April | May 2006 © 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 103

eEditor’s Note: In recognition of AWHONN

Lifelines’ 10th anniversary year, we’ll be tak-

ing an opportunity in this and other issues this

year to look back at articles from the Lifelines

archives to see how the knowledge of and evi-

dence surrounding certain topics have changed

10 years later. In this issue, we revisit the subject

of hormone replacement therapy from an article

by Valerie Cotter that appeared in the very first

issue of Lifelines.

As we all know, evidence, knowledge and

practice guidelines are continually changing and

evolving—sometimes at alarming speed and

causing great controversy and consternation for

nurses and the women and families we work

with. The intent of this feature is not to criticize

the original article or author(s), but rather to

Hormone Replacement Therapy

Anne Katz, PhD, RN

How Things Have Changed

point out how research and the evidence it pro-

duces change our way of thinking and of practic-

ing over the years.

The debut issue of Lifelines featured an

article entitled, “Hormonic convergence: Find-

ing balance through hormone replacement

therapy,” by Valerie Cotter (Cotter, 1997). In

her review, Cotter clearly laid out the prevail-

ing evidence for the widespread use of hor-

mone replacement therapy (HRT) in women.

A strong argument was made for the benefits

of HRT, including cardioprotection and the

prevention of osteoporosis and Alzheimer’s

disease. At the time, there were no definitive

data on breast cancer risk with HRT, and

Cotter stated that until the results of the

Dr. Anne Katz, PhD, RN,

is a clinical nurse specialist

at the Prostate Centre of

CancerCare Manitoba in

Winnipeg and the Editor

of AWHONN Lifelines.

DOI: 10.1111/j.1552-6356.2006.00024.x

Women’s Health Initiative (WHI) study were

released in 2007, the definitive answer to the

breast cancer question would not be available.

What a difference a few years can make!

Several things have changed since this article

was published. First of all, we no longer talk

about hormone replacement, but rather of

hormone therapy (HT), recognizing that

women do not need anything replaced.

Second, in Jul. 2002, five years after Cotter’s

article was published, one arm of WHI

trial was halted early. This part of the study

involved the use of Prempro™ (estrogen plus

progestin) only and showed that overall health

risks actually exceeded benefits (Writing

Group for the WHI, 2002). Specifically, the

rate of breast cancer in women participating

in the trial was increased, as was the rate of

coronary heart disease, stroke and pulmonary

embolism. Some benefits to taking HT also

were found: Women in the experimental group

had a lower incidence of colorectal cancer

and of hip fracture than did women in the

control group.

Two years later, on Mar. 2, 2004, the

National Institutes of Health (NIH) issued a

statement that the estrogen-only arm of the

WHI study also had been halted early—more

than a year before expected. The NIH state-

ment suggested that estrogen alone did not

appear to affect (either increase or decrease the

risk of) heart disease. This was a key research

question of the study. At the same time, estro-

gen alone did appear to increase the risk

of stroke.

Along with the WHI, other studies have

reported negative findings on HT. In the Jun.

25, 2003 edition of the Journal of the American

Medical Association (Chlebowski et al., 2003),

a study reported that women who received

estrogen plus progestin (Prempro™) were at

increased risk for breast cancer. These inva-

sive forms of breast cancer were larger when

detected and at a more advanced stage than

the breast cancers found in women who were

taking placebo. In addition, more women who

were taking HT for just one year were found to

have abnormal mammograms compared with

those in the control group. The conclusions

drawn from this study suggested that even

short-term use of HT increases the incidence

of breast cancer, the severity of the breast

cancers diagnosed and the incidence of abnor-

mal mammograms.

