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Estrogen During Menopause: To Take, Or Not to Take?

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Estrogen use for 11-plus years lowers breast cancer rates by 23 percent!!! It's the best news we've had in years! But instead of offering reassuring clarity in her column on April 9, Tara Parker Pope wrote, "Studies intended to be the last word on menopause revolutionized treatment, but they also led to confusion and debate. So what is the confusion and why the debate?

The response to this past week's Journal of the American Medical Association lead article should be a resounding "Relax! Treat your menopausal symptoms and be confident that you, as a young newly menopausal woman, have truck loads of science that confirm it's good for you!" (1).

If you take the time to read the article, the reassuring conclusions are that breast cancer is not caused by taking estrogen and is decreased in estrogen users. The huge majority of studies from the 1990's to the present confirm this very positive estrogen-alone finding. Confusion arose from the small but measurable negative effects of the synthetic progestin, Provera (Medroxy Progesterone Acetate, MPA) that was present in PremPro, and released with frightening negative media blitz in July, 2002 (the original WHI "HRT shock heard 'round the world" press release). MPA is not present in other formulations of hormones but has to be prescribed separately if desired for its uterine lining suppressive effects.

The intelligent clinician and consumer needs to see the delight as well as the devil in the details. And we are at a point of medical sophistication as well as consumer "demand-to-know" that clinicians simply have to become better informed and educated about the natural state of affairs for menopausal women as opposed to aging men.

All estrogen formulations are not alike! And they can have different long term effects! Just as intelligent consumers avoid trans fats at the grocery store, we need to "read the labels" and become informed about what is best for each of us as individuals, not as a "herd" of managed care members.

Tuesday, April 6 for a brief media moment, women could let go of breast cancer fears while taking estrogen for menopausal symptoms! Huge value exists in this latest research yet it has already faded from the scene, as "good news is not news." This latest huge study really is irrefutable confirmation of what many careful, thoughtful readers of the literature concluded as estrogen relates to women and healthy aging (doctors and researchers mostly are in this group). Here is the abiding kernel of truth: early replacement of estrogen in menopausal women prevents many of the measurable disadvantageous physiologic changes that sustained low estrogen create. The April 6, 2011, JAMA article provides important confirmation of not only our basic biology and hormone balance, but over the longer term 23 percent lower incidence of breast cancer and less risk for heart disease (10.7 years of follow up) in users of estrogen compared to women on dummy (placebo) pills.

The power of this information is huge. The simply written conclusion by the WHI investigators reads, "Among postmenopausal women with prior hysterectomy followed up for 10.7 years, CEE use for a median of 5.9 years was not associated with an increased or decreased risk of CHD, deep vein thrombosis, stroke, hip fracture, colorectal cancer, or total mortality. A decreased risk of breast cancer persisted in estrogen users compared to those women who took the placebo."

So why are we confused? And why does Dr. Joanne Manson not make a more definitive statement than that "...science worked the way its supposed to work," and then a non-sequitur about making sausage? We really do know better, and whatever is going on in science is not penetrating the media's message!

Responsible, cautious and concerned clinicians are outraged that such bland dispassionate comments dominate the landscape of women's health advice. And why quote Dr. Susan Love, a former breast surgeon turned self proclaimed righteous women's health advocate? Dr. Love has not practiced active patient care for quite some time now, neither in or out of the operating room. She is allowed her personal opinions but it is doubtful that any comment she may offer has power or relevancy to the thousands of highly symptomatic women who are desperate to sleep through the night, think clearly again, enjoy sex without pain of vaginal dryness and maintain optimal lean body mass, lower risk of diabetes, osteoporotic fractures and dementia.

We face a judgmental environment with unspoken negative views of estrogen hormone interventions as somehow being anti-feminist. It is unpopular to try to educate us about our own biologic inheritance and the (sorry) brutal biologic constraints that go along with the remarkable evolutionary biologic opportunity to conceive, gestate, give birth to and nurse offspring (we are amazing mammals!). The evolutionary selective pressure is for adaptation, not immortality. And what this simple fact yields biologically is that ovarian failure, in other words menopause, has no positive selective biologic pressure to make it a vigorous long term condition. It is simply the truth about our biology that for the vast majority of women, we need to replace what is insufficient, whether it is thyroid or estrogen, when glands cease to produce their health-supporting hormones.

As women let's reclaim our level heads! No longer should we be tossed around by every current trend or wind that hits our sails. We must demand our care providers present evidence-based information to guide our decisions regarding hormones, not fear generating sound bytes, (see The Pocket Guide to Bioidentical Hormones, Alpha Press, 2010, Ricki Pollycove, M.D., M.S., and The Hormone Decision, 2007, Rodale Press, by Tara Parker Pope).

