Wednesday Bubble: HRT – wait a moment!
Back in early May, I wrote a post about the difficulties in stopping hormone replacement therapy (HRT) and the disturbing fact that doctors have no guidelines to follow in order to advise their patients on the best strategies. Today’s Bubble is a perfect companion to that piece, as it addresses the fact that research now shows that women who start HRT and then stop it have a tendency to have significantly greater and more severe menopausal symptoms than had they never started HRT at all.
Writing in the online edition of Menopause journal, researchers say that among 3,496 postmenopausal women who completed a pre- and post- stopping therapy survey during the Women’s Health Initiative study (a trial that compared estrogen/progestin to placebo and was subsequently halted when HRT was found to double the risk of breast cancer) :
- Those who had not reported having hot flashes at the start of the study were more than five times as likely to report moderate to severe hot flashes after stopping HRT compared with women with no symptoms who took sugar placebo pills. However, women who had reported having hot flashes at the study’s start were only slightly more likely to report hot flashes after stopping HRT
- A similar pattern was seen for night sweats, i.e. women who had none at the study’s start were almost twice as likely to report them after stopping HRT
- Age at stopping HRT was increasingly associated with more joint pain, i.e. the older the woman, the higher the risk for experiencing joint pain
The researchers say that although there have been previous reports of a surge in vasomotor symptoms like flashes and sweats after stopping HRT, these findings show that estrogen, either alone or with progestin, may promote symptoms when HRT is stopped, even if a woman was not experiencing them when she started therapy. More specifically, the risk for menopausal vasomotor symptoms and joint stiffness is four to seven times more in women with and without prior symptoms when HRT is stopped.
The takeaway message is that it’s not only important to consider the health risks associated with HRT but also, what happens when you stop it. Clearly, even if your symptoms disappear while on HRT, your risk for symptoms after stopping therapy is fairly high.
You should always weigh the risk benefit ratio before starting any type of therapy. HRT may not be worth the trouble. Or the multiple risks.
p.s. More on this study from my friends at Reuters Health.
Read MoreWednesday Bubble: The HRT patch – is it safer?
Remember the diva and the doctor sitting on the roof espousing the benefits of the HRT patch? Well, it turns out that some of these patches might not be so safe after all. Results of a study of over 75,000 women published in the British Medical Journal, show that the use of high-dose transdermal (through the skin) HRT patches increases stroke risk by as much as 88%.
Granted, transdermal or through the skin delivery bypasses the liver, which typically makes patches safer than their oral counterparts. However, if the drug isn’t safe, well, then the patch might not be either.
In this latest bit of news, researchers evaluated women between the ages of 50 and 79 who had participated in the ongoing Study of Women Across the Nation (SWAN). Every woman who had had a stroke were matched for comparison to four women in the study, with similar characteristics, who had not. The women were further divided into groups based on their use and type (i.e. oral or patch) of HRT, including estrogen only, estrogen plus progestogen, progestogen only, and the estrogen alternative, tibolone (which is not available in the US).
The researchers say previous and recent studies suggest that oral HRT, including estrogen only or estrogen plus progestogen, is associated with a 30% increased risk of stroke. However, stroke risk differs between high- and low-dose patches. Overall, they report that:
- Low-dose patches do not appear to increase stroke risk, at least in the short-term (they say that they cannot rule out an increased risk with long-term use)
- High-dose patches, regardless of whether or not they are estrogen only or estrogen plus progestogen, appear to increase stroke risk by anywhere from 25% to 88%
- Risk was the highest among women who had used oral HRT before trying transdermal HRT, although this risk appeared to decline the longer the time period between stopping oral and starting the patch
- Findings remained even after adjustments were made for factors that might influence results, including age
What the findings mean
Despite claims to the contrary, it does not appear that HRT offers much protection against heart disease during and after menopause. What’s more, the HRT patch may not actually be safer than oral HRT, at least in so far as the high-dose HRT patch goes. Although the researchers state that they were unable to distinguish between types of stroke when evaluating the SWAN study data, they say that these data show the need to look further into how HRT is delivered, especially as use of the HRT patch becomes the norm.
As I’ve written previously, if your doctor suggests you try HRT for menopausal symptoms, it behooves you to ask the hard questions. While you may save your sleep, mood and a few articles of clothing, you may be placing yourself at a higher risk for cancer, heart disease and other serious conditions.
Read MoreWednesday Bubble: rhubarb rules the day
Today’s Bubble is straight from the research files and it’s not burstable. In fact, I’m pretty excited about this.
Researchers say that a phytoestrogen extract from Siberian rhubarb (rhapontic rhubarb), better known in studies as “ERr 731,’ is an effective alternative to HRT for alleviating menopausal symptoms.
Evidently Siberian rhubarb has been used for decades to treat menopausal symptoms, both in Germany, where it is readily and commercially available, and in Chinese medicine. Clinical studies suggest that ERr works very similar to estrogen in the body and in fact, has been shown to have properties that are equivalent to SERMS – selective estrogen receptor modulators – which are synthetic compounds that mimic the action of estrogen in the body without necessarily causing some of its harmful effects.
When I delved further into ERr 731, I found numerous, well-designed studies that demonstrate its benefits in perimenopausal women including:
- A significant decline in the number and severity of hot flashes over the short-term (i.e. 3 months) by as much as 50%, with further improvements through the long-term (i.e. 6 months).
- Improvements in other menopausal symptoms such as sleep disruption, mood and vaginal dryness.
- Improvements in self-reported quality of life.
- Minimal if any side effects and no changes in uterine or vaginal tissues among women taking the extract, suggesting that it may be safe in terms of breast or uterine cancer.
In the U.S., ERr 731 is marketed as a supplement called Estrovera. Although it appears to be safe, like any drug, you should speak to your practitioner before trying it.
I’m heartened to see that an herb that been in use for decades in both Western and Eastern cultures in finally available to US women. I’ll continue to monitor for additional studies but in the interim, I’d love to hear from you if you are taking Estrovera.
Read MoreHRT – 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.
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