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Women
Continue to Demand Hormones By: Judy Foreman 03/09/2004 All
right, ladies, here we go yet again.
About 20 months ago, it was postmenopausal women taking
combined estrogen and progestin therapy who panicked at the
then-new news that a popular hormone pill, Prempo, carried more
risks than benefits overall. Some
swore off hormones, causing Prempro sales to plummet by 66
percent. Some began cutting back on doses or trying different
formulations like creams or patches in hopes of improving the
risk-benefit equation. Still others stopped, then shopped around
for doctors who would put them back on hormones because of
intolerable menopausal symptoms. Well,
medical science crashed headlong into medical reality again last
week with the announcement from the Women’s Health Initiative
that women taking estrogen alone, without progestin (a synthetic
progesterone), also faced an increased risk, albeit a small one,
of stroke - and do not get any protection, as had been hoped,
against heart disease. Once
again, this is pitting well-respected researchers, armed with vast
amounts of data that doesn’t precisely answer the questions many
women have, against clinically-experienced gynecologists facing
women who know quite well that hormones don’t protect against
future heart disease but are miserable in the here-and-now. For
the record, doctors are still writing an estimated 57 million
hormone prescriptions a year, just slightly less than the 58
million they were writing in 1995, before a huge surge in the late
90s, when the question was “whether everybody, or almost
everybody” should be put on hormones protect the heart, noted
Dr. Rowan Chlebowski, a WHI investigator and medical oncologist at
the Harbor-UCLA Research and Education Institute. So,
to put all this in perspective. First
of all, the increased risk of stroke on estrogen alone was
comparable to that on combination therapy – 8 additional strokes
for every 10,000 women every year, which is not huge. Second,
the average age of women in both arms of the WHI study was 63 -
and the majority had not taken hormones since menopause, so these
results may or may not say much about women who start hormones at
menopause. As Dr. Alan Altman, a Brookline gynecologist, put it,
“Estrogen is a preserver, not a restorer” of tissue.
Others note that this effect has been shown primarily in animal,
not human, studies. Third,
both arms of the WHI study involved Premarin, which is extracted
from horse urine. Instead of Premarin, some gynecologists think it
may be better to take a “bio-identical” estrogen called
17-beta-estradiol, which is made in the body and can also be
synthesized from soy and yams. So far, however, there is little
epidemiological data on this in humans. Furthermore,
this may not be the last word. For one thing, the latest findings
contained a surprise – that estrogen alone does not increase the
risk of breast cancer, which means researchers must spend the next
two months, before publication of the results, trying to figure
out why. The
2002 data has already changed, albeit slightly. In a paper
published last August in the New England Journal of Medicine, WHI
researchers concluded that Prempro increased heart disease risk by
24 percent, not the 29 percent originally reported.
In a separate paper published in June in the Journal of the
American Medical Association, researchers said the increased risk
of breast cancer was actually 24 percent, not 26 percent. It’s
“splitting hairs” to make too much of this, said Dr. JoAnn E.
Manson, chief of the division of preventive medicine at Brigham
and Women’s Hospital and a principal investigator of the WHI.
The re-analysis, she said, showed that most of that increased risk
comes in the first year of use, when hormones increase risk by 81
percent. Obviously,
what’s needed is an alternative that carries the benefits of
hormones without the risks. But there’s little longterm data
herbal remedies like black cohosh. Antidepressants called SSRIS,
particularly Effexor, help some women with mild to moderate hot
flashes, said Manson, but don’t combat severe ones. Which
leaves some women, like Barbara Howerton, 50, a Brookline nurse,
going back and forth. Howerton had been taking hormone therapy for
a couple of years when the first WHI results came out. One doctor
“scared me to death,” she said. “He immediately took me
off” hormone therapy. “He said ‘you’re going to have
cardiovascular disease, breast cancer,’ he went through the
whole slew of things, all the bad press.” So
she stopped taking hormones – and began feeling miserable. “I
had hot flashes all day long and two or three times a night I’d
wake up so drenched I had to wash my hair. I was anxious and
depressed and had mood swings,” she said. “I thought I was
losing my mind. I had no energy. My memory was gone and I had zero
sex drive.” She
finally found her way to Brookline gynecologist Altman. “So many
women were taken off hormone therapy by their primary care
providers that it produced a backlash, with many women going back
on,” said Altman. Dr.
Carolyn Shaak, medical director of WomanWell, a menopause clinic
in Needham, said her office is “busier than ever because we are
offering options that were not offered in the WHI study.” Among
those options are hormones given transdermally (through creams,
gels or skin patches) or transvaginally (through a ring or
tablet), rather than orally, as well as hormone preparations that
are “bioidentical,” that is, chemically the same as a human
estrogen called estradiol. There
are theoretical reasons why these formulations might be better.
But so far, there are no large studies documenting that they are
any safer or have more beneficial risk-benefit ratios than
standard formulations, Manson cautioned. Still,
Mandy Waddell, 60, a retired teacher, singer, photographer and
kayaker from Weston, is convinced. She likes that Shaak tested her
blood for levels of 17-beta-estradiol, testosterone and
progesterone before writing any hormone prescriptions, and then
periodically re-tests it, changing the prescription as necessary.
Waddell then uses hormone creams that are “compounded”
especially for her by a pharmacist. All
that fussing is unnecessary, said Dr. Nananda Col, a menopause
researcher at Brigham and Women’s. “There is absolutely no
scientific basis for testing hormone levels to guide hormone use
– they go up and down all the time in women close to
menopause.” But
for Waddell, it provides a nice “comfort level. I have a real
understanding of what’s going on.”
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