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Old 10-18-2011
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Drug Indications of Hormonal Replacement Therapy?

A 53-year-old woman comes to your office for advice regarding hormone replacement therapy (HRT). She had her last menstrual period 1 year ago and since that time has had intermittent hot flashes that disturb her sleep. She has occasional migraine headaches and no other health problems. She had a left oophorectomy for ovarian torsion at the age of 29 and has had no other surgeries. She takes no medications and has no known drug allergies. She states that she has heard so much about HRT that she does not know what to think. She worries about breast cancer, heart attack, and stroke, but she has heard conflicting reports about the effect HRT can have on these diseases. She also worries about the hot flashes she is having. Which of the following is the proper counseling that should be given to this patient?

A. HRT can be used to prevent breast cancer
B. HRT can be used to prevent cardiac disease
C. HRT can be used to prevent stroke
D. HRT can be used to treat cardiac disease
E. HRT can be used to treat hot flashes
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Old 10-19-2011
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Correct Answer Answer

The correct answer is E. Hormone replacement therapy (HRT) refers to the use of estrogen and progestin in postmenopausal women. For many years it was thought that HRT had numerous health benefits for postmenopausal women, based on observational studies. However, recently performed prospective, randomized-controlled trials have shown that HRT is associated with increased morbidity and mortality from some conditions. Most notably, the Women’s Health Initiative (WHI) Study demonstrated that HRT was associated with increased rates of breast cancer, heart attack, stroke, and venous thrombosis. This finding led the United States Food and Drug Administration (FDA) to require a “black-box” warning to be placed on all estrogen-containing products for menopausal women. All estrogen-containing products for postmenopausal women must now carry a black box warning, which is the strongest type of warning on a drug label. The black box for estrogen-containing products states that they should not be used for the prevention of heart disease. Estrogen is indicated for the treatment of hot flashes, such as this patient has, but the risks and benefits must be weighed by the physician and patient.
Counseling this patient that HRT can be used to prevent breast cancer (choice A) would not be correct. HRT has now been shown to increase rates of breast cancer. While there is still some controversy on this topic, it would not be advisable to recommend that HRT be used to prevent breast cancer.
Advising this patient that HRT can be used to prevent cardiac disease (choice B) is not correct. As stated earlier, on the basis of prior observational studies it was previously thought that HRT would help to prevent cardiac disease. Given the result of the randomized-controlled trials, however, this no longer appears to be the case.
Telling this patient that HRT can be used to prevent stroke (choice C) would not be correct. In randomized-controlled trials, women taking HRT were found to have increased rates of stroke.
Stating that HRT can be used to treat cardiac disease (choice D) is not correct. The evidence from available trials suggests that in women with preexisting cardiac disease, HRT causes increased morbidity and mortality from cardiac disease.
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