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Newsflash: So, estrogen is safe?

Posted by Liz on Jul 22, 2013 in estrogen | 5 comments

If you’ve been following this blog for any period of time, you know that I’ve consistently shared data that demonstrate the hormones, particularly combination hormone replacement therapy (HRT) can be dangerous, depending on age, time since menopause and other concomitant health issues. Yet, the medical community continues to beat the dead horse of trying to prove the hormone replacement in any form has a role in women’s health. And because I have promised to share the facts, regardless of whether or not I have questions about the motivation underlying their derivation, I am writing this post.

According to research appearing in the July 28 online issue of the American Journal of Public Health, estrogen actually prevents deaths among women who have had hysterectomies. By the way, that’s estrogen ALONE, not estrogen plus progestin, and that is a critical distinction.

Onto the findings. When researchers took another gander at the Women’s Health Initiative data, they sought to determine how the rate of excess mortality among women who took placebo versus those who took estrogen over the course of the landmark study actually translated into premature deaths that might have been preventable. And what they found is pretty shocking:

• The researchers looked at deaths in women who had undergone hysterectomy and still had an ovary intact compared with those who did not have any ovaries (note that sightly more than half — 54% — of women have both ovaries removed at the time of hysterectomy)
• They also examined the use of oral estrogen among the 50 to 59 year old set between the years 2001 and 2004, noting a decline by as much as 60% (largely the result of the the findings of the Women’s Health Initiative) and a relative decline by as much as 71% by the year 2009.
• In composite, they were able to calculate that between 2002 and 2011, a least 18,601 excess deaths occurred and as many as 91,61o excess deaths occurred among women who had had hysterectomies and chose not to use estrogen. This translates to an actual toll attributed to the decision of 40,292 to 48,835 deaths.

The researchers say that estrogen therapy alone reduces mortality mainly by reducing the number of heart disease-related deaths; notably early surgical menopause and complete removal of the ovaries boost the risk for coronary heart disease. Estrogen prevents the development of atherosclerosis and helps maintain normal blood flow.

It’s important to remember that these findings do not apply to women younger than age 50 or older than age 59. Moreover, they also fail to consider other reasons for the increase in heart disease among women as their estrogen declines, such as a surge in cholesterol. And, despite the improved odds against dying from heart disease, these data also ignore other health issues associated with estrogen alone, such as incontinence, hip fracture and of course, breast cancer among certain subsets of women. Hence, again, I am forced to ask the question why researchers continue to beat this horse to death when the deaths prevented may carry the cost of other issues?

I don’t believe that this is anything that will be resolved any time soon. And, as I have written previously we’re drowning in politics, medicine and industry. And it’s difficult to discern truth from fiction, data from data, risk from benefit. Ongoing analyses will eventually reveal what’s what. Meanwhile, read the library of HRT posts on Flashfree. Talk to your physician. Avoid hasty decisions. And consider alternatives. If the medical community can’t agree, perhaps it’s time to put down the gauntlet and wait out the firestorm.

The choice is yours’. Which side are you willing to err on?

Wednesday Bubble: U.S. Preventive Services Task Force Recommends Against Use of Hormone Therapy for Chronic Disease Prevention

Posted by Liz on Oct 22, 2012 in estrogen, HRT | 0 comments

I just can’t help myself. It’s Monday. But this news item calls for a Wednesday Bubble. And yet another nail in the HRT coffin.

The U.S. Preventive Services Task Force (USPSTF) issued an update to its 2005 statement on hormonal therapy late this afternoon. It reads:

“The U.S. Preventive Services Task Force (USPSTF) recommends against the use of of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women” (evidence grade D – There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits).

“The USPTF recommends against the use of of estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy (D recommendation).

Wondering what this means?

The USPTF recommendations are clear that they refer to the use of HRT and hormone therapy for the purpose of reducing a woman’s risk of developing certain chronic diseases, such as heart disease or dementia and not for the purpose of treating considering hormone therapy for menopausal symptoms such as hot flashes or vaginal dryness/atrophy. However, they are also clear about the data that explores the use of hormone therapy for chronic diseases, noting that while combined HRT has been shown to decrease the risk for fractures, this decline is accompanied by an increase in the risk for serious events that include:

• stroke
• invasive breast cancer
• dementia
• gallbladder disease
• blood clots in the veins or lungs

Additionally, they report that data do not demonstrate a decrease in heart disease and even show an increased likelihood — 1.22 times the norm — for some type of heart event.

