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Several recent large studies have provoked concern amongst both health professionals and
the general public regarding the safety of hormone replacement therapy (HRT). This article
provides a review of the current literature surrounding the risks and benefits of HRT in
postmenopausal women, and how the data can be applied safely in everyday clinical
practice.
Paragraph 2
10
Worldwide, approximately 47 million women will undergo the menopause every year for the
next 20 years.1 The lack of circulating oestrogens which occurs during the transition to
menopause presents a variety of symptoms including hot flushes, night sweats, mood
disturbance and vaginal atrophy, and these can be distressing in almost 50% of women.
Paragraph 3
For many years, oestrogen alone or in combination with progestogens, otherwise known as
hormone replacement therapy (HRT), has been the treatment of choice for control of
problematic menopausal symptoms and for the prevention of osteoporosis. However, the
use of HRT declined worldwide following the publication of the first data from the Womens
Health Initiative (WHI) trial in 2002.2
Paragraph 4
The results led to a surge in media interest surrounding HRT usage, with the revelation that
20 there was an increased risk of breast cancer and, contrary to expectation, coronary heart
disease (CHD) in those postmenopausal women taking oestrogen plus progestogen HRT.
Following this, both the Heart and Estrogen/Progestin Replacement Study Follow-up
(HERS II)3,4 and the Million Women Study5 published results which further reduced
enthusiasm for HRT use, showing increased risks of breast cancer5 and venous
thromboembolism (VTE),4 and the absence of previously suggested cardioprotective
effects3 in HRT users. The resulting fear of CHD and breast cancer in HRT users left many
women with menopausal symptoms and few effective treatment options.
Paragraph 5
Continued analysis of data relating to these studies has been aimed at understanding
whether or not the risks associated with HRT are, in fact, limited to a subset of women. A
30
recent publication from the International Menopause Society6 has stated that HRT remains
the first-line and most effective treatment for menopausal symptoms. In this article we
examine the evidence that has contributed to common perceptions amongst health
professionals and women alike, and clarify the balance of risk and benefit to be considered
by women using HRT.
Paragraph 6
One of the key messages from the WHI in 2002 was that HRT should not be prescribed to
prevent age-related chronic disease, in particular CHD. This was contradictory to previous
advice based on observational studies. However, recent subgroup analysis has shown that
in healthy individuals using HRT in the early postmenopausal years (age 5059 years), there
was no increased CHD risk and HRT may potentially have a cardioprotective effect.8
Paragraph 7
Recent WHI data has suggested that oestrogen-alone HRT in compliant women under 60
years of age delays the progression of atheromatous disease (as assessed by coronary
arterial calcification).9 The Nurses Health Study, a large observational study within the USA,
40 demonstrated that the increase in stroke risk appeared to be modest in younger women,
with no significant increase if used for less than five years.
Paragraph 8
The WHI results published in 2002 led to a significant decline in patient and clinician
50 confidence in the use of HRT. Further analysis of the data has prompted a re-evaluation of
this initial reaction, and recognition that many women may have been denied treatment.
Now is the time to responsibly restore confidence regarding the benefit of HRT in the
treatment of menopausal symptoms when used judiciously. Hormone replacement therapy
is undoubtedly effective in the treatment of vasomotor symptoms, and confers protection
against osteoporotic fractures.
Paragraph 10
The oncologic risks are relatively well characterised and patients considering HRT should
be made aware of these. The cardiovascular risk of HRT in younger women without overt
vascular disease is less well defined and further work is required to address this important
question. In the interim, decisions regarding HRT use should be made on a case-by-case
basis following informed discussion of the balance of risk and benefit. The lowest dose of
hormone necessary to alleviate menopausal symptoms should be used, and the
prescription reviewed on a regular basis.
60
Lack of circulation
Age
Low progesterone levels
Low FLUFXODWLQJestrogen levels
14. What has been the effect of the 2002 WHI study?
a.) HRT has become less popular.
b.) HRT has increased in popularity as the treatment of choice for problematic menopause
symptoms.
c.) There has been an increase in combined estrogen and progesterone therapy.
d.) The women!s health initiative has since been established to investigate HRT.
15. Why were many women left with menopausal symptoms and no effective treatment?
a.)
b.)
c.)
d.)
16.
a.) Surveys since WHI have attempted to find out if the WHI results are representative.
b.) Results of past surveys are only valid for a subset of women, whether or not the public is
aware of this.
c.) The present study aims to show that HRT is safer than previously believed.
d.) Women should ask their doctors to clarify the balance of risks and benefits of HRT.
Which study showed an increased risk of VTE?
17.
a.)
b.)
c.)
d.)
18. Which of the following does the article recommend HRT should NOT be used to treat?
a.) Vasomotor symptoms
b.) Atheromatous disease
c.) Age-related chronic disease
d.) Osteoarthritic symptoms
19. Why were women denied treatment? (Paragraph 9)
a.)
b.)
c.)
d.)
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Occupational English Test
Practice Papers
Part B
1.
life expectancy
1. B
2.
2. C
3.
3. B
4.
dementia
4. A
5.
6.
2.4.2 million
7.
4.6 million
8.
non-fatal stroke
9.
60
10.
double
11.
Latin America
12.
80%
13.
2050
12. &
14.
risk exposure
13. '
15.
health transition
14. B
16.
sedentary lifestyles
15. C
17.
16. D
18.
17. %
19.
supervision
18. C
20.
institutional care
19. $
21.
agitated
22.
rule out
23.
educate
24.
distraction
25.
Canadian
26.
onset
27.
4 years
5. B
6. C
7. D
8. B
9. A
10. A
11. C
20. A