On February 1st, the New York Times Magazine published an article describing some perimenopausal women’s struggles with menopause and the role of hormone therapy in relieving symptoms. The WHI hormone trials are cast in a rather unfavorable light in this article, mostly because the trial was not designed to address the concerns of perimenopausal women. The WHI Steering Committee has written a letter to the editor of the New York Times in response and a brief edited version of the response was published in today's print version of the New York Times. The full response letter can be found below:
Lost in Translation
To the Editor:
Susan Dominus' article entitled "Women have been misled about menopause" brings a personal perspective to the very real struggles some women experience with menopause.
Unfortunately, the article mischaracterizes critical aspects of a landmark large-scale national study that increased understanding of chronic disease risk and prevention in women. The mischaracterization of key insights from these randomized trials, which were part of the larger Women’s Health Initiative (WHI) program, could lead to harmful conclusions impacting women’s health.
The article focuses on using hormonal therapies to treat menopausal symptoms. When the WHI was launched in 1993, the effectiveness of estrogen-based therapies for relief of menopausal symptoms was already well-established. It continues to be FDA-approved and recommended by professional societies for this purpose. The objective of the WHI was never to test the use of menopausal hormone therapy for treating menopausal symptoms; its purpose was to focus on other unanswered questions.
The WHI menopausal hormone therapy trials were rigorously designed and conducted to test the benefits and risks of specific hormonal therapies for chronic diseases. They definitively established that menopausal hormone therapy should not be used to prevent heart disease, stroke, and other chronic diseases, an increasingly common practice at the time. The resulting worldwide decrease in their use in older women, often many years after menopause, undoubtedly has saved millions of lives and billions of U.S. health care dollars. Understandably, these raised questions for younger, peri-menopausal women, who were not the focus of the WHI hormone trials.
It is human nature to want to simplify concepts, and to categorize hormones as “good” or “bad.” This can lead to misunderstanding of the level of risk. The truth is much more nuanced.
The WHI provides some insights that are helpful to younger women. Firstly, it is imperative that women and their care providers distinguish between combined hormones (estrogen plus progesterone) for women who have not had a hysterectomy, and estrogen alone for women who have had a hysterectomy. The risks and benefits for major chronic diseases seen with combined hormone therapy use weighed heavily towards overall risk, including for breast cancer, with no significant trends by age. For estrogen used by itself among women who had had a hysterectomy, there were fewer adverse effects, a reduced risk of breast cancer, and a trend with age towards overall benefit for younger women. Secondly, for both women with and without a uterus, the absolute risks, i.e., the excess numbers of women who would experience adverse effects, rather than the percentage change, are much lower in younger women.
Therefore, we agree that the benefit of symptom relief may well outweigh any small risks in perimenopausal women. This is especially so for estrogen alone, but even for combined hormone therapy, the short-term risks are low. Of course, treatment decisions should consider a woman’s individual profile, such as severity of symptoms and presence of risk factors for heart disease, stroke, breast cancer, and bone fractures.
We wholeheartedly agree with a theme of the article that our society must stop discounting women’s health concerns and must invest in high-quality research to address them. The WHI investigators and many thousands of loyal participants in the study are part of that effort and will continue to offer valuable insights to women as they journey through life.
For the Women’s Health Initiative Steering Committee