|
What
now? Alternatives to HRT Okay,
now what? Last
week, a small group of experts set up to monitor emerging results from
the massive Women’s Health Initiative, a landmark study on hormone
replacement therapy, dropped a bombshell. To
the surprise of millions of us on hormone therapy – 38 percent of all
postmenopausal ladies in America – and to many of the researchers in
the study as well, the monitoring committee concluded that a popular
hormone combination, Prempro, which contains estrogen and a synthetic
progesterone, causes more harm than good.
Only
5.2 years into the 8-year study, the committee called an abrupt halt to
the part of the study involving roughly 16,000 women on Prempro because
the data showed that Prempro tended to modestly raise the risk of breast
cancer, heart disease, stroke and blood clots, though it reduces the
risk of hip fractures and colon cancer. The committee did not stop the
arm of the study involving roughly 11,000 women taking estrogen alone. The
announcement left millions of women, including this one, scrambling for
alternatives to HRT’s uncontested, ability to combat symptoms of
menopause like hot flashes and vaginal dryness and to accomplish the
other things that HRT used to be prescribed for: Long term protection of
bones and hearts. Luckily,
there are many alternatives – from different combinations of hormones
that may be safer than Prempro to herbal remedies like black cohosh to
learning to love tofu, or at least soy protein powder, to finally
getting really serious about
diet and exercise to protect against osteoporosis and heart disease (the
main reasons many women have stayed on HRT for years). So,
without further ado: The
first thing to remember is that the increases in risk in the WHI study
were small. For every 10,000 women taking Prempro, there would be an
extra 7 cases of cardiovascular disease, 8 strokes, 8 blood clots in the
lungs and 8 cases of invasive breast cancer. This means that for any
individual woman, the risk of harm is really quite small. Some doctors
even question whether these increases are really statistically
significant. Secondly,
it’s only combination hormone therapy that appears worrisome. Since
estrogen alone has not (yet) been shown to carry the same risks, it may
be the progestin that is the bad actor in the combined regimens. (Progestin,
an anti-estrogen, has to be taken with estrogen by women who still have
a uterus because, if taken alone, estrogen can increase the risk of
uterine cancer.) Moreover,
the study did not even look at all possible progestins in combination
with estrogen. It focused only on Prempro ( Premarin, an estrogen, and
Provera, a progestin), despite the fact that there a dozens of other
estrogens and progestins available. “We’ve
known that the Provera part of Prempro has been a problem for half a
decade,” says Dr. Alan Altman, an assistant professor at Harvard
Medical School and a menopause specialist
in private practice in Brookline. “Provera
is too potent,” he says. He believes Prometrium, a form of micronized
progesterone may be safer than Provera. Another option is Femhrt, a pill
that combines an estrogen (ethinyl estradiol) with norethindrone
acetate, a different progestin. Still other options are Prefest and
Activella. Estratest, a combination of estrogen and testosterone, may
also help some women. These
decisions get tricky. For instance, estrogen patches (as opposed to
pills) may be better for some women. Adding progesterone further
complicates things. In terms of cardiac effects, for instance, estrogen
increases, HDL, the good cholesterol, but it also increases
triglycerides, an undesirable effect, notes Dr. Richard Karas, director
of preventive cardiology at New England Medical Center. Provera blunts
both this good and bad effect; Prometrium does, too, but to a lesser
extent. Go figure. Another
option is to cut back to a lower dose of estrogen (say 0.3 milligrams of
Premarin a day instead of 0.625) and to cut back on or change progestins
accordingly. There are several ways to do this. For instance, you can
take 100 milligrams of Prometrium every day along with low dose
estrogen. Or, you can take half of a 5 milligram pill of Aygestin
(another progestin) for 10 days every three or four months. This should
bring on a period, which is the point. If the lining of the uterus has
been building up for several months on estrogen alone, it must be shed
every few months to reduce the risk of uterine cancer. If
you do decide to toss out your hormone pills or patches entirely, taper
off slowly. If quitting leaves you with vaginal dryness, you can try a
tiny pill called Vagifem that, once inserted, sticks to the vaginal
wall, or a little device like a diaphragm called Estring. These
products, sold by prescription, supply low doses of estrogen directly to
the vagina without seeping out to the rest of the body. But precisely
because of that, warns the North American Menopause Society, these
approaches will not help with hot flashes. Another option is to use a
vaginal estrogen cream, but this will
get absorbed into the rest of the body – with all the pros and cons
that that means. A
nonhormonal, over-the-counter remedy for vaginal dryness is to use
