The Womens Health Initiative (WHI) from the National Institutes of Health recommends that all health care providers remain current regarding these studies and integrate the findings into their practices to maximize the health of their female population. In keeping with this, well look at the issue of hormone replacement therapy (HRT), including the most recent research and clinical recommendations, and what these mean to our patients ocular health.
It is not uncommon for O.D.s to be the only health care provider that patients see consistently over a number of years. Its one of the reasons we take blood pressures in our office. Since the results of the Estrogen-Progestin study directly impact the morbidity and mortality of women, we are in a unique position to query and/or inform our patients about the risks vs. benefits of HRT.
Out With the Old In Need of A Change
HRT is the use of both estrogen and progesterone, or any combination of medications involving estrogen, progestin and androgens. Historically, physicians have prescribed HRT to decrease:
Side effects of menopause.
The risk of developing heart disease in menopausal women with existing diagnoses or risk factors.
The risk of developing osteoporosis, dementia and other mental health disorders such as depression.
A year ago, however, the Heart and Estrogen/Progestin Replacement Study (HERS), the nations largest study of this combined form of HRT in healthy post-menopausal women, found that its risks clearly outweigh the benefits.1 In fact, the study was scheduled to run until 2005, but was stopped after an average of 5.2 years of follow-up due to a significant increase in risk for invasive breast cancer.
HERS left doctors and patients wondering what to do. The North American Meno-pause Societys (NAMS) advisory panel published these recommendations:2
Symptom relief should be the primary reason for HRT.
Add progestins to estrogen-only therapy to prevent endometrial cancer. If a woman has had a hysterectomy, there is no need for progestins in her therapy.
Do not prescribe HRT to prevent heart disease. Explore other measures to reduce cardiovascular risk.
Though HRT can help build stronger bones and avert osteoporosis, patients should carefully weigh the risks of this therapy.
Prescribe HRT for the shortest amount of time possible. Base the time frame on the patients symptoms, benefits derived from therapy and individual health risks.
Consider prescribing the lowest dose of HRT whenever possible.
Consider alternate ways of providing HRT, like transdermal patches or creams. However, studies are not clear on the long-terms risks and benefits of this method.
Evaluate every womans personal health risks before prescribing any form of HRT. Women should understand the risks and be aware of alternatives to HRT.
Some alternatives for symptom relief include:
Anti-depressants such as selective serotonin reuptake inhibitors (SSRIs) can re-duce hot flashes and mood swings.
Bisphosphanates or Selective estrogen receptor modulators (SERMs) can help prevent osteoporosis.
Adhere to a low-fat diet and regular exercise.
Researchers also found an increased risk of coronary heart disease, stroke and blood clots. Specifically, when compared with the control group, women taking estrogen and progestin had a 41% increase in stroke, 29% increase in heart attacks, 26% increase in breast cancer and a doubling of the rate of venous thromboembolism.
The study did find some benefits to HRT, such as a 37% reduction in cases of colorectal cancer, 33% reduction in hip fracture rates and 24% reduction in total fractures. However, researchers concluded the risks outweigh the benefits.
HRT for the O.D.
So, how do these findings affect your patient care? We have an opportunity as O.D.s to contribute to a patients health and well being and a responsibility to provide better care for these patients.
Ask questions. The current standard of eyecare requires a complete ocular and systemic history, including any medications that the patient is currently taking. When reviewing your patients history, ask if she and her doctor have reviewed the latest findings on HRT. If she answers no, consider providing a brief summary of the study and strongly encourage the patient to schedule an appointment with her primary care physician to re-evaluate the benefits of HRT for her individual needs. Then let the patient know you will discuss how HRT can impact her eyes before the exam is completed that day.
Be up to date about HRT and dry eye syndrome. Estrogen receptors are present in the lacrimal glands, meibomian glands, lids, palpebral and bulbar conjunctiva and cornea. This indicates that dry eye syndrome may result from a complex hormonal influence.
A recent study looked at 25,000 post-menopausal women on HRT.3 Women who took estrogen alone were found to have a 69% greater risk of dry eyes. Women who took both estrogen and progestin had a 29% greater risk of dry eyes. The study also found that the incidence of dry eye increased 15% for each three-year interval of HRT. The researchers concluded that estrogen receptor sites on meibomian glands may be a cause of dry eye syndrome in these patients.
Commit to treatment options. Its not enough to diagnose dry eye. It is important to distinguish between types of dry eye in our patients, tailor the course of treatment accordingly and consider the latest treatment options available.
Dry eye is a common ocular conditions in this population. We need to continually update our arsenal of treatment options: Restasis (cyclo-sporine, Allergan) Systane (Alcon), oral supplements with Omega-3-fatty acids, Sterile spray like Natures Tears (Bio-Logic Aqua), new designs of punctual plugs and canalicular occlusion are all options for dry eye treatment.
Topical hormone treatments are also currently being investigated as a treatment for dry eye.
1. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmeno-pausal women: principal results from the WHI randomized controlled trial. JAMA 2002 Jul 17;288(3):321-33.
2. The North American Menopause Society. Amended report from the NAMS Advisory Panel on Postmenopausal Hormone Therapy. Menopause 2003 Jan-Feb;10(1):6-12.
3. Schaumberg DA, Buring JE, Sullivan DA, Dana MR. Hormone replacement therapy and dry eye syndrome. JAMA 2002 Nov 7;286(17):2114-9.
