As a gynecologist, practicing for over 25 years and having treated thousands of women of all ages and stages of their lives, I am certain of the following: Unless and until we have all our facts -- regarding all aspects of our health and health care -- we cannot make informed decisions. Many women live paralyzed by fear, hearing misinformation regarding medical studies. Misrepresentation of the absolute risk of various choices has created mass confusion and and in some cases, the reactive discontinuation of potentially helpful medications. These fear-induced reactions create a dangerous schism between women and their care providers. When I'm not engaged in individualized patient care I'm advocating for women to get the facts that may save them unnecessary misery, lower their quality of life and increase their risks for many diseases of aging. With a steady stream of intelligent, clear, organized and useful evidence-based good information, a sense of a working knowledge of their basic biology and body science, women can understand their options -- something the sensationalized style of medical reporting and conventional medicine keeps us from having.
We live in a paradoxical time with regard to women's health care consciousness. How the generation of Baby Boomer feminists, the burners of the bra, the women who took control of their fertility with the pill, who fought for equality in their professions, could retreat so far into submission in fear is certainly puzzling. Case in point: the debate about hormone replacement therapy. It is clear that misrepresentation of the facts by journalists is frightening women from something that may benefit their health and certainly enhance their quality of life.
The single largest barrier to women taking estrogen/hormone therapy and allowing themselves to feel better after menopause is the fear of breast cancer. A powerful recent example is the New York Times, October 20th headline which read "Prempro Hormone Therapy Amplifies Breast Cancer Risks, Study Finds."
The study released on October 20th regarding hormone replacement therapy (HRT) and breast cancer (from Women's Health Initiative group Chlebowski et., al JAMA,) was met with fearful reactions by the news media, but aside from getting terrified by the reports, what can we actually learn from this study? For one thing, this study has absolutely no impact on women who are not taking Prempro, and for those who are, the absolute risk is exactly what we already knew. There is a .008 percent increase risk for a breast cancer diagnosis with an increase risk of death from breast cancer of .012 percent. These are very tiny individual risks of an increase of 8 cases per 10,000 women years of use. The reader was led to believe that there was a 29 percent increase in deaths from Prempro, with an absolute difference of 1.2 women in 10,000 years of use! Placing such data in perspective is a great service to aid women in placing risk in a meaningful context. Why are we not told this? What is to be gained from frightening us? Why can't we know the truth? Women are competent to know these facts and figures as adults making long term self care choices.
The new information from the study published on October 20th in JAMA actually is in the details of breast cancer cell types associated with the particular progestin found in Prempro, and the incidence of higher death rates. The increase in the risk of death from breast cancer while taking Prempro compared to a placebo, in the new report, was one woman per 10,000 woman-years of use -- a level described by the FDA as "extremely rare" -- while the estrogen alone trial of the WHI study showed a 23 percent decreased risk of being diagnosed with breast cancer.
The detail of which hormones a woman takes is very important. We must help make women aware of news about different products that do not relate to their risk status. For example, we even have very reassuring data about estradiol and natural progesterone not statistically increasing risk for breast cancer (Breast Cancer Res Treat. 2008 Jan;107(1):103-11. Epub 2007 Feb 27) and also showing much better survival if one does get a breast cancer diagnosis if the woman is on estradiol at the time of diagnosis. Improved breast cancer survival among hormone replacement therapy users is durable after 5 years of additional followup, Christante D). (These are identical hormones to naturally produced estrogen and progesterone, also called Bioidentical hormones by some with FDA approved products available all across the U.S.)
The bottom line is there are many better options than Premarin or PremPro. Simply look at the estrogens delivered through the skin, all biologically identical to that which we naturally make in our bodies and for which nature selected over millions of "randomized blinded trial years" (the process of natural selection at its finest in my opinion). In all sorts of research, at cellular levels, as well as gene regulation and gene suppression/expression studies, estradiol is very positive in its effects on cell differentiation; in essence, keeping healthy breast cells healthy. That is the goal of ideal hormone support for every tissue we study: The enhancement of balanced, regulated cell growth and positive antioxidant effects of estradiol.
The truth is that after all the hullabaloo over the past nine years since the initial termination of the HT arm of the WHI, estrogen turns out to be quite safe, the MPA has a cloud of suspicion, and the future recommendation is for careful assessment on an individual basis for every women transiting menopause to determine health status, future risk for disease, and a decision based on a clear indication whether hormones are truly needed and recommended in her situation. If a woman chooses hormone support then current knowledge should be used to determine what dose, type and route of administration is best for her.
The WHI has succeeded in adding valuable information showing that postmenopausal hormone therapy has clear rewards and very small risks when started in newly menopausal women. It remains a woman's right to choose, not just a legal abortion, but to engage in a process of education and transparent explanation of the facts. Each of us can check these facts in a clear and unbiased way at the North American Menopause Society's website.
Let's think about why these studies are misinterpreted, over-inflated and misreported, an important question and one I will address in future posts.
Statements made in this blog are the personal opinions of Dr. Ricki Pollycove, a board-certified specialist in women's health care, specializing in healthy aging throughout all stages of women's lives. She has been in active clinical gynecology practice since 1981, and author of the "Pocket Guide to Bioidentical Hormones." Information provided here is not intended to substitute for individualized medical choices which should be made with the supervision of the treating clinician. Always consult your care provider before making any medical decisions or changes in your health practices based upon the information provided in this blog.