Last word has yet to be said on risks and benefits of hormone therapy

Medicine & Science

March 15, 2004|By Judy Foreman | Judy Foreman,SPECIAL TO THE SUN

All right, ladies, here we go again.

About 20 months ago, postmenopausal women taking combined estrogen and progestin therapy panicked at the news that a popular hormone pill, Prempro, carried more risks than benefits overall.

Some swore off hormones, causing Prempro sales to fall by 66 percent. Some began cutting back on doses or trying different formulations, such as 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 this month with the announcement from the Women's Health Initiative that women taking estrogen alone, without progestin (a synthetic progesterone), also faced an increased risk of stroke, albeit a small one. And they get no protection against heart disease, as doctors had hoped. Once again, this exercise pits respected researchers armed with vast quantities of data against 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.

Doctors are still writing an estimated 57 million hormone prescriptions a year, just slightly less than the 58 million they were writing in 1995. That was just before the huge surge in hormone treatments.

So, to put all this in perspective: First, the increased risk of stroke on estrogen alone was comparable to that of 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 might not say much about women who start hormones at menopause. As Dr. Alan Altman, a Brookline, Mass., 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 prefer a "bio-identical" estrogen called 17-beta- estradiol, which is made in the body and can also be synthesized from soy and yams.

This might 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. So researchers must spend the next two months, before official publication of the WHI results, trying to figure out why.

Obviously, what's needed is an alternative that carries the benefits of hormones without the risks. But there's little long-term data on herbal remedies such as black cohosh. Antidepressants known as SSRIs, particularly Effexor, help some women with mild to moderate hot flashes but don't combat severe ones, 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.

Which leaves some women, like Barbara Howerton, 50, a nurse in Brookline, 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 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," Altman said.

Dr. Carolyn Shaak, medical director of WomanWell, a menopause clinic in Needham, Mass., 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. She also offers hormone preparations that are "bio-identical" - that is, chemically the same as a human estrogen, called estradiol.

There are theoretical reasons why these formulations might be better. But there are no large studies documenting whether they're safer or have better risk-benefit ratios than standard formulations.

Still, Mandy Waddell, 60, a retired teacher, singer, photographer and kayaker, is convinced. She likes the fact that Shaak tested her blood for levels of 17-beta-estradiol, testosterone and progesterone before writing any hormone prescriptions. The doctor periodically re-tests it, changing the prescription as necessary. Waddell then uses hormone creams that are "compounded" specifically for her by a pharmacist.

All that fussing is unnecessary, said Dr. Nananda Col, a menopause researcher at Brigham and Women's Hospital in Boston. "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."

Judy Foreman is a lecturer on medicine at Harvard Medical School.

Baltimore Sun Articles
Please note the green-lined linked article text has been applied commercially without any involvement from our newsroom editors, reporters or any other editorial staff.