HRT – Put up your dukes
Ladies (and gents)…in this corner, weighing in with fear, loathing and disease-mongering, hormone replacement therapy (HRT). And in the other – weighing in as ‘snake oil,’ everything that “doesn’t work,” remains “unproven,” is “unsafe,” hasn’t been approved by the Food & Drug Administration, alternative strategies. Put up your dukes!
Sounds like a boxing match without a referee, eh?
Adding to the controversy are recent study findings showing that Pfizer’s Preempro (estrogen plus progestin) HRT may increase the risk of aggressive, invasive breast cancer and deaths from breast cancer in some women. In fact, the lines continue to be drawn between those who will fight for their hormones no matter what and individuals who believe that either greater regulation is needed or that hormones should be taken off the market altogether. It reminds me of the controversy over mammography, which has been not been proven to decrease breast cancer rates or improve survival. That’s a post for another day, although I encourage you to check out the posts that my friend Marya has written.
The argument against using the Women’s Health Initiative Study (WHI) data to demonstrate the dangers of HRT focuses on the small percentage of women enrolled in the original study who were in the age group (5o to 54 years) when women would be starting hormone therapy. Indeed, research shows that in addition to the type of progesterone added to estrogen, the time on hormone therapy can significantly influence health risks. Moreover, in the WHI, women who took estrogen only were not shown to have increased breast cancer risk (but a heck of a lot other increased risks – just look at the data). And yet, after the WHI hormone study was halted in 2002, substantial declines in the rates of breast cancer were noted in numerous countries, including Canada and the United States. Adding fodder, many pro-HRT experts argue that the alternatives – bioidenticals or complementary medicine – are unproven and downright unsafe.
In case you’ve not been reading this blog regularly, I believe the following and wrote it to a very passionate reader of HealthNewsReview Blog who felt that I was marginalizing women’s suffering:
For decades, women have been duped into believing that menopause is a disease that requires medical treatment, but at the same time, researchers have been unable to differentiate many of its symptoms from those of aging. Consequently, it’s imperative not only to ask what we are treating but why and how.
By all means, if you are comfortable with HRT and other treatments, go for it. But use them with eyes wide open and always examine the risks versus benefits. You might be surprised by what you learn. And how much we still don’t know.
I recently ran across the following statement with regards to the confusion:
“Some things don’t need to be healed; they just need to progress naturally.”
When you’re down for the count, sweating and flashing and swinging without a referee, the call about HRT can be a tough call to make. The good news? Menopause won’t kill you and symptoms do eventually go away. It is just one more of life’s transitions that we have to navigate. Just try to steer yourself towards informed choices and decisions and always, ask the hard questions. There are always those who ‘do,’ and those who ‘don’t.’ Just be sure you’re doing or not for the right reasons.
HRT and breast cancer – more red flags
More bad news from the Women’s Health Initiative study and hormone replacement therapy (HRT, combined estrogen and progestin) front: not only does combined HRT appear to double the risk for breast cancer in some women, but these cancers are more invasive/agressive and more likely to lead to death.
The WHI findings have been repeatedly criticized by HRT advocates, who claim that the the women who were studied were not representative of the typical menopausal population, e.g. they were older and well past menopause at enrollment. So it is true that the potential benefits of HRT that might have been experienced by younger women were not explored. Indeed, time on hormones and the relationship between hormone use and how far into menopause a woman is can influence risk, as can the progestagen component. (If you want to read more about these specific factors, click on the links.) Nevertheless, what is also clear is that following the 2002 findings and the significant decline in HRT prescriptions, a substantial decrease in breast cancer rates were observed in both the US and Canada, so much so that the Canadian Cancer Society recently recommended that HRT be taken only as a last resort.
And the latest study findings?
In their continuing quest to determine insights into the risk-benefit ratio of HRT, researchers continued to follow and evaluate data from 83% (12,788) original trial participants. They found that HRT increased the incidence of invasive breast cancers by as much as 8% (compared with placebo), and that these cancers were also likelier to spread to the lymph nodes (24% of women taking HRT were found to have lymph node tumors compared to 16% of women taking placebo). Moreover, twice as many women on HRT died as the result of their cancer.
In an accompanying editorial, Dr. Peter Bach, a health outcomes researcher from Sloan-Kettering Medical Center in New York City, suggests that the latest study findings may only be the tip of the iceberg and that “it is possible that the increase in breast cancer deaths due to hormone therapy has been underestimated in the current study and that with longer follow-up, the deleterious effect will appear larger.” Additionally, he notes that “available data dictate caution in the current approach to hormone therapy, particularly because one of the lessons from the WHI is that physicians are ill-equipped to anticipate the effects of hormone therapy on long-term health.” Nor, have short-term approaches to hormone therapy been proven in clinical trials. As Dr. Bach points out, how can practitioners help patients make informed decisions if they are ill-informed themselves and the information, “speculative.” Nevertheless, the North American Menopause Society is taking the opposite stance, stating that ” clinicians can help women put the breast cancer risk into perspective by informing them that the increased risk of breast cancer using estrogen plus progestogen for 5 years is very similar to the increased risk of breast cancer associated with having menopause 5 years later. This increased risk of breast cancer occurs with a woman’s own internal, natural estrogen and progesterone.”