Astroglide, a lubricant, during sex. For
women who want to get off hormones but are concerned about osteoporosis,
one approach is to use bisphosphonate drugs such as Actonel and Fosamax,
1200 milligrams a day of calcium and 600 to 800 International Units of
vitamin D. Evista, a “designer” estrogen, can also help protect
bones, though it causes hot flashes. For
women who dump their hormones but worry about heart disease, the statin
drugs, which can lower both cholesterol and the risk of heart attack,
may be a good choice. (Obviously, for both osteoporosis and heart
disease prevention, exercise is also key.) For
nondrug solutions to menopausal problems, the best bet is undoubtedly
soy. Soybeans
are legumes that are rich in plant estrogens (also known as
phytoestrogens). The most important ones are genistein and daidzen,
which are also known as isoflavones. But a warning: Like the estrogens
that humans make in their bodies or buy by prescription, phytoestrogens
may drive cell proliferation – which means soy could spur cancer
growth, particularly breast cancer, which is often driven by estrogen. Though
soy is a popular way to combat hot flashes, studies suggest it’s only
somewhat better than placebo. A reasonable dose is 50 grams of soy
protein a day, which you can get either from protein concentrate, a cup
of tofu, a quarter of a cup of soy beans or a glass and a half of soy
milk. If
you prefer supplements, you can take one pill containing 25 milligrams
of soy isoflavones twice a day, says Dr. Machelle Seibel,
medical director of Inverness Medical, Inc. in Waltham, which
makes SoyCare products. Soy can also help lower cholesterol and can slow
down the rate of bone loss at menopause, he adds. It won’t help much
with the memory problems that spur many women to take HRT, except to the
extent that, by reducing hot flashes, you may get a better night’s
sleep and therefore have fewer memory troubles. (Flax seed oil may also
help, but appears less potent than soy.) Other
remedies for hot flashes are the SSRI antidepressant drugs such as
Effexor, Paxil, Zoloft, Prozac and the like, says Dr. JoAnn Manson,
chief of preventive medicine at Brigham and Women’s Hospital, or a
blood pressure medication called Catapres. Vitamin
E at 400 to 800 International Units a day may also help, but it’s
effects are minimal – it will probably eliminate only one hot flash a
day, says Dr. Nananda Col, a menopause specialist also at Brigham and
Women’s Hospital. Among
the herbals, black cohosh is probably the best for combating hot
flashes, and some women swear by it. But if you take a black cohosh
product like Remifemin, don’t take more than 40 milligrams a day, and
don’t take it for more than 6 months because there’s no reliable
longer-term data. Gynecologist
Altman makes a deal with patients who take Remifemin. Because it has
both estrogen-like and progesterone-like effects, he insists that women
have a “progesterone challenge” once a year, which means they take
progesterone to stimulate shedding of the uterine lining. If they bleed,
they must have a mildly invasive procedure called an endometrial biopsy
to make sure they are not developing uterine cancer. Another
option for hot flashes is red clover (which comes in products such as
Promensil). “It seems to help some people,” says gynecologist Altman
“but there are no definitive studies to say it’s better than
placebo.” Forget
Dong Quai, a favorite among some herbalists. A Kaiser Permanente study
several years ago showed it to be no better than placebo. Oil
of evening primrose seems to help some women, though the evidence is
scanty,The oil is a prostaglandin, which means it could in theory cause
pain and uterine contractions. Ginseng
is another question mark. It seems to help some women when herbalists
prescribe as a part of a mixture with other herbs, but isn’t effective
alone in head-to-head comparisons with placebo, notes Altman. And
skip the wild yams. For one thing, notes Col of Brigham and Women’s,
they can cause serious liver toxicity. For another, there’s no
“there” there. As Altman puts it, “wild yam cream is utterly
useless because there’s no progesterone in Mexican yams.” What there
is is a chemical called
diosgenin that, when extracted and exposed to enzymes in the lab, can
produce steroid hormones, including progesterone. But human beings do
not possess the hormones needed to make this conversion. Because
hormone replacement therapy had been prescribed for so many short and
long term menopausal problems, replacing it with a hodgepodge of other
remedies will mean a lot of individual experimentation as women, and
their doctors, sort through the options. But
look at it this way. The new results that are now creating such chaos
for so many women stem from precisely the kind of rigorous research that
women have (rightly) been clamoring for for years. We
asked for it. We paid for it. We got it. Now we have to live with it.
That’s science. Judy
Foreman is Lecturer on Medicine at Harvard Medical School and an
affiliated scholar
at the Women’s Studies Research Center
at Brandeis University.. Her column appears every other week.
Past columns are available on www.myhealthsense.com.
|
