HRT – How do you stop?
A Twitter friend recently asked me about stopping hormone replacement therapy (HRT). It was a question that I hadn’t explored on this blog. Although the foundation of Flashfree is to provide information about alternatives to HRT, I’ve never really considered the “what now” of the issue, as in, what if you decide to go off hormones or try alternatives after you’ve been on HRT? So this post is dedicated to her, and to those of you who want to know if there is a safe and effective way that HRT should be stopped.
Interestingly, when I looked into the issue, the answer seemed to be even less clearcut than the therapy. In fact, there are no guidelines for stopping HRT. To be honest, this disturbs me quite a bit; don’t you believe that if a physician is going to recommend that you take hormones, that he or she should have some clear guidelines as to how to take you off of them? Granted, until the Women’s Health Initiative started to reveal the dangers and risks of HRT, there was no real reason to stop therapy, (although, I’m of the mindset that there’s really no good reason to start HRT).
Fortunately, researchers are finally starting to look into this issue although study findings (which are published in the online edition of Menopause) highlight that the practice of stopping HRT is intuitive and not evidence-based.
So, what did they learn?
Among 438 group practice physicians surveyed, an overwhelming majority believed that women should taper HRT, with most believing that the best strategy was not only to slowly decrease the dose, but also to reduce the number of days HRT was taken per week. However, they had no suggestions with regards to how to taper use of HRT patches, even though the patch is increasingly being recommended and touted as a safe solution to oral hormone therapy. (Notably, like the evidence from this particular study I am talking about, the evidence that shows the safety aspect of the HRT patch is mostly observational, meaning that it is subject to personal bias.)
More interesting, however, was the finding that the majority of the physicians who participated in the study were more strongly influenced by their personal beliefs than by colleagues’ actions or most importantly, by a woman’s preference. In other words, physicians are not asking their patients about what they would like or if they have any thoughts about stopping therapy. More shocking was the fact that only 2% of physicians surveyed relied on actual evidence to stop hormone therapy. Physicians who indicated that they believed that some action should be taken if symptoms returned after stopping hormones overwhelmingly turned to behavioral changes or exercise, not to alternative therapies such as herbs.
In an era of evidence-based medicine and strategies that integrate eastern and western philosophies, why are our physicians relying on their own personal belief systems rather than real facts? Why aren’t they asking their patients how they feel about stopping therapy or if they have fears about symptoms returning and then thoroughly exploring alternatives with them. Are these findings in a vacuum or will they be found on a broader basis? Does the problem lie in fact that there are no standards? What’s more, why hasn’t the American Medical Association or American College of Obstetrics & Gynecology devised guidelines for stopping HRT therapy? Why hasn’t the Food & Drug Administration demanded this guidance in labeling?
Finally, why do we continue to play Russian Roulette when it comes to women’s health? Isn’t it time for a change?
Let’s start with HRT. There are a lot of folks out there who continue to espouse the benefits, deny the risks and ignore the facts. Clearly, this story continues to unfold. Unsafe medical practices are even more unsafe when they are not backed by evidence, right? Is HRT the exception? What do you think?
Read MoreWednesday Bubble: HRT – Ask the Hard Questions
Your doctor has just recommended that you try hormone replacement therapy, better known as HRT. You’ve heard the horror stories about increased risk for breast cancer, lung cancer, ovarian cancer, heart disease…yikes! And yet, you are flashing like nobody’s business, sweating like you’ve just run a marathon and moody as all hell. What should you do?
Ask the hard questions.
Anyone who reads this blogs knows that I am not a huge fan of hormone replacement therapy. There are numerous reason for my personal biases, ranging from the inherent health risks to the belief that menopause has been treated as a disease for far too long and that the paradigm needs to change. These reasons represent the initial driving force behind this blog, which is to explore viable and evidence-based alternatives to HRT and discover strategies for dealing with the emotional and physical aspects of midlife and the transition in more positive and empowering ways.
However, I also support any woman’s decision to use HRT. Your life is your life and only you can control the decisions that feel right for you.
Nevertheless, it’s critical to ask the hard questions.
So, what do I mean by that?
Medications are meant to heal, sometimes even cure what ails. But medications can be dangerous if they are misused, overused, or inappropriately prescribed. It can be confusing, because who can you trust to deliver the truth? And where should you turn when the media can’t agree on the story, when doctors are misinformed or too busy to take the time to thoroughly vet a patient or when one internet source states one thing and the other, another? What’s more, what’s at stake?
So, I’d like to put forth some initial questions for your consideration.
For your doctor
- Why is your doctor recommending HRT? What does he/she believe it is going to help? What are your personal risks, based on your current health status, family history, genetics and disease profile? Are you a smoker, drinker? have heart disease, lung disease, diabetes, etc?
- Does your doctor have any personal investment in HRT, i.e., has he/she done research on HRT on behalf of companies who manufacture it?
- What is the risk/benefit ratio for you? Are the risks higher than the benefits or visa versa?
