The range of excess deaths was estimated to be approximately 40,300-48,800, when the researchers used the best available point estimate values with year-by-year adjustment, and adjustment for differential rates of estrogen use with and without retaining ovaries at hysterectomy.
"If you choose to believe that the formula is correct, then this is a very impressive paper," said Dr. David M. Jaspan, a pelvic surgeon at Einstein Medical Center in Philadelphia, who was not involved in the study. "Others may say you’re looking at a paper where the authors came up with their own calculation using ‘extrapolated’ data to generate their own results, so it’s garbage in, garbage out.
"In my opinion, this paper was successful in making the reader think about what we’re doing and think about the data we have, and think, ‘Are we extrapolating the information to patients who do not fit the WHI model?’ This paper should allow the reader to think about the postmenopausal patient population as individuals rather than all postmenopausal women as a group," he said in an interview.
The study authors emphasized that they were not being prescriptive, and that discussions about hormone therapy should be individualized.
"We’re not saying that the WHI harmed anybody," said Dr. Katz. "The only reason we know that there’s a survival advantage with estrogen is because of the WHI. What we’re lamenting is the oversimplified translation of WHI findings into headlines, which have characterized hormone replacement as all bad. Where medicine meets media, we have lumped together baby and bathwater. That’s the problem we’re trying to fix."
The study had several limitations. The estimates may be lower than they actually are because some of the hysterectomies are now done laparoscopically outside of the hospitals and were not taken into account in the calculations. The authors noted that they used the decline in use of oral ET-only for their estimates. They also did not include transdermal ET use, which was included in the WHI studies, and is found to be more effective than oral estrogen in preventing cardiovascular events. Meanwhile, the use of vaginal estrogen has increased between 2001 and 2009, but its effect on mortality needs further study, they said.
Dr. Katz had no disclosures. Dr. Sarrel has been a medical consultant for Noven Therapeutics, which is the maker of transdermal estrogen patches. Dr. Jaspan had no relevant disclosures. The article was funded by the Centers for Disease Control and Prevention.
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