Estrogen: Worth the risk?
Any regular reader of this blog knows that I am not a fan of hormone replacement therapy (HRT) nor the health risks associated with it. Nevertheless, although I espouse alternative strategies for dealing with menopause, I do feel that sharing news about HRT is important; accurate information leads to informed and shared decisionmaking.
So, do they (i.e. hormones) or don’t they (cause harm)? Undoubtedly, important variables come into play, including current age, how close to menopause hormones are started, current health status, whether or not a woman has had a hysterectomy, smoking history, etc. Also important is whether estrogen is used alone or in combination with progesterone. And yet despite these factors, many medical organizations continue to recommend that HRT be used for the shortest time period possible if at all.
Still, researchers continue to delve into data from the now infamous Women’s Health Initiative Study to tease out the bad, ugly and even the good.
This week, they are reporting on over 7,600 women who had taken estrogen alone for approximately 6 years, had had prior hysterectomies and were followed for an average of 10 years after the trial ended. If you recall, there has been some controversy as to whether or not estrogen alone is safer than combined HRT and actually lowers the risk for breast cancer in particular, which is why these data are particularly intriguing.
The researchers report that age at the time that hormone therapy (in this case, estrogen alone) is started is important. In fact, women who started estrogen therapy in their 50s, an increased risk for stroke and embolism, which appeared while taking estrogen, actually disappeared in the years that followed. Unfortunately, so did protection against hip fracture. Moreover, earlier reports of a decline in breast cancer risk were upheld despite body mass indices. However, the researchers say that this finding in particular, runs contrary to the preponderance of evidence from the majority of observational studies which show that estrogen use increases the risk of breast cancer, especially in lean women and after a long time period of use.
In an accompanying editorial, also in JAMA, the authors point out that more than 80% of women who took estrogen as directed only used it for an average of 3.5 years. Their point is that the results don’t directly address the “balance of risk and benefits associated with longer term estrogen use.” They also point to a larger review of data that show duration is an important factor when it comes to breast cancer risk, especially among lean women. Additionally, they say that tamoxifen, which actually antagonizes estrogen, has been shown to reduce breast cancer by 50%, which has led the International Agency for Research on Cancer to “conclude that unopposed estrogen therapy and combination HRT are carcinogenic.”
Are you confused yet?
Both set of researchers say that the decision to use estrogen or not is one that should be made between a woman and her doctor. Don’t forget: study findings continue to contradict. They add that while “there may still be a role for short-term use of unopposed estrogen for treating some women with menopausal symptoms, this role may be vanishing as existing and emerging data continue to be better understood in terms” of patients.
My thoughts? Err on the side of caution. Always.
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 MoreStressed out? No wonder you can’t remember…
I have a friend on Twitter who coined the phrase “can’t remember shit.” This phrase greets me throughout the day because I am constantly forgetting even the simplest things. Why did I enter this room? What was I going to look up? How did I get here? Why can’t I focus? And lists? Fuggedaboutit – they don’t do squat; even when I have them, I forget.
I blame my memory and focus problems on hormones all the time. However, if this were true, then the addition of hormones, in particular estrogen, would balance out the forgetting and boost my attention and focus, right?
Hence, I was intrigued when I ran across a small study in Menopause looking at cognition and stress, which seemed to back an earlier contention that stress plays a huge part in recall ability in menopausal women.
In this rather small trial, 22 postmenopausal women (50 to 83 years) took either placebo or an estrogen tablet (1 mg estradiol daily for one month and then 2 mg daily for two months). After three months, they were asked to ingest a substance that depleted certain compounds (called monoamines) that the body manufactures and uses to stabilize mood, perform a mildly stressful test, and then undergo a series of tests on stress levels, mood, anxiety and cognition.
It appears that at least in this small group of women, taken estrogen was actually linked with poorer cognition following a stressful event, including the ability to recall words and slower reaction time. Because this occurred independently of the depletion of mood compounds or negative mood, the researchers say that the effect of estrogen, which has been shown in some studies to improve cognition, is not as straightforward as previously believed. What’s more, the significant increase in stress and stress reactions during menopause may actually interfere with estrogen benefits in so far as memory and recall go.
Our lives are increasingly busier, especially now that we can be connected 24/7. Personally, I can’t even get a work out into my day without some sort of interruption. That’s why it’s so important to figure out how hormones interact with stress, so that we can make informed decisions — not only about menopausal decisions — but also about general life decisions.