Logical, plausible, coherent information that integrates principles of basic physiology, observed clinical outcomes and wise hormonal relief of menopausal symptoms is available to every woman. Women have to seek it and be confident in their own relief of troublesome symptoms, observe how each woman feels with the verifiable pure hormones she is prescribed, and the reliable, unbiased scientifically-documented information that exists.

Estrogen is a powerful antioxidant in breast tissue, blood vessels and acts favorably throughout the body. So it makes sense that the larger effect of estrogen will be health-enhancing in many organ systems, including the breast and cardiovascular systems. It is also well known that "bad things happen" with respect to heart disease risk factors in women once estrogen levels fall. Dr. Manson herself was lead author on another subset of this same post-hysterectomy population showing a decrease in coronary artery disease in estrogen users as compared to non users after 7.4 years (2). The simple conclusion of her coronary calcium investigation reads, "Among women 50-59 years old at enrollment, the calcified plaque burden in the coronary arteries after trial completion was lower in the women assigned to estrogen than those assigned to placebo." And heart health-enhancing effects of estrogen have been clearly shown for over 25 years in monkey models of menopause (work in Dr. Tom Clarkson's lab at Wake Forrest University) as well as being confirmed by more recent clinical studies in women (3).

Truck loads of data shout that for optimal prevention of heart disease timing is very important -- earlier is better (4). All sorts of clinical studies have pointed to this important heart disease risk reducing power of early estrogen administration in menopause yet consumers and clinicians remain paralyzed with fear.

The fact that some professional disagreement exists is not hard to explain, kind of like the two party system of government. Study design can be misleading and experts get invested in defending one trial over another. But the fact that reputable doctors still cling to old misconceptions is mystifying and disappointing. Starting hormones early in menopause (at least within the first 10 years) allows us optimal disease risk reduction for virtually all systems examined closely.

The facts are quite clear: women who do not take estrogen, as a group, suffer acceleration of disease risks (heart, bones, diabetes, loss of muscle mass, brain-neuron loss) after menopause. A deep inquiry into the neuroscience of estrogen and women's brains is sobering. Neurons are not as healthy or functional when deprived of estrogen (5). This is the brutal biologic truth and we need to stop wasting precious time!

Outliving our natural evolutionary life spans places women at greater risk for diseases as we age as compared to men (6). Lucky for them, men continue to produce ample amounts of estrogen (and testosterone, of course) well into their 80's and 90's! We are living longer and so now have the diseases of aging afflicting millions of women each year.

Estrogen is not the fountain of youth. It won't turn back the clock entirely. But it slows down the harmful effects of sustained low estrogen levels that accelerate aging processes of every organ system. For those women who have had a hysterectomy, as in this study, post menopausal estrogen is safe and can be easily tailored to meet each woman's personal needs.

And for those who still have their uterus, natural progesterone (often prescribed as Prometrium brand of micronized bioidentical FDA approved progesterone) or progesterone-like opposing progestin (such as Aygesten brand or Norethindrone generic) on a periodic basis, can be adjusted to each woman's life style and estrogen dose required to feel her best, keep the uterus healthy and avoid menopausal symptoms.

For more comprehensive information, and a quick read, see my book, The Pocket Guide to Bioidentical Hormones, Alpha Press, 2010. Each organ system and symptom complex is addressed chapter by chapter, paying attention to your unique menopausal experience and goals for optimal health and quality of life. The better the information, the more confident you will be in making the right health-enhancing choice.

References:
1. JAMA. 2011 Apr 6;305(13):1305-14.Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: a randomized controlled trial. LaCroix AZ, Chlebowski RT, Manson JE
2. [Manson J et al, NEJM 2007, 356; 25, 2591-2602]
3. [Hodis HN, Assessing the Risks and benefits of Hormone Therapy in 2008: New evidence with regard to the heart. Cleveland Clinic J Med 75(4) May 2008, S1-S12]
4. [The Timing hypothesis, Sowers, MF, Randolph, J, et al, Arch Intern Med 2008; 168(19); 2146-2153]
5. [Morrison JH, Brinton RD et al, Symposium: "Estrogen and the Aging Brain. How basic Neuroscience can Inform Hormone Therapy in Women," J Neurosci Oct 2006, 26(41) 10332-10248].
6. ["The Evolutionary Origin and Significance of Menopause," in the journal, Menopause, Vol 18,number 3, pages 336-342, March 2011, by Pollycove R, Naftolin F, Simon, JA.]

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