Benefits and harms associated with hormone replacement therapy: clinical decision analysis

Abstract

Objective: To evaluate harms and benefits associated with use of combined hormone replacement therapy (HRT) for five years in women with different baseline risks for breast cancer.

Design: Probabilistic clinical decision analysis.

Setting: Hypothetical population of white UK women aged 50 years with different baseline risks for breast cancer.

Main outcome measure: Gain or loss in quality adjusted life years (QALYs).

Results: Women free of menopausal symptoms showed a net harm from HRT use, which increased for increasing baseline risk of breast cancer. Those with a baseline risk of 1.2% would expect a loss in QALYs of 0.4 months (- 0.03 QALYs, 95% credibility interval - 0.05 to - 0.01). The main analysis showed HRT to be on average beneficial in women with symptoms, with benefit decreasing with increasing baseline risk of breast cancer. The results were sensitive to the assumed value of quality of life with menopausal symptoms, therefore a contour plot was developed to show the probability of net harm for a range of different values and baseline risks.

Conclusions: HRT for primary prevention of chronic diseases in women without menopausal symptoms is unjustified. Perceived quality of life in women with symptoms should be taken into account when deciding on HRT. Thus, a decision analysis tailored to an individual woman is more appropriate in clinical practice than a population based approach.

Figures

Fig 1

Structure of net benefit decision model

Fig 2

Graphical presentation of net-benefit model, with 95% credibility intervals, after exclusion of menopausal symptoms (top) or inclusion of symptoms with QoL weight 0.75 (bottom)

Fig 3

Probability of net harm (%) associated with HRT use for five years according to utility attributed to menopausal symptoms by individual women and their baseline risks of breast cancer. Isolines define combinations of utility and baseline risk with same probability of net harm