- How long does the doctor expect that you will need to take HRT? How does this affect your risk/benefit ratio?
- Has the doctor had any patients who have had bad experiences with HRT? Would he/she be willing to discuss those experiences generally?
About your information source
- What is the source of information about HRT? Is it/he/she reputable? Have you taken the time to follow the trail and looked into its/her/his personal interest in HRT?
- Is he/she/his/her company or association sponsored by manufacturers who have a financial interest in HRT?
- How accurate is the news report? Do you thoroughly understand the news report? Does the news report seem like it has a bias? Has it throughly explained the study that it is basing its information on? (Gary Schwitzer’s HealthNewsReview provides excellent guidance on reading health news and what you should be looking for.)
- Who sponsors the website you are getting my information from? Is it industry sponsored? What is the background of the people who are writing the information that is highlighted on that website?
I am sure I’ve missed some important considerations or questions but these represent great starting points.I’d love to hear your thought. Or if you feel that I’ve missed the boat entirely.
Always…if you want the truth, you’ve got to ask the hard questions.
Read MoreWednesday Bubble: HRT and the “Window Hypothesis:” Hope or Hype. Guest post c/o The Better Health Blog
HRT and the Window Hypothesis. Sounds a bit daunting, doesn’t it?
I was awed and inspired by this post on HRT, which was written by Dr. Peggy Polaneczky and appeared on the Better Health Blog on April 21. As the author states, Pfizer (formerly Wyeth), the maker of Premarin, is working furiously to frame the HRT argument around the Window Hypothesis, which refers to the time period in which a woman must start HRT in order to fully gain its benefits. Is the Window real? Or another mother of all inventions to convince women that HRT is as necessary as a daily vitamin?
So, dear readers, I’ll leave it to you to decide. Despite the length of the post, I am including it in its entirety because the issue is so important. I’d also like to state that I am grateful to Dr. Val Jones, the founder and CEO of Better Health, LLC, who has graciously granted me permission to repost the piece on Flashfree.
It’s only Wednesday, and so far three patients have come to their office visits carrying Cynthia Gorney’s article from Sunday’s New York Times entitled “The Estrogen Dilemma.”
The article explores the stories of three women who found relief from perimenopausal symptoms by using hormone replacement, framing the discussion in the larger context of what is being called the “window hypothesis” — the idea that starting estrogen replacement in the perimenopause and continuing it into later life may be neuroprotective and even cardioprotective, in contrast to beginning its use 10 or more years after menopause, where it can trigger heart disease, stroke and dementia.
The window hypothesis is one way of explaining away the findings of the Women’s Health Initiative, and goes something like this: “The WHI enrolled women who were too late into menopause to benefit from estrogen. If we had instead studied women starting estrogen at the right time, namely the perimenopause, we would have found that it protects against heart disease and Alzheimers.” Or as I explain it to my patients: “Think of it like exercise. If you work out vigorously and regularly from a young age, you can prevent heart disease. But take an overweight, out of shape 65 year old and have him/her run full out and you could trigger an MI.” (It’s a crude analogy, but it works.)
The Times article does a good job framing both the hope and the hype around the window hypothesis, and the dilemma it appears to pose for women entering menopause today, which is this: If you wait for data that proves the window hypothesis is right, by the time the results are in, you’re outside the window and it’s too late to start HRT. If you start HRT now and the hypothesis is proven wrong, then you’ve been taking medication with potential risks for years without any benefit. Or as author Cynthia Gorney so succinctly put it:
“If I make the wrong decision about this, I am so screwed.”
The pharmaceutical industry, particularly Wyeth, the maker of Premarin, is, not surprisingly, working hard to get the word out about the window hypothesis. Indeed, several of the researchers working on the hypothesis who are quoted in Gorney’s article have ties to Wyeth. At the risk of further hyping a hypothesis that may prove to be unfounded, I encourage you to read the Times article, and then take the time to peruse the intelligent discussion in the comments section. If anything it is testimony to just how well-informed the American public has become about HRT.
I myself have been hearing about the hypothesis for years now, but have yet to see definitive data to prove it. Fortunately, there are studies in progress that may settle the question within the next few years. But even if the window hypothesis proves to be correct, it will not mitigate the risks of breast cancer that accompany long term estrogen use in the menopause. That risk remains, in my opinion, the biggest concern for my patients when it comes to HRT, and it is surprisingly downplayed in the Times article.
The biggest problem I have with the article is that Gorney’s experience with both menopause and HRT is anything but typical. Most women get through the transition without major mood issues, although crankiness and irritability are common, especially in women who are not sleeping because of night sweats. When true depression hits, as it did for Gorney, antidepressants are needed, with or without HRT (Gorney takes both). I have seen the occasional woman who declares “I am back!” after starting HRT, and one particularly memorable patient whose depression was cured, but this is the exception, not the rule. Most perimenopausal women who take HRT are just relieved to be able to sleep through the night or get through a meeting without hot flashes.
