This summer one of the most prescribed group of drugs in the U.S. has become one of the most controversial.
Two weeks ago, the American Heart Association issued new guidelines recommending that women not go on hormone replacement therapy (HRT) solely to prevent heart attacks and stroke, a change from its former position.
Earlier this summer, an editorial in the Journal of the American Medical Association made national news by questioning whether estrogen helps prevent fractures caused by osteoporosis in older women.
Some recent clinical studies have suggested that the benefits of the powerful drug aren't so clear-cut as scientists once thought and the risks may be greater. (Other studies have been more positive.)
"We have magical thinking about estrogen," says Dr. Deborah Grady, one of the authors of the JAMA editorial. "We don't think about it as a drug, just something that older women are lacking that we ought to replace. But there's been a large change in the way [the scientific community] thinks about estrogen in the last few years."
Dr. Grady, a University of California, San Francisco professor of medicine and epidemiology, plans to take one of the new nonhormonal drugs if she has bone mass loss after menopause. "The evidence is better that it works, and its main side effect is heartburn."
The decisions women must make about whether to go on HRT are getting more complicated. Should they take estrogen, a drug with potentially serious side effects, every day for the next 30 or 40 years to prevent diseases of aging? Or if they decide to use estrogen, should they stay on it for a short time simply to deal with the unpleasant symptoms of menopause?
"One of the problems we're seeing is that [HRT] is being marketed as a preventative to a broad number of women," says Amy Allina, program director for the National Women's Health Network, a Washington-based nonprofit organization. "For many health care providers, one size fits all. Far too many prescriptions are being written for women who probably don't need it."
Treatment for menopause
Unless you're a woman around 50 or older who wonders if menopause means the end of your sex life and the beginning of a dowager's hump, you may not even know what HRT is.
Hormone replacement therapy is most commonly prescribed to relieve the symptoms of menopause (such as hot flashes and sleep problems) as estrogen levels decline. But for many women and their doctors, it's also the key to a longer, healthier and more youthful old age.
Replacing female hormones after menopause may -- or may not -- prevent heart attacks, lessen your chances of fracturing your hip, help you remember where you left your keys, keep your skin looking youthful, make you less irritable and improve urinary tract symptoms.
"I have a real problem with aging," says Nicky Schleider, 64, of Baltimore, who has been on HRT for 15 years and says she has had no side effects. She's done her homework on the subject and thinks she's better off taking estrogen and progestin in spite of the recent negative press the hormones have received. "You're damned if you do, and you're damned if you don't," she adds, reflecting the dilemma women face in making one of the major decisions of their lives.
Until last year, when a cholesterol-lowering drug edged it out, Premarin (a brand of estrogen tablets) was the most widely prescribed drug in the United States. That's surprising when you consider its market is limited to women who don't have their periods anymore. More than 17.5 million of them are taking female hormones, according to Wyeth-Ayerst Pharmaceuticals, the company that manufactures Premarin.
True, estrogen can increase the risk of uterine cancer and perhaps breast and ovarian cancer. Other side effects include the possibility of blood clots and irregular bleeding. But for almost 60 years, women and health care providers have felt the benefits outweighed the risks because there were no alternatives.
Now new nonhormonal drugs with fewer side effects are available to treat serious diseases of aging like heart trouble and osteoporosis. (These don't, as Dr. Anthony DelConte, a spokesman for Wyeth-Ayerst, points out, have other benefits, such as relieving menopausal symptoms.)
Women are told that taking hormones is a highly individual decision that must be made in consultation with their health care providers. In theory, this sounds like good advice. But health care providers are faced with the same conflicting evidence that their patients are.
"Doctors act in light of current knowledge," says Dr. Jacques Rossouw, acting director of the Women's Health Initiative, a huge randomized study of HRT based in Bethesda. "Currently, we don't know much. I don't think we're there yet -- to encourage or discourage [HRT] use. Fifty years after its introduction, we don't know the long-term effects."
Scientists say two things are certain about estrogen: