What's New in Research: March 29, 2004
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"Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results
from the Women's Health Initiative Randomized Controlled Trial," by the Writing Group for the Women's
Health Initiative Investigators (J.E. Rossouw, et al.), JAMA-Journal of the American Medical Association,
288(3): 321-33, 17 July 2002.

[Authors' affiliations (Writing Group): 9 U.S. institutions]

Abstract: "Context Despite decades of accumulated observational evidence, the balance of risks and benefits for
hormone use in healthy postmenopausal women remains uncertain. Objective To assess the major health benefits and risks of the most commonly used combined hormone preparation in the United States. Design Estrogen plus progestin component of the Women's Health Initiative, a randomized controlled primary prevention trial (planned duration, 8.5 years) in which 16608 postmenopausal women aged 50-79 years with an intact uterus at baseline were recruited by 40 US clinical centers in 1993-1998. Interventions Participants received conjugated equine estrogens, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, in 1 tablet (n=8506) or placebo (n=8102). Main Outcomes Measures The primary outcome was coronary heart disease (CHD) (nonfatal myocardial infarction and CHD death), with invasive breast cancer as the primary adverse outcome. A global index summarizing the balance of the risks and benefits included the 2 primary outcomes plus stroke, pulmonary embolism (PE), endometrial cancer, colorectal cancer, hip fracture, and death due to other causes. Results On May 31, 2002, after a mean of 5.2 years of follow-up, the data and safety monitoring board recommended stopping the trial of estrogen plus progestin vs placebo because the test statistics for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits. This report includes data on the major clinical outcomes through April 30, 2002. Estimated hazard ratios (HRs) (nominal 95% confidence intervals [CIs]) were as follows: CHD, 1.29 (1.02-1.63) with 286 cases; breast cancer, 1.26 (1.00-1.59) with 290 cases; stroke, 1.41 (1.07-1.85) with 212 cases; PE, 2.13-3.25) with 101 cases; colorectal cancer, 0.63 (0.43-0.92) with 112 cases; endometrial cancer, 0.83 (0.47-1.47) with 47 cases; hip fracture, 0.66 (0.45-0.98)
with 106 cases; and death due to other causes, 0.92 (0.74-1.14) with 331 cases. Corresponding HRs (nominal 95% CIs) for composite outcomes were 1.22 (1.09-1.36) for total cardiovascular disease (arterial and venous disease), 1.03 (0.90-1.17) for total cancer, 0.76 (0.69-0.85) for combined fractures, 0.98 (0.82-1.18) for total mortality, and 1.15 (1.03-1.28) for the global index. Absolute excess risks per 10000 person-years attributable to estrogen plus progestin were 7 more CHD events, 8 more strokes, 8 more PEs, and 8 more invasive breast cancers, while absolute risk reductions per 10000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures. The absolute excess risk of events included in the global index was 19 per 10000 person-years. Conclusions Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal US women. All-cause mortality was not affected during the trial. The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases, and the results indicate that this regimen should not be initiated or continued for primary prevention of CHD."

This 2002 report from the Journal of the American Medical Association was cited 128 times in current journal articles indexed by Thomson ISI during November 2003. This marks the paper's first actual decline in bimonthly citations (down from 183 in the September-October tally) in the eight consecutive periods in which its citations have been tracked. The latest two-month total, nevertheless, still surpassed that of any paper published in the last two years (spanning all fields, and including reviews), and the paper tops the list of medicine's most cited for the seventh bimonthly ranking in a row. Prior to the most recent count, citations to the paper have accrued as follows: 

September-October 2003: 183 citations
July-August 2003: 142
May-June 2003: 131
March-April 2003: 105
January-February 2003: 87
November-December 2002: 82
September-October 2002: 46

Total citations to date: 904

Related information:
View the top 10 scientists in Clinical Medicine; for the period of January 1993-December 31, 2003.

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