For estrogen alone, they again note the benefits in terms of fracture reductions and even a small decline in risk of developing or dying from invasive breast cancer (e.g. 8 fewer cases or 2 fewer deaths per 10,000 person years). However, estrogen-alone has also been associated with “important harms” including:

• stroke
• blood clots in the veins
• gallbladder disease

Like combined hormone therapy, estrogen alone does not reduce the risk for coronary heart disease.

The Task Force also points out that both forms of hormone therapy have been associated with an increased incidence of stress, mixed or urge urinary incontinence after one year.

Mind you, naysayers will say that the average age of women participating in the Women’s Health Initiative were a bit older than the vast majority of women who are transitioning through menopause. To a certain extent, the Task Force agrees, calling for “new research to help better define whether there is a differential balance of benefits and harms based on age at initiation, duration of use and dose or delivery mechanism. Still, they conclude with “high certainty that there is zero to negative net benefit for the use of combined estrogen and progestin therapy for the prevention of chronic conditions and concludes with moderate certainty that there is no net benefit for use of estrogen alone.” Moreover, major health organizations are aligned with the new recommendations. For example, the American Heart Association and American Congress of Obstetricians and Gynecologists recommend against using hormonal therapy to prevent heart disease. The Canadian Task Force on Preventive Health Care and American Academy of Family Physicians are totally aligned with the USPSTF in terms of the use of hormonal therapy to prevent chronic illness in postmenopausal women. Even the North American Menopause Society, a huge proponent of hormone therapy, does not believe that hormones should be used to protect the heart or prevent dementia.

Let’s place the recommendations in context.

By the time most women reach menopause, they are expected to live at least 30 additional years. During this time, they have varied risks for developing chronic diseases, ranging from 30% for coronary heart disease and 21% for stroke to 22% for dementia and 11% for breast cancer. In an accompanying press release, Associate Professor of Medicine and of Epidemiology and Biostatistics at the University of California, San Francisco , Dr. Kirstin Bibbins-Domingo, says “the Task Force recommends a number of important preventive measures women can take to prevent chronic diseases, including quitting smoking and identifying and treating high blood pressure and high cholesterol. There are also other effective ways that women can reduce their risk of bone fractures, such as weight-bearing exercise and being screened and treated, as appropriate for osteoporosis.”

In other words, speak to your practitioner about evidence-based strategies to maintain good health and prevent disease. In this case, the evidence for HRT in disease prevention efforts during menopause is scant and the risks appear to outweigh the benefits.

Under pressure: still drinking the HRT kool-aid?

Posted by Liz on Jul 16, 2012 in heart disease, HRT | 0 comments

Proponents of hormone replacement therapy (HRT) want you to believe that the only negative analyses that are being published are the ones that examine data from the Women’s Health Initiative study. Guess what? That is not true. In fact, there is an evolving body of literature looking at other studies that are coming to similar conclusions: HRT may be a panacea for hot flashes, night sweats and mood swings. But when it comes to cancer and heart disease, you’ve got to be vigilant and aware of your risks. And yet, women continue to be ‘under pressure’ to look the other way, embrace the ‘same as it ever was’ and sift through the facts and fallacies.

Nowhere is the confusion greater than with heart disease. Some data show that long-term HRT protects against heart disease while others suggest that HRT does not.

So does it or doesn’t it?