If this study and its accompanying editorial don’t raise a few flags, nothing will. And despite the pro-HRT stance of the North American Menopause Society, I encourage all women to start educating themselves before making the HRT leap. What’s more, be aware that once you start taking hormones, your practitioner might not be able to provide evidenced-based information on how to stop them, should you decide that they are not for you.
Ask yourselves, what is the trade-off here?
(Reuters Health, as usual, has a few more gems from this study that are required reading. You can find them here.)
Read MoreWednesday Bubble me this: end the ‘silent suffering’
Bubble me this. When you think “chronic health condition,” what do you think of? I think heart disease, diabetes, multiple sclerosis or cancer. I don’t automatically think vaginal atrophy. And yet, it’s what’s for World Menopause Day.
The International Menopause Society (IMS) joined forces this year with Novo Nordisk FemCare Ag (marketers of Activella®) to ‘end silent suffering’ and promote recommendations for the management of vaginal atrophy during the menopause. A key problem, they say, is that results of a phone survey show that women are not discussing vaginal atrophy with their practitioners, who in turn, are not openly asking questions about vaginal health.
Vaginal atrophy refers to the thinning of the vaginal and vulvovaginal tissues due to a decline in estrogen, and can lead to pain, burning and soreness during sexual intercourse. Recent estimates suggest that vaginal atrophy affects about 50% of menopausal women. Symptoms can be mild or severe, and unquestionably, the more a woman feels pain, the more she is likely to be distressed during intercourse or lose interest in sex altogether. What’s more, according to survey results, the majority of postmenopausal women incorrectly attribute vaginal atrophy symptoms to urinary tract and yeast infections. More importantly, the report notes that roughly 63% of surveyed women did not realize that vaginal atrophy was “a chronic condition requiring ongoing treatment of the underlying cause.”
A chronic condition requiring treatment?
Granted, a chronic condition is defined as a health problem lasting three years or longer. And depending on how long a woman’s menopause lasts, well, vaginal atrophy theoretically fits into that category. But aren’t we being a bit alarmist about the ‘silent suffering’ of women with this chronic condition?
Mind you, I am not mocking or doubting the horrible impact that vaginal atrophy can have on a woman’s life. In fact, aging and its accompanying aches and pains aren’t fun. Neither are hot flashes, night sweats, mood swings or vaginal pain. And I am heartened to see that the IMS has published recommendations for recognizing and managing vaginal atrophy. They include:
- Greater collaboration and open discussion with postmenopausal women about their vaginal health
- Early detection of vaginal atrophy
- The value of estrogen therapy in treatment, including HRT or preferably, vaginal tablets, cream or rings
According to these recommendations, lubricants and moisturizers are not universally recommended for use by themselves because they can be irritating and offer only temporary relief of symptoms. However, as Dr. Diana Hoppe points out in her book, Healthy Sex Drive, Healthy You, “to get the vagina adequately lubricated, I initially recommend lubricants [e.g. Replense or Astroglide]. If lubricants do not work to make sex more comfortable, I prescribe vaginal estrogen therapy, which comes in different forms.” The point that she makes is that it is important to consider lubrication issues (and the resulting atrophy) as something that can be addressed in a step-wise fashion. Nor does she discuss atrophy and dryness as if they are symptoms of a chronic condition. In fact, like Dr. Christine Northrup, Dr. Hoppe emphasizes that women’s health issues, in particular desire, are multifaceted and emotionally and physically related. Toward that end, is it possible that by focusing solely on the physiological aspects of atrophy, practitioners might miss other important factors?
The IMS recommendations also fail to mention selective estrogen receptor modulators (SERMS), which mimic the action of estrogen in the body but theoretically, without associated risks and side effects. Most importantly, while ‘localized’ estrogen (i.e. topically or vaginally applied) may have a better safely profile than systemic estrogens (which directly enter the bloodstream after being ingested or injected) it is not without risks; according to its package insert, Activella is associated with pain, headache, nausea, vomiting, irregular bleeding and thickening of the vaginal wall and and also has a boxed warning about heart disease, stroke and blood clotting.
There’s an inherent lesson here, which is why this piece is featured on Wednesday: by all means, seek help for vaginal atrophy but ask questions about the therapy your doctor or practitioner recommends. If your symptoms are severe, well, you might want to skip the lubricants and go for the big guns. And be sure to consider factors other than estrogen depletion that might be contributing to a declining libido. If there’s one thing that appears to permeate all women’s health issues, it’s this: nothing is as cut and dry as it seems.
I hardly believe that we’re on the verge of an atrophy epidemic or that we need to dramatize the “silent suffering” of countless women across the globe.
Bursting this one? Yeah, you bet.
Read MoreIt’s World Menopause Day! Chew on this.
