Women aren't getting straight answers about hormone therapy

October 20, 2002|By Susan Reimer

I keep an illustration pinned up at my desk, right where I can see it.

In it, there is a picture of an old-fashioned control panel with lots of switches, dials, gauges, toggles, meters and lights.

It is labeled "female sexuality."

Above it, in the same illustration, is a picture of a light switch.

It is labeled, "male sexuality."

That illustration serves to remind me that the failure of medicine to help women manage their sexual health might not be the result of malevolence or neglect.

It might be because we are very complicated, and there are no simple answers.

I have needed that reminder of late.

Last spring, the Heart and Estrogen / progestin Replacement study of post-menopausal heart disease patients found that hormone treatments that included estrogen plus progestin failed to protect against heart attacks.

Then in July, a government-sponsored study was abruptly halted when it was found that women in the study who were taking estrogen plus progestin were more vulnerable to breast cancer, heart attacks and blood clots.

In an attempt to sort out what we know and what we don't know about hormone therapy, the health care providers who treat women in menopause met recently in Chicago.

The North American Menopause Society has 2,000 members. That 1,500 of them signed up to attend is an indication of the level of concern and confusion out there.

Since the abrupt halt to the Women's Health Initiative study in July, anxious women have been demanding answers from their doctors: Do I take hormones or not?

To answer these questions, the NAMS put together a panel of healthcare professionals from both inside and outside its membership and asked them to recommend guidelines.

The experts began by reminding doctors that hormone replacement was originally prescribed to deal with menopausal symptoms: hot flashes, vaginal dryness, sleeplessness and general foggy-headedness.

Somewhere along the line, HRT was pitched to women as a way to prevent heart disease and bone loss, too, and they signed up enthusiastically.

But the NAMS recommends that women and their doctors get back to basics, using HRT in the smallest possible doses and for the shortest amount of time to manage the so-called "quality of life" issues that menopause presents.

How small a dose? How short a time? There was no consensus because there is no data that demonstrates at exactly what point the disadvantages of HRT begin to outweigh the advantages.

The common sense answer seems to be, go off HRT and see what happens. If you are still miserable, consider going back on it.

There were also no recommendations for women in premature menopause or women in the stage that is known as peri-

menopause, when the symptoms of this transition begin to emerge. That's because the average age of the women in the study was 63.

For the prevention of heart disease, women should exercise and use soy products and cholesterol-lowering medicine, the panel concluded.

To prevent bone loss, the panel recommended women consider alternative therapies, such as substantially increased calcium intake.

Though the marketing of herbal products has muddied these waters, the panel suggested black cohosh, an herb, for the relief of hot flashes. It might also improve moods and sleep when taken in doses of 39 milligrams to 127 milligrams, they reported.

The panel also trotted out that old standby cure for what ails you: eat a healthy diet, get plenty of exercise and maintain a normal weight.

Dr. Richard Marvel of the University of Maryland Medical School, an assistant professor of obstetrics, gynecology and reproductive health, says women need to think of hormone replacement therapy in terms of what it means to them and their health. It isn't helpful to think in terms of what it meant to all 10,000 women in a study, he said.

"From a public health point of view, should we put a million women on hormone replacement to decrease their risk of heart disease? The answer is probably no.

"But, should Sally Jones take HRT because she is having hot flashes? The answer is probably, yes," he said.

"If you get symptomatic relief by being on HRT, then it is a valuable, safe and effective therapy for you. You are getting a benefit, and that is good."

Though the NAMS recommendations clarify the confusion over HRT to some degree, this is very much like the conflicting messages women receive about cancer-screening mammography: is this an early detection tool or not? And does early detection mean cure, or not? Should we get a mammogram or not?

We just don't know.

"Research is very important from a public health standpoint, in terms of treating a million women. But it gives us much less information about how to treat the women sitting across from me in my office," Marvel says.

"This study does not answer the question for every woman."

If women seem irritable, our irritation might be a symptom of menopause.

But it might also be impatience with the fact that, when it comes to our reproductive health, we can't seem to get a simple answer.

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