But most importantly, what does Gorney’s individual experience with HRT and mood have to do with the window hypothesis? She is not taking HRT to prevent Alzheimer’s or heart disease, she is using it to augment the effects of her antidepressants. The whole window discussion thing is distracting from the real question at hand for her, which is sinply this: How long should she take HRT? That depends, not on whether the window hypothesis is true, but on how she feels when she tries to stop taking HRT.
If I were Gorney’s doctor, I’d be focusing her off the window hypothesis and onto why she is taking HRT in the first place — for emotional well-being. Now that it’s been a few years on the stuff, I’d say, let’s lower your dose and see how you do. If you do well, then stay on that dose for 6 months to a year, then go off and see if you still need it. Based on Gorney’s experience with occasional missed patches, I’ll predict she’ll still need HRT, but will be able to get away with a lower dose. But if she feels just as well off HRT, then I would advise her to stay off. Do everything else she can do to prevent heart disease – diet, exercise, low salt, get enough sleep (you know the drill.)
As for using estrogen to prevent Alzheimers, well, that’s a big leap of faith that I for one am not yet ready to take. Which does not mean that I don’t have an occasional patient (usually a scientist) taking HRT because she hopes it will prevent Alzheimers. Such women, in my experience, are much less worried about breast cancer than about cognitive decline, in an attitude similar to that of Julia Berry, one of the women profiled in the Times article, who had this to say:
“I could have my breasts removed. I like them. But they’re not my life.”
Recent data suggests that Berry may not need to make this Sophie’s choice between her brain and her breasts. The mental confusion so many women experience in perimenopause may in fact resolve itself once we come out the other side, irrespective of hormone use. This suggests that it is the widely swinging hormones of perimenopause that pose the most trouble for women, but that once things settle down, so do we.
Now that’s a window hypothesis you won’t hear Big Pharma talking about.
Read MoreEvery breath you take…lung cancer and HRT
Remember last year’s post on hormone replacement therapy and increased risk of deaths from lung cancer? Researchers now report that HRT that combines estrogen and progestin can increase the risk for developing lung cancer, especially when used for long time periods.
In the latest nail in the HRT coffin, researchers evaluated 36,588 peri- and postmenopausal women between the ages of 50 and 76 over six years. During the study, 344 women developed lung cancer. Overall, the findings showed that the longer women took HRT, the higher their risk for developing lung cancer, with use of 10 years or more associated by as much as a 50% increased risk. Note that while an increased risk for developing lung cancer was also seen in women used HRT for up to 9 years, it was about half as much, or 27%.
While the researchers are quick to point out that this study does not prove that HRT causes lung cancer, it does show that taking HRT for certain periods of time can significantly increase the risk for lung cancer, even when other important factors are removed from the equation. Similar increased risk has not been observed in women taking estrogen alone.
In the latest position statement on hormone replacement therapy from the North American Menopause Association, a panel of experts currently conclude that the evidence shows that both smoking and age played an important role in promoting growth of existing lung cancers in women taking HRT, in particular among older women. On the other hand, they say that other studies suggest that HRT theoretically lends some protection against lung cancer in younger women.
Clearly these data are at odds. However, as a wonderful report in Reuters points out, the latest study ‘sheds light on the question’ because it looks at HRT use over a longer period of time.
Every breath you take…could eventually be your last. It all depends on your decision about HRT. Is the short-term gain worth the long-term risk? Only you and your doctor can evaluate your individual risk and determine if HRT is the right choice.
Read MoreWednesday Bubble: Another nail in the coffin for HRT
Still hearing that HRT can’t hurt your heart? Findings from yet another study, this time published in the February 16 edition of Annals of Internal Medicine, confirm the dangers that HRT poses to your heart, especially in the short-term.
In this latest analysis, researchers evaluated data derived from 16,608 postmenopausal women enrolled in the Women’s Health Initiative trial who still had their uterus. The findings?
Compared to women who had never used hormone replacement therapy, those who had used it continuously over 10 years had more than twice the risk of developing heart disease over the first 2 years, and more than 1.5 times the risk over the subsequent 8 years. For women who started hormone therapy after 10 years of entering menopause, there was also a trend towards developing heart disease over the first 2 years. Of note, researchers did observe a possible protective effect after 6 years in the women who started therapy closer to menopause as risk did start to level off at this time.
The upshot is that the first two years of taking HRT can be a dangerous time for women regardless of whether they start hormones closer to menopause.
Another nail? Yes, I’d say so.
But don’t take my word for it. Knowledge is power. Educate yourselves. And if you’d like to learn more about heart disease and menopause, I’ve written about it numerous times on this blog. I also encourage you to visit the American Heart Association website. Finally, I’d love for you to take a stand. Don’t you think it’s time for the FDA to start paying attention? These drugs are dangerous for women. Yet, they remain on the market and are prescribed daily. Whose nail, whose coffin?
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