According to study findings published this month in PLOS ONE, it does not. In fact, the longer you use HRT, the greater your risk of developing high blood pressure, a major, proven factor in heart disease. Here’s what you need to know about this latest information:

• Researchers examined information collected on over 43,000 Australian women who were part of a large-scale study on aging. The women were 45 and older, postmenopausal, had an intact uterus and had not been diagnosed with high blood pressure prior to entering menopause.
• Factors that might influence high blood pressure risk, such as obesity, smoking or lack of physical activity were also examined. On average, the women in the study who used HRT reported having sufficient levels of physical activity, were past (but not current) smokers, drank alcohol and had a healthy body-mass index.
• In the study, the average age that women entered menopause and had ever used HRT was 48 years and most were about 52 years old when they started hormone replacement. Comparatively, women who used HRT developed high blood pressure by age 58.
• The findings showed that younger women (<55 to 61 years) who used HRT had 1.5 times the odds of developing high blood pressure than women who did not. The risk dropped slightly as women got older (between the ages of 62 and 70, HRT users had 1.2 times greater odds of high blood pressure).
• The longer that HRT was used, the greater the odds of developing high blood pressure, with highest risk among women who had used hormone replacement for 6 to 10 years or more. Again, as women in the study age, this risk appeared to decline.

One of the biggest criticisms of the Women’s Health Initiative was that it looked at an older group of women who were not representative of the average age that menopause starts. Here, the data show that in younger women, the odds of HRT being associated with high blood pressure are significant regardless of other potential confounding lifestyle factors. The investigators say that women should be prescribed HRT for the shortest time as possible and that they should be closely monitored for blood pressure before, during and after they stop hormones. Further, they state that “high blood pressure should be conveyed as a health risk for people considering MHT (menopausal hormonal therapy) use.” They also add that these recommendations are aligned with current recommendations for hormone use by the US Food & Drug Administration.

Are you still drinking the HRT kool-aid? You may want to switch beverages, especially if you care about your heart.

Wednesday Bubble: Politicizing Menopause

Posted by Liz on Jul 11, 2012 in HRT | 5 comments

This past weekend, the International Menopause Society (IMS) issued a public statement calling on the National Institutes of Health (NIH) to revise current recommendations on use of hormone replacement therapy (HRT). In this statement, the IMS stated that it believed that the “NIH has been guilty of unbalanced reporting in failing to inform women of the latest information,” adding that it “calls on the WHI (Women’s Health Initiative) and the NIH to revise its advice to reflect current consensus — not just the initial WHI results.” IMS President Dr. Tobie de Villiers said “Of course there are differences between what the WHI thinks and what the menopause community thinks, but I think that it’s fair to say that in many ways the WHI has moved more towards our position over the last 10 years. In spite of this, they have not been particularly even-handed in presenting results. For example, the main NIH patient brochure on HRT has not been updated in the last 7 years, in spite of a wealth of new information…the least that they can do is agree that HRT is a good option for symptom relief for most women going through the menopause.”

If you’ve been following the news or this blog closely for the past four years, evolving analyses of WHI data don’t entirely support this last statement. Moreover, several organizations, including the US Preventive Task Force, the US Food & Drug Administration, the American Association for Cancer Research and the Canadian Cancer Society have issued warnings about of combination HRT or estrogen alone with regards to timing and duration of use. And, two years ago, I quoted lead study investigator for the Canadian Cancer Society — Dr. Prithwish De, who said that “The Canadian Cancer Society’s ongoing review of the evidence on HRT and breast cancer since 2003 led us to our current position and the research study findings reaffirm this position. The Society recommends that women avoid taking HRT for any reason other than to relieve severe menopausal symptoms that have not responded to other treatment. We understand that each woman’s experience with menopause is unique. If, after consulting with their healthcare professional, a woman decides to take HRT, it should be the lowest effective dose for the shortest time possible.”  Notably, like the IMS, the North American Menopause Society’s recommendations also tend to minimize certain noted risks.

So, why the disconnect?

Is it at all possible that menopause has been overpoliticized, medicalized and poorly characterized, a “phenomenon not so much hijacked by medicine as gradually occupied, [with] authorities throughout the ages grimly trying and failing to define their subject?”1

In a recent editorial in Menopause journal, several authors express concern that the North American Menopause 2012 recommendations on use of HRT do not include caveats with regards to prevention of coronary heart disease (CHD) or stroke and also ignore data suggesting that longer-term use of estrogen-alone may not be safe. Noting that “long term observational data are especially unreliable for CHD (as they reflect the experience of women who were not susceptible to early risk), they add that 1) lifestyle choices have the ability to influence the likelihood of developing heart disease and 2), that generalizations as to ongoing lower risk rates should HRT not be used for longer periods cannot be assumed. They also point out that the NAMS statement blatantly understimates stroke risk on younger women who choose hormone therapy. These concerns are largely echoed by Jacques Rossouw, M.D., National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Chief, Women’s Health Initiative Branch, who sent me an email statement when I asked for a comment. He writes:

