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.
Rebecca Booth, MD: Hot Flash Help Is on the Way...
Patricia Yarberry Allen: Menopause Weight Gain? Or Is It Your Lifestyle?
Dr. Nalini Chilkov: Breast Cancer Risk: A Screening 3 Times Better Than Mammograms
Hormone Replacement Therapy: MedlinePlus
Hormone therapy: Is it right for you? - MayoClinic.com
Is Hormone Replacement Therapy Right for You? - Oprah.com
Hormone Replacement Therapy - HRT
Hormone Replacement Therapy: MedlinePlus
Hormone therapy: Is it right for you? - MayoClinic.com
In fact it is only Premarin that comes from horse urine. It is a combination of concentrated extracts from the urine of pregnant mares since 1942 when it became FDA approved. It was formerly made by Wyeth, sometimes taken as Premarin alone in women after hysterectomy or combined with a synthetic progestin, Provera (discussed in my post blog) in women who still have a uterus to prevent overgrowth of the lining that can lead to an increase risk for uterine cancer. No other estrogen or progesterone hormones come from anything except plants. So please allow women who have symptoms to feel not only better when estrogen relieves them, but better still in knowing that they are NOT causing cruelty to any animal in producing these elegantly effective and very pure hormones.
all the same I can't get away from this: what ever happened to "aging gracefully"?
everyone will be better off if they accept mortality for what it is
So you're all for going back to the dark ages, before modern medicine and nutritional information let folks live longer and feel better? Weird.
'cause I didn't say any of that stuff about going back to the dark ages and tossing medicine out the window
but if you like to have fantasy arguments, be my guest
There is a bottom line to this issue. Natural hormones cannot be patented; therefore, there is no profit motive to produce them, although small companies put them out. Big pharma companies have to create a unique "product" in order to be able to patent it. So, an extra molecule - methyl something or the other, is added to an already toxic formula of horse hormones.
PREgnant MARe's urINe - get it? Premarin comes from pregnant mare's urine, from poor animals that are raised in horrendous conditions so that they are pregnant or nursing all the time, and greedy pharma companies use this procedure to make huge profits off of medicine that gives women cancer! Go figure!!
Additionally, "progestin" is NOT a natural human hormone. That would be "progesterone." These words are often used interchangeably, but they are NOT the same. Don't be fooled!!!
One does not need to search beyond the FDA approved estrogen patches, rings, gels (many brand names are covered by insurance plans, like Elestrin, Divigel, Estrogel) and even a spray (Evamist). Estrace Cream has been available in the US for many decades and is pure bioidentical estradiol cream. These are all bioidentical estradiol products with reliable data, studied extensively in real women for our protection, with predictable effects that are well known. Dose levels are important considerations. So the compounding pharmacy products have the negative risk of not being as well documented or reliable in preventing uterine cancer and relieving menopause symptoms. Safety is the key word here, not marketing hype. Doctors and NP's make no money on whatever they prescribe. Can that be said of the unregulated BHT Industry?
Why are the smart women switching to bioidentical hormones? Bioidentical hormones are safer and more effective than chemically altered synthetic hormones.
To read more:
http://jeffreydach.com/2008/06/27/the-safety-of-bioidentical-hormones-by-jeffrey-dach-md.aspx
jeffrey dach md
You have had good care in my opinion. The data for women who have had a hysterectomy is the most positive of all: their estrogen use lowers risk for almost all diseases, including breast cancer (23% less breast cancers in the WHI estrogen-alone group). The risk for gall bladder problems is slightly higher, even in those using an estradiol patch, though it is significantly less than if estrogen were taken by mouth, and considered a very small risk when compared to the total-body benefits you would expect over many years of use.
Then she broke down and tried it, and her quality of life shot up like a cannon.
In Health!
I agree 100% re: a plant-based diet. I do take a supplement every day - fruit and a plant-based protein powder (by Vega) that is phenomenal. I am a vegetarian but haven't made the switch to vegan as of yet. I do not eat much sugar and try to stay away from bad stuff; however, when I went on cumadin for the blood clot, I was told to stay away or limit leafy greens that contain vitamin K and that has upset my diet balance big-time... as I was eating a lot of spinach and leaf lettuce and cranberry, which I'm also supposed to avoid. So now my diet is not nearly as good (ironically), and I'm trying to find out alternatives that don't contain too much vitamin K.
Not only that, but even herbal remedies can interfere with cumadin, so I'm just completely frustrated.
I find it really annoying that there is literally no help for me to alleviate my symptoms because of the blood clot. It seems counter-intuitive but then I'm new to all this, having never had any medical issues ever.
I also exercise daily, weigh 125 lbs, etc. so it's not like I have any reason to have a blood clot in the first place, which led the folks at Kaiser to decide it was caused by the bio-identical hormones I was taking.
Dustin
Show some courage.
Now... I'm not positive that the blood clot was caused by the hormones. No one does. But what absolutely sucks is that now the doctors I see tell me I cannot be on ANY hormone therapy because of the blood clot. They may revisit it in 3-6 months. In the meantime, I wake up every couple hours to night sweats.
I have an impeccable diet, I've cut out caffeine over a year ago. Not sure what else I can do.
I do know that I would not take Premarin. Just research how it's made (from pregnant mares' urine) and what they do with the baby colts of those pregnant mares.
At least bio-identical hormones come from soy or yams.
I was really only taking them short-term (8 months or so) and then I got this blood clot and so i'm told to stay off them... which sucks! I have had many tests and my thyroid, etc. are fine. Believe me, when you get a blood clot, they take nearly all the blood out of you for tests (oh the irony). I asked the Gyno yesterday whether or not I should get a hormone test. He said I'd have to be tested every hour of the day because hormonal levels fluctuate so much! That really floored me. I had been told by my acupuncturist that getting a hormone test was a good idea. So... now I am completely confused (I use Kaiser, btw... not sure if that makes any difference).
In any case, talk about being frustrated. Unless I take the chance that the HRT didn't cause the clot and continue even though told not to (by Kaiser), I guess I'm just out of luck as far as aleviating my symptoms.
Also thought you might be interested in this article on bio-identical hormones because it explains more about the mechanisms and differences from conventional hormone replacement - http://www.lef.org/magazine/mag2009/oct2009_The-Unscientific-Bioidentical-Hormone-Debate_01.htm.
I wish you the very best with your health and Happy Holidays!
Dustin Rudolph Pharm.D.
www.PursueAHealthyYou.com
Happy Holidays to you as well.
If the experience of one person is all you need to make a decision, than go with it.
Bioidentical hormones are found in pharmaceuticals (e.g., bioidentical estradiol patches such as Climara or Vivelle, bioidentical progesterone such as Prometrium, and bioidentical testosterone such as Androderm, Androgel, or Testopel) as well as in individual preparations made by compounding pharmacists.
No masquerading here.
Sure, it may not feel great to get hot flashes, but it is natural, and is meaningful to a woman's new stage of life both physically and psychologically.
Why are we so desperate to pretend we can live forever, be young and beautiful forever, have great sex forever? Perhaps nature has another intention for post-menstrual women, and the physiological transformation of menopause is intended (if acknowledged) to prepare her.
I have used bioidentical hormones for ten years without any side effects. I use them to feel better and to help prevent thinning bones. I feel wonderful and look wonderful and my health has never been better.
You are one of the lucky ones. Congratulations. But I dare you to come sit in our waiting room and tell the women walking in to our office that what they are experiencing is a gift. They would tear you apart.
Count your blessings.