For two years, I’ve run the same piece on World Menopause Day. That post remains one of my favorites and I encourage you to check it out. This year, however, I’d rather call attention to the fact that having only one day devoted to menopause seems to run counter to the marketplace. Just check out the endless Wednesday Bubbles on Flashfree and you’ll realize that menopause is big business. Recent estimates place the market for hot flashes alone as high as $8B and that doesn’t necessarily focus on new applications for existing treatments, for example, antidepressants for hot flashes. With a market this huge and the shrinking HRT market as the result of potential risks exposed in the Women’s Health Initiative, no wonder menopause has become such a hot commodity. Hell, there’s even a burgeoning market for male menopause, an oxymoron if I’ve ever heard one.
- Feeling old? There’s a pill for that.
- Flashing? There’s a gum AND a drink for that.
- Wrinkly skin? Try this wonder cream!
- Don’t like your vaginal appearance? How about some rejuvenation? Better yet, get a two for one and a few botox shots while you’re at it.
…Tapes, magnets, ‘all-in-one’ supplements, everything for anything and everything that ails.
Beneath the hype, marketers are actually saying us that they don’t want us to look or be our age. But don’t try to look younger or date younger because then you are just inappropriate or better yet, a Cougar. In fact, just don’t exist. You’re over the hill, washed up, invisible. Call it a day.
But wait!
Why not have a ‘World Menopause Don’t Call it a Day… Yet?’ The old fat lady dressed inappropriately still has a few tunes left in her.
Rather than celebrate a year or hum a new menopause jingle, can we just find a way to embrace ourselves and what we are going through? We did great in our 40s, comfortable in our skins, more beautiful than ever. And then 50+ or its precipice started to get in the way and here we are, with a day on a the calendar and nothing to wear. How about wearing ourselves for a change or for the change?
Just a wee bit of fodder on yet another day of the year, week, month. Chew on this, won’t you?
Read MoreNational Domestic Violence Month – You are not alone
I don’t generally get too overexcited about National [fill in the blank] months, days or years. In fact, these days, we are so innundated that it’s a wonder that any initiative that deserves attention actually gets it. However, I believe that National Domestic Violence Month is one of those ideas that deserves attention. A lot of attention.
I am not going to bombard you with statistics about sexual abuse or violence against women; they are readily available though organizations like National Coalition Against Domestic Violence and the Centers for Disease Control and Prevention. However, I do want to focus on something that women need to be aware of, especially if they are newly-divorced or newly-single and back on the dating scene again.
When you think domestic or intimate partner violence, what do you think of?
More often than not, the first thing that comes to mind is sexual and physical abuse, right? And no wonder, because it is truly a national if not an international problem, and increasingly prevalent among teens as well. It can cross genders, ages and race. However, domestic or intimate violence can also be emotional, either in conjunction with physicality or by itself. In fact, like physical abuse, emotional abuse is similarly based on power and control. Emotional abuse is verbal or non-verbal, it is constant criticism and repeated disapproval, it is blame, insults, accusations and insinuations. And, although it is intangible, it systematically destroys self-confidence and creates deep scars that can take years and a lot of work to heal. A key reason that women often don’t report being emotionally abused is that it’s hard to prove. And its wounds can be so deep that the cycle becomes too powerful to break.
I know strong, self-empowered women who wound up in a cycle of emotional abuse, hardly realizing what it was other than it made them feel terrible on a daily basis.
I am one of those women.
I am not going to name names or provide details. But I will share that over time, self-blame starts to set in and it’s easy to believe that there’s something wrong with you, not your partner. And instead of walking away, you stay long after you should stay.
My story is a common story. I partnered with someone who presented himself as one way to the world and another to me. A seemingly charming man who wooed me and then turned into Mr. Hyde.
Bad day? My fault. High rent? My fault. His unhappiness? All my fault. Another viewpoint? Nope, not allowed. The ‘boss’ of [fill in the blank]? Him, not me. Compromise? Not real good at it. Invalidation? All the time. Highlighting my flaws? Yes. Explosive anger? You bet. I walked around on eggshells for most of the relationship, always trying to please, to try to make him like me, to make things better…”if I, then” set in fairly quickly.
He really didn’t like me. And you know what? I didn’t really like him. But I stayed with it because damn it, I was going to prove to him that I was worth it.
By the time the relationship was over and I made the decision that it was time to cut my losses, I had lost a lot of weight and a lot of me. At the end, 12 pounds lighter and in for a long haul of therapy, I realized that I was angry, damn angry. But mostly at myself for allowing the abuse.
The weight eventually came back on. I did (and continue to do) a lot of therapy. I had another relationship and learned to trust — not only him — but also myself. But I’m still wary. And some of the trauma and self-doubt remains with me to this day.
Emotional abuse is ABUSE. Don’t let it happen to you. Talk to someone. Let them in. If you need help, please, please get it. Contact the National Domestic Violence Hotline (1-800-799.SAFE).
Truly, you are worth it. And you know what? I am too.
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