“WHI has made substantial contributions to our understanding of the effects of hormone therapy, providing women and their physicians with much better information on which to base an informed decision about the use of hormone therapy.  In women close to menopause, the risks of short-term use of hormone therapy for treatment of hot flashes and night sweats are small, and WHI investigators have supported short-term use, provided that patients are fully informed of the risks and benefits. The main objective of the WHI was to address whether hormone therapy should be used to prevent cardiovascular disease in postmenopausal women ages 50 to79, and the data on this are overwhelming.  The risk of coronary heart disease is particularly increased in older women, especially among older women with hot flashes and night sweats. Therefore, hormone therapy should not be used in older women to prevent coronary heart disease or even to relieve vasomotor symptoms (hot flashes and night sweats). Even in younger women, long-term hormone therapy is unwise because of the likely increasing risk of breast cancer over time, and uncertainty about long-term cardiovascular effects.  The hormone prescriptions for older women have decreased more markedly than in younger women, and this seems an appropriate response to the data. It is not possible to evaluate whether hormone prescriptions to younger women are at an appropriate level.”

We’re drowning in politics, medicine and industry. And it’s difficult to discern truth from fiction, data from data, risk from benefit. Ongoing analyses will eventually reveal what’s what. Meanwhile, read the library of HRT posts on Flashfree. Talk to your physician. Avoid hasty decisions. And consider alternatives. If the medical community can’t agree, perhaps it’s time to put down the gauntlet and wait out the firestorm.

1. Louise Foxcroft, Hot Flushes, Cold Science. A history of the modern menopause. London: Granta Press. 2009.

Personality and hormone replacement. Give me an “A!”

Posted by Liz on Jul 9, 2012 in HRT | 4 comments

Researchers say that personality plays a role in driving health beliefs, taking medication as directed and ultimately, health outcomes. However, does it also drive treatment choice?

Evidently yes, at least according to a fascinating study published online in Fertility and Sterility journal. In fact, if you are a type A (i.e., possess a sense of time urgency, are a high achiever, ambitious and competitive), you may be likelier than other personality types to make the choice to use hormone replacement therapy (HRT) during menopause. Although the reasons may be more complex than laid out in this article, they appear to be related to the desire to be self sufficient, rely on problem-solving coping strategies and a tendency to disregard threatening information when making decisions. In other words, women with type A personalities may choose hormone therapy over other options in order to attain immediate relief rather than focusing on the future and longer term delayed ramifications.

They came to this conclusion by reviewing ongoing questionnaire data over a period of 18 years that measured both personality type and hostility.  Among the 1,800 or so women who completed the surveys over this time period, 51% used hormone therapy within a year of starting menopause. Despite the fact that the researchers accounted for factors such as age, psychological factors like depression and hostility, and even factors such as education, the frequency of seeing a gynecologist or degree of menopausal complaints, personality type was the only variable significantly associated with hormone replacement. Additionally, they did not find any link between hormone use before or after 2002 when the Women’s Health Initiative results were unveiled and personality type.

The researchers say that the link between hormone use and personality type may exist because menopause threatens a type A’s goals and lifestyle and the need for achievement and power, dominance and self-confidence. In order to maintain an active lifestyle and problem-solving focus, overachievers naturally reach for concrete, immediate solutions such as hormones.What’s more, the tendency to minimize information that threatens ones core belief system may also influence how one interprets benefit-risk, and the interpretation of short-term gains over long-term dangers. They also say that physicians may be more motivated to prescribe HRT to type A women because they interpret them as being “responsible, committed, decision-prone and persistent.”

I am not sure what to make of this research as I consider myself and many of my friends to be type A, driven women who make choices based less on haste and more on education. The question remains as to whether or not we are the exception or actually the rule.

What drives your health decisions? Is it an “A?”