- The Washington Times - Monday, July 21, 2003

To use HRT or not to use HRT: That is the dilemma bedeviling women generally in middle age and beyond following a series of negative reports about the value and safety of hormone replacement therapy. Whatever else has come out of the latest research into HRT’s effectiveness, the publicity certainly has been an education for women who are using HRT or considering doing so. Pressure, and some of the confusion, inevitably has affected doctors, too — chiefly gynecologists — to whom women look for counsel in such matters.

Previously, HRT was recommended for women as a means of relieving the symptoms of menopause. It also was thought to protect against heart disease and have other health benefits, depending on a woman’s history and individual body chemistry.

“Patients are coming in with just as many questions as we have concerning the study,” says Dr. Lorraine Gillian, an obstetrician-gynecologist affiliated with Washington Hospital Center. “Patients ask me: ‘What do I believe?’ Many [other] women who have come in already are experimenting with alternatives and ask what I suggest.”

Most doctors feel a need to remind patients that the Women’s Health Initiative study done by the National Institutes of Health used only one combination of estrogen and progestin, a brand called Prempro. They note that the research was conducted on an older population, specifically 16,608 healthy post-menopausal women ages 50 to 79 who had taken Prempro for at least five years.

One goal of the study, the results of which were announced in May 2002, was to check the previously held assumption that HRT helps reduce heart disease. The study showed that was not true. In an average year during the study, 37 women out of 10,000 had heart attacks, compared with 30 of 10,000 women taking a placebo. Thirty-eight of 10,000 HRT users developed breast cancer while 30 non-HRT users developed the disease. There were 29 cases of stroke among the HRT users, compared to 21 cases for the non-users per 10,000, and 34 cases of blood clots among HRT users compared to 16 cases among the placebo group.

Another, smaller NIH study conducted since then refutes the belief that HRT also aids a person’s mental agility, even to the point of helping prevent dementia.

HRT still remains effective in helping reduce the risk of osteoporosis, several doctors point out.

Until the NIH results came in, Dr. Gillian, who at 53 is nearly through menopause herself, had been taking Premarin, an estrogen substitute made from the urine of pregnant horses. She went cold turkey and now is eating a lot of soy products, which she finds can reduce hot flashes, but she doesn’t advise all patients to do the same.

“I say they can go to one method and then another,” she says. “They can go to synthetics, such as black cohosh that is sold as Remofemin. … I have transferred patients from one product to another.” Another such product is Activella, which she describes has having the same chemical formulation as estradiol, the estrogen produced in women’s bodies.

“It’s all over the map,” she says. “A patient who says ‘I cannot suffer the hot flashes’ is one thing, but if a patient says ‘I can’t remember as well as I used to’ and is having acute onset menopause, they may go for the combination [of estrogen and progestin].”

The critical decision, she says, is to wean oneself slowly off a higher amount of HRT. “Many patients will say they have hot flashes and sweats but deal with it the old-fashioned way, with ice water by the bed, a fan and sleeping without clothes. We’re not stupid. We don’t want to kill ourselves. Patients understand the risk and the fact they can’t stay on it forever — that HRT is not a fountain of youth.”

The study’s conclusions were quite specific, as noted by Dr. April Rubin in an essay published last month in a local community paper. “Contrary to considerable misreporting in certain media, it was not concluded that all use of HRT should be abandoned,” she wrote.

The “to use or not to use” question requires a range of answers, as all doctors interviewed for this article make clear. Solutions must be custom-tailored for each individual, depending on that person’s health problems and family history.

“Hot flashes, or what we term vasomotor instability, is the only [reason] for hormone replacement therapy at this time,” Dr. Rubin states. She doesn’t categorically renounce its use because she, like several other doctors, point out that the increased risks described are real, but relatively small overall.

If a bone-density scan reveals the danger of osteoporosis, she urges taking medication such as Fosamax rather than relying on HRT. If there is mild depression around the time of menopause, she asks whether it is hormonal or whether the mood disorder relates to other life-changing events in a woman’s life.

She doesn’t have much confidence in soy products and other alternatives, mainly because no studies have been done about what a soy pill does. Nor, she points out, have studies been done on alternate delivery methods for hormones, such as skin patches and vaginal creams.

“Some women will want to take just the estrogen, but we know if they have a uterus it will increase the risk of cancer,” she says. For women with more severe depression problems, she recommends antidepressant medicines such as Prozac or Paxil, that, in about 70 percent of cases, she notes, also work to relieve hot flashes. A testosterone cream can help with sexual dysfunction often associated with antidepressants.

While acknowledging the value of the NIH study, doctors of obstetrics and gynecology such as Dr. Gregory Koons of Inova Fairfax Hospital and Dr. Craig Winkel, newly retired department head at Georgetown University Hospital, admit they are troubled by some interpretations of the data.

“Everyone is trying to feel their way through this,” Dr. Koons says.

One problem, he says, is that the average age of the women involved in the study was 63 — a much later age than the average onset of menopause: “The ones you want to study were the 50-year-olds. The difference in the heart vessels of a 53-year-old and a 63-year-old is massive.”

Dr. Winkel is even more critical of the study and how the data was presented. “The woman who is worrying about this is still smoking,” he says. “You don’t hear anything about smoking in this age group, but it is still a much greater risk than the one associated here. What I’m telling patients is that this latest article on cognitive functions is no different than what we have been telling patients in the last four or five years.”

He supports a woman taking estrogen if, as he phrases it, quality of life is at stake and hot flashes are severe. In some trial studies, alternatives such as black cohosh, acupuncture and soy products have not been proved to be more effective than a placebo, he says.

“The way to improve quality of life is to stay healthy and exercise and keep your mind active,” says Dr. Barbara Howard, president of MedStar Research Institute at the Washington Hospital Center, which participated in the NIH study.

“Estrogen helps skin undeniably,” says Dr. Michele Wylen, of Georgetown University Hospital, who advocates using the lowest possible dose if a patient chooses to take it.

Early diagnosis of breast cancer is key, regardless of whether a woman uses HRT, because such cancers tend to be slow-growing. “If found early, they can be cured,” she says.

“I tell patients that being overweight increases breast cancer more than hormones. When you are obese, you make a lot of estrogen in your peripheral fat tissue, and enzymes convert hormones into estrogen. … Age is the biggest risk factor for breast cancer — one in eight without hormones. If you live long enough, there will be problems in your cells.”

If somebody at 70 is on HRT and is feeling good, she recommends the person try to get off it. Because of a lack of safety data, substituting herbal alternatives can be risky, she notes: “Even Chinese herbalists don’t recommend taking black cohash longer than six months.”


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