A new twist to menopausal hormone replacement dilemma.

More than a decade after a massive study of hormone replacement therapy was halted due to higher rates of breast cancer, heart attack and stroke among women assigned to the drugs to treat menopausal symptoms, a new follow-up study has found those women had no higher risk of death as of 2014 than participants who took a placebo.

The latest findings were published in JAMA journal by investigators in the Women’s Health Initiative, the same multi-institutional research program that conducted the original trial begun in 1993 and stopped in 2002 because of those adverse effects. The new study focuses on “all-cause mortality,” or deaths from any cause, up to 18 years after the start of therapy and 10 to 12 years after the therapy was stopped. It offers reassurance to postmenopausal women who took hormone replacement therapy during the trial that they have not increased their risk of dying.

Overall, the researchers found that the risk of dying from any cause through the end of the follow-up period in 2014 was the same for women who had taken hormone therapy as for women who had taken a placebo. To Manson, the study results give women and their doctors useful information when considering a complex treatment decision. They also offer comfort to younger women now contemplating hormone therapy to bring relief from hot flashes, night sweats and higher rates of bone loss or fractures due to menopause.

“We think the findings of no increase in mortality provide reassurance for women who are seeking hormone therapy for management of symptoms in early menopause,” she said.

Dr. Garnet Anderson, a co-author of the new JAMA study and senior vice president and director of the Public Health Sciences Division at Fred Hutchinson Cancer Research Center, said these latest results are statistically sound, but she also issued a note of caution. “I do think these results will be somewhat reassuring to women,” she said, "but they aren’t the entire picture.”

The newest analysis, she noted, leaves untouched the fundamental findings from the original WHI hormone study report in 2002 showing that women taking a combination of estrogen and progestin to counter menopausal symptoms had a higher rate of those potentially life-altering side effects. Anderson said that for women taking combined hormones to prevent menopausal symptoms, this should still give them pause. For women with a hysterectomy considering taking estrogen alone for menopausal symptoms, the effects on chronic diseases were more balanced, and the benefits for symptom relief may be worth it. The new JAMA paper shows that participants in the original studies who had hysterectomies and took estrogen alone had a 45 percent lower risk of death specifically from breast cancer.

The new study also showed that those who took combined hormone therapy of estrogen plus progestin had a 44 percent increase in breast cancer mortality, but that result failed to reach statistical significance.

Fred Hutch’s Anderson has stated in the past that women eligible for estrogen-only therapy may want to consider it for a year or two, despite an elevated risk of stroke, if their symptoms are severe. “A woman having a few moderate hot flashes may not want to take the risk of a stroke to relieve those,” she told Fred Hutch News Service in 2014. “But for a woman waking up nightly from hot flashes or night sweats, for a woman going for days without any quality sleep, that trade-off may seem much more reasonable.”

On the other hand, for women who have not had a hysterectomy, Anderson sees combined hormone replacement therapy as a much riskier tradeoff. “Estrogen plus progestin has all of these adverse effects - breast cancer, heart disease, stroke, blood clots, dementia,” she said previously.

Anderson said the risks and benefits for hormone replacement therapies should always be conside