concerned about the risk of breast cancer, she says. But, so far, the general opinion was that the benefits outweighed the risks. Many have prescribed long-term HRT for prevention of osteoporosis in older women, but not for those with underlying cardiac problems.
Quizzed on the anti-ageing properties of HRT, Radha Reddy says that "Anti ageing is not a priority in majority of our population ... HRT was used to improve `quality of life' by `prevention of age related disorders,' a concept not appreciated by many of our women ... " Others feel that this will not be as big an issue in India as in the West because those who use HRT for such purposes are in a minority. The study has come at a crucial time. Now counselling on non-pharmacological and non-hormonal measures is possible. "It was never an across the board prescription," says Uma Ram. Usha Krishna, a gynaecologist from Mumbai, agrees that the treatment has to be individualised and well monitored, as does Usha Sriram. "It is a careful use prescription, not as a feel good pill," she says.
A real cause of worry for doctors is the possibility of prescription misuse, which is rampant in India. HRT is not very expensive; Uma Ram pegs it at around Rs. 300 a month. So the spectre of prescriptions being misused is frighteningly real. According to Duru Shah, apart from this, some have been prescribing HRT without full knowledge of its contraindications or dosage.
Both Jaya Narendra and Duru Shah strike a cautionary note. The current WHI data refers only to the estrogen plus progestin trial. They advise waiting for results from other arm, i.e. use of estrogen only in women who do not have a uterus, before doing away with HRT.
What, then, does all this imply? One, HRT should not be prescribed to prevent heart disease. Other methods are available like lifestyle changes and drugs. Two, in the case of osteoporosis prevention, women should consult their doctor and weigh the benefits against personal risks for cardiac problems and breast cancer. Also, there are other measures to help. Three, women should continue their regular schedule of mammograms and breast self-examinations. Last, those using HRT for relief from menopausal symptoms may reap more benefits than risks. The bottom line is talk to your doctor and learn about the pros and cons before deciding.
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