In the same volume of the journal, another

study (Li et al., 2003) reported on patterns (con-

tinuous or sequential progestin use in addition

to estrogen or estrogen alone) and duration of

HT use related to breast cancer. Women who

were taking unopposed estrogen for up to

25 years were not found to be at increased risk

of breast cancer. However, those taking any

combination of estrogen and progestin (con-

tinuous or sequential) had an increased risk of

breast cancer (1.7-fold) and an increased risk

of invasive lobular cancer (2.7-fold) or inva-

sive ductal cancer (1.5-fold). In subsequent

analyses from the same study, estrogen and

progesterone were found to increase the risk of

incontinence (Hendrix et al., 2005), and estro-

gen alone or estrogen plus progesterone were

found to increase the risk of Alzheimer’s disease

(Shumaker et al., 2004).

The fallout from these studies was felt

across the world, as tens of thousands of

women stopped taking HT. We continue to

read about new findings from the WHI, as well

as additional evidence from other studies, that

provide answers in some instances, but also

increase confusion in others. What’s important

for us as nurses is to realize that the evidence is

constantly changing, and we have an obligation

to be informed and critical readers and users

of the vast amount of literature that reaches us

through various media formats—print, broad-

cast, Internet, etc. We cannot be content to

practice and educate based on what we think

we know or remember from our training. We

must read, think, analyze and criticize in order

to remain current in our practice and account-

able to our colleagues and our patients.

Medicine is an evolving—not static—

science. That’s part of what makes it such an

exciting and rewarding field to work in. But

the ever-changing nature of the field is also

what requires us to evolve as well, in our think-

ing, in our learning and in our caring

for patients.

References

Chlebowski, R., Hendrix, S., Langer, R.,

Stafanick, M., Gass, M., Lane, D.,

et al. (2003). Infl uence of estrogen

104 AWHONN Lifelines Volume 10 Issue 2

April | May 2006 AWHONN Lifelines 105

plus progestin on breast cancer

and mammography in healthy

postmenopausal women.

Journal of the American Medical

Association, 289, 3243-3253.

Cotter, V. (1997). Hormonic

convergence: Finding balance

through hormone replacement

therapy. AWHONN Lifelines,

1(1), 37-42.

Hendrix, S., Cochrane, B., Nygaard, I.,

Handa, V., Barnabei, V.,

Iglesia, C., et al. (2005).

Effects of estrogen with and

without progestin on urinary

incontinence. Journal of the

American Medical Association,

293, 935-948.

Li, C., Malone, K., Porter, P., Weiss, N.,

Tang, M., Cushing-Haugen,

K., et al. (2003). Relationship

between long durations and

different regimens of hormone

replacement therapy and risk

of breast cancer. Journal of the

American Medical Association,

289, 3254-3263.

Shumaker, S., Legault, C., Kuller, L.,

Rapp, S., Thal, L., Lane, D., et al.

(2004). Conjugated equine

estrogens and incidence of

probable dementia and

mild cognitive impairment

in postmenopausal women.

Journal of the American

Medical Association, 291,

2947-2958.

Writing Group for the Women’s

Health Initiative. (2002).

Risks and benefi ts of estrogen

plus progestin in health

postmenopausal women:

Principal results for the

Women’s Health Initiative

randomized controlled

trial. Journal of the American

Medical Association, 288(3),

321-333.

Celebrate Lifelines’ 10th Volume Year Anniversary by sharing your thoughts on nursing, women’s health or newborn care—where we’ve been and where we’re going, and you could win a Lifelines’ logo’d USB Flash Memory Stick (64 MGs)!

In 250 words or less, refl ect on nursing, women’s health or newborn care: “10 Years Ago; 10 Years From Now . . .” If we publish your refl ection on where we’ve been, and where we’re going, we’ll mail you a USB Flash Drive to celebrate with us!

Thoughts can include—but aren’t limited to—what practice looked like 10 years ago, and what practice looks like now; where we thought we’d be today 10 years ago and where we actually are now, etc.

We will celebrate throughout 2006—but hurry—there’s a limited number of USB Flash Drives available for those who get published—send your thoughts today!

Celebrating 10 Years of Clinical ExcellenceLifelines 2006: Volume 10

“10 Years Ago; 10 Years From Now . . .” Contest!

Email your refl ections on “10 Years Ago; 10 Years From Now . . .” to Lifelines@AWHONN.org

64 MG USB Flash Memory Stick!