25,000 women taking part in a
federal study of hormone replacement therapy have been informed by
researchers that, far from protecting the heart as many researchers had
assumed, the therapy may have put the women at a slightly higher risk of
heart attacks and strokes.
The study, known as the
Hormone Replacement Therapy trial of the Women's Health Initiative, is the
first large-scale controlled clinical trial asking whether the therapy
prevents heart disease in healthy post-menopausal women.
But in letters sent out on
Friday, participants were told that those who had been randomly assigned
to take estrogen were having slightly more heart attacks, strokes and
blood clots in the lungs than those who had been assigned to take dummy
pills for comparison. While the effect was not sufficiently pronounced to
stop the study, the researchers themselves were taken aback.
An estimated 10 million
American women take Premarin, an estrogen that was approved only to
alleviate the symptoms of menopause, like hot flashes, and for the
prevention and management of osteoporosis.
The drug's maker, Wyeth-Ayerst
Laboratories, a subsidiary of the American Home Products Corporation, says
the estrogen is the best-selling prescription drug in America.
Doctors and individual women
say that one reason for estrogen's popularity is that there is a
widespread belief that it will prevent heart disease. But that hypothesis
came from indirect evidence.
Dr. Claude Lenfant, director
of the National Heart, Lung and Blood Institute, said in a statement on
Monday that the new information is "preliminary." It does not
address the larger issue of long-term benefits and risks of hormone
replacement therapy, he said, "and, therefore, it should not
influence current medical practice."
Previous studies have shown
that women who take estrogen after menopause have fewer heart attacks than
women who do not.
But since women who take the
hormone tend to be better educated, less likely to smoke and more likely
to eat balanced diets and exercise, it was hard for researchers to tell
whether the therapy or other factors in their lives contributed to their
lower risk. The only way to know for sure was to do a large study like the
current one.
Dr. Jacques E. Rossouw, who is
acting director of the hormone replacement trial, said in an interview
yesterday that even though it was too soon to say whether the increased
risk of heart attacks and strokes would hold up as the study continued, he
felt morally obliged to inform the women about the finding.
"This wasn't anticipated
when they enrolled," Dr. Rossouw said. "We told them all about
the risks and benefits but we didn't tell them there might be an increased
risk of heart disease."
He added that he fervently
hoped that the women would stay in the study and that other women would
not panic because the number of women who had had heart attacks and
strokes was minuscule.
"If my women friends ask
me, 'How does this affect me?', my advice is it doesn't change a
thing," Dr. Rossouw said. "I would say there never was proof
that hormones help heart disease and there still isn't. The only qualifier
is, if you're expecting an early benefit from heart disease it looks less
likely."
Investigators emphasize that
only a small number of women in the study actually had heart attacks,
strokes or blood clots in the lungs or the legs. The exact numbers were in
the hands of an independent committee that oversees the study, and its
members would not reveal them even to the study investigators. But
overall, only about 1 percent of all the women, who were 50 to 79, had
these problems in the first two years of the study. The effect seems to be
diminishing as the study continues, the researchers say. Yet apparently,
these grave medical problems were disproportionately concentrated in the
women taking hormones that were supposed to prevent them.
"This is the most widely
prescribed drug in America," said Cindy Pearson, the executive
director of the National Women's Health Network, an advocacy group in
Washington. "A lot of the women are taking it because they've been
told by their doctors that it will prevent a heart attack. Those are the
women who should be sitting up and taking notice and going to their
doctors and saying, 'Why am I taking this? What's the point of this?'
"
Ms. Pearson said that in her
opinion no woman should be taking estrogen to prevent heart disease
outside of a clinical trial asking if it has that effect.
Some heart disease researchers
said that they already were wary about estrogen because it can elicit
blood clots, which can cause heart attacks and strokes. Birth control
pills, which contain estrogen, may cause clots, and a recent study found
that women who already had heart attacks might not be protected from new
ones if they take estrogen.
The study, directed by Dr.
Stephen Hulley of the University of California at San Francisco, found
that in the first year, women taking estrogen actually had more heart
attacks and other manifestations of heart disease than those taking a
placebo. The effect diminished in subsequent years, and by the fifth year
the women taking estrogen did better than those taking the placebo. But
the study failed to show that overall, women who had had heart attacks
were helped by estrogen.
Another study, decades ago, in
which men took estrogen in the hope of preventing heart attacks, had to be
discontinued because the hormone was causing heart attacks instead.
Those who hoped estrogen might
benefit healthy women pointed to the studies showing that women who
happened to take estrogen had fewer heart attacks than those who happened
not to take it. They also noted that estrogen increased the amount of
beneficial cholesterol in the blood, the HDL fraction, while decreasing
the fraction of the harmful LDL cholesterol. But, Dr. Hulley noted, his
study of women who had had heart attacks indicated that those changes
could be misleading.
Yet, investigators said, the
Women's Health Initiative remains scientists' best hope of learning
whether estrogen replacement therapy is helpful or harmful to healthy
women.
"No one else is going to
do a study this big on hormone replacement therapy," said Dr. Marcia
Stefanick, a Stanford University professor who is chairwoman of the
study's steering committee. "If we don't answer the questions on
hormones, they're never going to be answered."
In the letters they received,
participants in the Women's Health Initiative were urged to stay in the
study. The study, they were told, "is more important than ever."
So far, said Dr. Rossouw, the women are reacting calmly.
In the meantime, said Dr.
Michael Criqui, an investigator in the study who is a professor of family
and preventive medicine at the University of California at San Diego,
"one cannot recommend to a woman to take estrogen to prevent heart
disease at this time." So far, he said, "there's no evidence
that it will."