The WHI estrogen plus progestin trial enrolled predominantly healthy postmenopausal women to assess the risks and benefits of daily oral CE (0.625 mg) in combination with MPA (2.5 mg) compared to placebo in the prevention of certain chronic diseases. The primary endpoint was the incidence of CHD (defined as nonfatal MI, silent MI and CHD death), with invasive breast cancer as the primary adverse outcome. A "global index" included the earliest occurrence of CHD, invasive breast cancer, stroke, PE, endometrial cancer colorectal cancer, hip fracture, or death due to other causes. This trial did not evaluate the effects of CE plus MPA on menopausal symptoms.
The WHI estrogen plus progestin trial was stopped early. After an average follow-up of 5.6 years of treatment, the increased risk of invasive breast cancer crossed the predefined stopping threshold. The global index was supportive of a finding of overall harm. The absolute excess risk of events included in the global index was 19 per 10,000 women-years. Results of the trial, which enrolled 16,608 women (average 63 years of age, range 50 to 79; 83.9% White, 6.8% Black, 5.4% Hispanic, 3.9% Other) are presented in
Table 5. These results reflect centrally adjudicated data after an average follow-up of 5.6 years.
TABLE 5. Relative and Absolute Risk Seen in the WHI Estrogen Plus Progestin Trial at an Average of 5.6 Years
a,b
| Event | Relative Ratio (95% CI)
c | Risk Difference (CE/MPA vs placebo/10,000 WYs) |
CHD events Non-fatal MI CHD death | 1.18 (0.95-1.45) 1.24 (0.98-1.56) 1.05 (0.76-1.45) | 6 (41 vs 35) 6 (35 vs 29) 1 (16 vs 15) |
| All Strokes | 1.37 (1.07-1.76) | 9 (33 vs 24) |
| Deep vein thrombosis
d | 1.87 (1.37-2.54) | 12 (25 vs 14) |
| Pulmonary embolism | 1.98 (1.36-2.87) | 9 (18 vs 9) |
| Invasive breast cancer
e | 1.24 (1.01-1.53) | 9 (43 vs 35) |
| Colorectal cancer | 0.62 (0.43-0.89) | -6 (10 vs 17) |
| Endometrial cancer
d | 0.83 (0.49-1.40) | -1 (6 vs 7) |
| Hip fracture | 0.67 (0.47-0.95) | -6 (11 vs 17) |
| Vertebral fractures
d | 0.68 (0.48-0.96) | -6 (12 vs 17) |
| Total fractures
d | 0.76 (0.69-0.83) | -51 (161 vs 212) |
| Overall mortality
f | 0.97 (0.81-1.16) | -1 (52 vs 53) |
| Global Index
g | 1.12 (1.02-1.24) | 20 (189 vs 168) |
aAdapted from numerous WHI publications. WHI publications can be viewed at www.nhlbi.nih.gov/whi.
bResults are based on centrally adjudicated data.
cNominal confidence intervals unadjusted for multiple looks and multiple comparisons.
dNot included in Global Index.
eIncludes metastatic and non-metastatic breast cancer with the exception of
in situbreast cancer.
fAll deaths, except from breast or colorectal cancer, definite or probable CHD, PE or cerebrovascular disease.
gA subset of the events was combined in a "global index" defined as the earliest occurrence of CHD events, invasive breast cancer, stroke, pulmonary embolism, endometrial cancer, colorectal cancer, hip fracture, or death due to other causes.
Timing of the initiation of estrogen plus progestin therapy relative to the start of menopause may affect the overall risk benefit profile. The results of the WHI estrogen plus progestin trial in women 50 to 59 years of age (N=2,837 for CE/MPA; N=2,683 for placebo) are shown in
Table 6.
Table 6. Relative Risk and Risk Difference Observed Among Women 50-59 Years of Age in the WHI Estrogen Plus Progestin Trial at an Average of 5.6
a,b
| Event | Relative Ratio (95% CI)
c | Risk Difference (CE/MPA vs placebo/10,000 WYs) |
CHD events Non-fatal MI CHD death | 1.34 (0.82-2.19) 1.32 (0.77-2.25) 0.77 (0.33-1.79) | 5 (23 vs 17) 4 (19 vs 15) -2 (6 vs 8) |
| All Strokes | 1.51 (0.81-2.82) | 5 (15 vs 10) |
| Deep vein thrombosis
d | 3.01 (1.36-6.66) | 10 (15 vs 5) |
| Pulmonary embolism | 2.05 (0.89-4.71) | 6 (11 vs 5) |
| Invasive breast cancer
e | 1.21 (0.81-1.80) | 6 (33 vs 27) |
| Colorectal cancer | 0.79 (0.29-2.18) | -1 (4 vs 5) |
| Endometrial cancer
d | 1.07 (0.33-3.53) | 0 (4 vs 3) |
| Hip fracture | 0.17 (0.22-1.45) | -3 (1 vs 3) |
| Vertebral fractures
d | 0.38 (0.15-0.97) | -6 (4 vs 10) |
| Total fractures
d | 0.82 (0.68-1.00) | -25 (120 vs 145) |
| Overall mortality
f | 0.67 (0.43-1.04) | -10 (21 vs 31) |
| Global Index
g | 1.12 (0.89-1.40) | 12 (103 vs 91) |
aAdapted from 2013 WHI trial (CE/MPA n=2,837; placebo=2,683). WHI publications can be viewed at www.nhlbi.nih.gov/whi.
bResults are based on centrally adjudicated data.
cIn the WHI studies, hazard ratios were estimated using Cox proportional hazards models comparing treatment to placebo; however, they are described here as relative risks. Nominal confidence intervals unadjusted for multiple looks and multiple comparisons.
d Not included in “global index.”
e Includes metastatic and non-metastatic breast cancer with the exception of in situ cancer.
f All deaths, except from breast or colorectal cancer, definite or probable CHD, PE or cerebrovascular disease.
gA subset of the events was combined in a “global index,” defined as the earliest occurrence of CHD events, invasive breast cancer, stroke, PE, colorectal cancer, hip fracture, or death due to other causes.