Women Misinterpret Health Benefits, Hazards Of Hormone Therapy

October 5, 2004

GAINESVILLE, Fla. — Menopausal women continue to overestimate the real risks and benefits of hormone replacement therapy — and so do their doctors, University of Florida researchers report in the American Journal of Obstetrics and Gynecology.

As a result, some women with debilitating hot flashes, night sweats and other symptoms who might be good candidates for the treatment go without, the scientists say.

The findings dovetail with renewed interest in who should take hormones and what the risks might be for those who do. The American College of Obstetricians and Gynecologists today released a guide aimed at helping women make educated decisions about whether to use hormones. Last week the group published recommendations for physicians after reviewing research studies published before and after the landmark Women’s Health Initiative results were released in 2002.

The current confusion stems from widespread news accounts detailing findings from that federally funded, large-scale study, which assessed the major health benefits and risks of the most commonly used hormone preparations. The study showed that estrogen plus progestin increased the risk of heart disease, stroke, breast cancer and blood clots in postmenopausal women who had used the combined therapy for about five years.

The bottom line: Many women whose menopausal symptoms are severe can indeed benefit from hormones, although those who take them should use the lowest effective dose for the shortest duration possible.

“Despite the really large amount of media attention given to the Women’s Health Initiative results, there is a huge amount of misunderstanding about what it actually said,” said Dr. R. Stan Williams, the Harry Prystowsky professor of reproductive medicine and associate chairman of obstetrics and gynecology at UF’s College of Medicine. “Our study essentially shows that women have a very poor understanding of what the real risk and benefits are of hormone replacement therapy, and so they dramatically overestimate both the risk and the benefits of hormones.”

UF researchers mailed a survey to 6,468 middle-aged Florida women that was designed to assess their opinions and understanding of hormone replacement therapy. Most of the 1,076 respondents were menopausal, and more than half had taken hormones, primarily for menopausal symptom relief. A third said they took it for other perceived benefits as well, including protection from heart disease, Alzheimer’s and osteoporosis. Of those who took hormones, most — 80 percent — had a positive view of the treatment, and only a third of respondents said they would not recommend the therapy to a friend.

Nonetheless, many women greatly overestimated the risks, with a third of those surveyed believing hormone replacement therapy hikes the risk of heart disease 10 percent to 30 percent per year. Furthermore, 81 percent of all respondents believed breast cancer risk increases for women on hormones, with slightly more than half believing the increase was as high as 10 percent to 30 percent per year.

Although the survey suggests the Women’s Health Initiative results did not affect attitudes about hormone replacement therapy in most women who were already taking it, the UF findings highlight the need to educate others who construed the magnitude of the risks associated with treatment to be much greater than they actually are, Williams said. The risk for developing heart disease, stroke or breast cancer, for example, actually increased minimally for every year hormone therapy was used.

The misconceptions stem from the fact that the media and even the original published findings from the WHI primarily focused on describing the results in terms of a percent increase or decrease in relative risk, a definition of risk used by scientists but not usually by the general public, he said.

More specifically, relative risk is the rate of occurrence of a disease or condition among those receiving a treatment divided by the rate among those not receiving it. The average woman, however, is interested only in her personal risk of developing a certain disease if she is taking hormones compared with her risk if she is not.

In the paper, UF researchers pointed out that some media reports cited a 24 percent increased relative risk of breast cancer per year in those who received hormone replacement therapy.

“The general public, not understanding the concept of relative risk, probably interpreted this statement as a 24 percent chance of developing breast cancer each year on HRT,” the UF authors wrote in their paper. “In the current survey, 53 percent of respondents thought that the increase in breast cancer in women on HRT was 10 percent to 30 percent per year, although the WHI attributable risk reported was 0.08 percent per year.”

In other words, in any given year, only about one additional case of breast cancer occurs among every 1,000 women receiving the treatment.

Patient and physician education will be key to conveying study results in a way that will help women make informed decisions about whether to take hormones, Williams said, adding that UF researchers recently completed a similar survey of community physicians and found that they, too, misconstrue the risks and benefits of the therapy. Those findings will be presented at a scientific meeting in January.

“Obviously, if women have a gross misunderstanding of what the risks and benefits are, they can’t make an informed decision,” he said. “They clearly really [want to] talk about absolute risk: What is your risk of having an event over and above the natural incidence of these events in people who are not on hormones. That’s their real risk.

“For each one of the risk categories, less than 0.1 percent per year are going to have an adverse event,” he added. “They have to weigh, ‘Are my severe hot flashes bad enough to warrant taking hormones?’ with that risk profile. The majority of women say clearly, ‘Yes, I’m willing to take that remote risk for alleviation of my menopausal symptoms.’ ”

In the same issue of the journal, Dr. Murray A. Freedman, an Augusta, Ga., physician, authored a discussion of the UF paper and reiterated the need to dispel common misconceptions about health risks of all kinds.

“Although the publication of the WHI has certainly contributed to the confusion, women have remained notoriously misinformed about their health risks for quite some time,” Freedman wrote. “Women have had the erroneous impression that breast cancer is a much more prevalent health hazard than cardiovascular disease and that breast cancer mortality exceeds that of all other cancers combined. Furthermore, as demonstrated in the current survey, most women have a very imprecise understanding regarding the actual magnitude of the risks and benefits associated with HRT.”