Look, memory recall and attention are undoubtedly linked to aging, at least to some extent. But now? Stress may be playing a role in how hormones impact our reactions, focus and attention span, and memory. So the next time you can’t remember shit? Maybe a few deep breaths can help.
No wonder!
Read MoreWednesday Bubble: osteoporosis – all bets are off!
Which came first? The chicken or the egg?
When it comes to osteoporosis, all bets are off. Researchers are now saying that age and not estrogen decline is the primary culprit in development of osteoporosis in women. Estrogen simply acts to “accentuate” the negative results.
Aging increases what science refers to as “oxidative stress.” This means that as we age, an imbalance is created between certain molecules that freely circulate in the body (better known as free oxygen radicals) and cause major damage to cell and vessels walls and the body’s natural ability to fight them off. Not surprisingly, oxidative stress has been linked to numerous chronic illnesses, including cancer, heart disease and diabetes.
In so far as osteoporosis goes, the loss of estrogen and androgens decrease our natural defenses against oxidative stress in bone in particular, leading to increased bone breakdown (resorption). The body also starts to overproduce certain hormones that directly affect the the vitality of the skeleton, causing bones to become brittle and more prone to fracture. However, studies also show that bone loss can begin in both women and men as early as age 30 or so, well before any major changes in sex hormone production.
The question is, what can we do about it?
Researchers have also found that there is a specific family of proteins in our bodies that act as a natural defense against oxidative stress. These proteins, better known as FOS (foxhead box transcription factors) are integral to a healthy lifespan and also, preserving bone mass. If researchers can identify what causes the decline in FOS, they may be able to devise strategies to preserve our reserves. Meanwhile, estrogen gets at least a partial reprieve this time.
Sources: Manolagas SC. Endocrine Reviews. 2010. Ambrogini E. Cell Metabolism 2010;2:136-146.
Read MoreHope for hops: hot flashes and night sweats
Do you remember last August’s post about beer and bone health? If not, research suggests that beer boosts bone density, or more specifically, a certain component in hops — namely female flowers — have high estrogen properties that help bone formation. More recently, researchers have been evaluating a standardized hop extract (8-prenylnaringenin) for the treatment of menopausal hot flashes. Among the many phytoestrogens contained in the female hop flowers, 8-prenylnaringen has been associated in laboratory studies with the highest estrogenic potency compared to others.
In a small, randomized, scientifically-sound study, researchers assigned menopausal women to either a hops extract 8-prenylnaringenin for eight weeks or placebo for 8 weeks; then they switched. Although both groups showed modest reductions in mild vasomotor symptoms (hot flashes, night sweats) during the first 8-week period, only women taking the hops extract after first taking placebo experienced higher average reductions in their flashes and sweats. Although these changes were not considered “significant” they did lead the researchers to conclude that preparations containing 8-prenylnaringenin might offer an alternative to hormones for women who experience mild vasomotor symptoms.
Are hops completely safe?
Most people do not experience side effects when taking hops. However, like any herb or drug, reactions are individual. In some people, hops can cause allergic skin reactions (e.g. rash) when handled. Hops can also cause mild drowsiness, which is why hop extracts shouldn’t be taken with sedatives. In some cases, hops has been shown to lower blood sugar levels. And of course, as a phytoestrogen, it should not be used at the same time as hormone replacement and only under doctor supervision if you’ve had breast cancer.
So, it’s too soon to tell. But indeed, there’s hope for hops!
Read MoreUnchain my lungs…estrogen and asthma
As the evidence continues to accrue against the use of combined hormone replacement therapy (HRT), attention must be turned to estrogen-only hormone replacement therapy. However, is it safer?
In the Women’s Health Initiative, which was halted last decade, taking estrogen alone was associated with an increased risk of blood clots, stroke, impaired cognitive function and dementia. In the latest bit of information to hit the news, estrogen-only therapy may also increase the risk for developing asthma.
Results of a 12-year study among almost 58,000 women who were not suffering from asthma at the start of menopause showed that they were 21% more likely to develop asthma symptoms. This risk was significant among women who had been taking estrogen only compared to women who had never used hormones, had a 54% greater risk of developing asthma. The risk was even greater among women who had never smoked, although a small proportion of study participants had allergies prior to developing asthma.
Once again, Reuters has done an excellent job of reporting on this study and has some great quotes from the researchers as well.
Meanwhile, what should you do if you’ve been taking estrogen to combat the symptoms of menopause? As always, you have a choice and only you and your practitioner can determine if you are at risk for developing any of the conditions that are associated with hormonal therapy. The good news? Breathe easy. Yet another reason to lose the hormones…for good.
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