Subject: Menopausal Hormones: Friend or foe?
Dear Dr. Health Coach:
I am a fit 54 year old school teacher and have been on 1 premarin tablet
every day for 7 years. I was started on them by my gynecologist at that time when I had my uterus and both ovaries taken out for heavy painful fibroids. No history of breast cancer but I still faithfully have regular check-ups and mammograms. I was told then that I should take these hormones for life to protect me from heart attacks (my dad died at 55 from heart attack). I was also told that they will make my bones stronger and improve my 'private' life. Mind you I feel great taking them and am active and regularly exercise. My question is this: Lately I've read that these hormones are bad and won't protect your heart and may cause more breast cancer than once believed.
What are your thoughts on this matter?
Reply from Dr. Bazos:
Your question is informative, extremely relevant and important to so many females. Before I answer your specific concerns I feel it important to give some definitions and some historical background to provide an understanding as to why this controversial topic has become so complicated.
Menopause by definition, is the permanent cessation of menstrual periods. It is part of the climacteric during which women undergo hormonal, bodily and psychological changes.
These changes that women undergo are related to aging and to estrogen depletion. At this time, usually between 48 - 52 years old, their ovaries become depleted of follicles and stop making estrogen. In your case, Jean, menopause was created by your doctors after it was decided to surgically remove your uterus for painful heavy fibroids. If my math is correct this operation was done when you were about 46 years old. I have concerns as to why both of your ovaries were also taken out at that time. Presumably these ovaries were also felt to be 'diseased'. If you do not know for sure, then you are entitled to an explanation from your gynecologist as to why this was done.
You are taking Premarin which is the most commonly prescribed form of female menopausal estrogen hormone replacement. For the remainder of this discussion I will refer to menopausal hormones as estrogen hormone replacement therapy or HRT for short. Now Jean, I wish to review some of the advantages and disadvantages of taking estrogen as you have illustrated in your question.
BENEFITS OF ESTROGEN HORMONE REPLACEMENT THERAPY (HRT)
Estrogens are the best agent we as physicians have for providing rapid relief of these vasomotor hot flushes.
b. Treatment of Vaginal Dryness
c. Prevention of Heart disease, A Historical Overview
Now what if you already had a heart attack and wish to take estrogen for protection. Then I would suggest giving you a very low dose estrogen alone initially to get the full beneficial effect before I would start any combination progestin to reduce the risks for endometrial hyperplasia (a potential precursor to cancer).
We know that if you lower LDL cholesterol, you lower the risk of a heart attack. We know that HDL cholesterol, if it's very low, is a risk factor for heart attack and triglycerides; if they are high, are risk factors for heart attack; and fibrinogen, if it's high, is a risk factor for heart disease.
We don't know exactly how estrogens prevent heart disease. Ten years ago, the teaching was it was related to the lipid profile. This is too simplistic. It's probably because estrogens prevent atherosclerosis by serving as an antioxidant and we also know that estrogen is a very potent vasodilator. There are many different ways how estrogens might prevent heart disease.
d. Treatment and Prevention of Osteoporosis
e. Prevention of Cognitive Deficiency and Alzheimer's Disease
Then came a startling study, which suggested an association between hot flashes and brain cell (neuronal) loss. "It is hypothesized that the hot flush may result in an irreversible loss of neurons such that the women who enter their 70's and 80's with a history of hot flushes have a decrease in neuronal reserve and thus are more likely to express Alzheimer's Disease at an earlier age." This was naturally all hyped-up and sensationalized in women's magazines, Time, and most of the lay media.
When you really go into this study and other similar ones in great detail you will see that there is no evidence that women with hot flushes will be destroying neurons in their brains to affect cognition and hence predispose them to Alzheimer's Disease. Rather, women with a lot of hot flushes may not be sleeping well and this may affect their concentration, but they're not destroying their neurons.
So what do I think of all this? If I had to sum up the role of estrogens in preventing Alzheimer's disease, I'd have to say that yes there are retrospective studies that suggest estrogens might prevent the disease, but these studies are not randomized. Remember that women who are better educated and eat better and exercise more are less at risk for Alzheimer's disease and maybe those are the women who take estrogens in the first place, especially the better-educated women. When you put all this together, if a patient of mine wants to take estrogens to prevent Alzheimer's disease, I'll say, "Okay, but I'm not convinced of the data."
O.K. Jean. Now let us examine your concerns as to the risks or as you put it "foes" of taking estrogens.
RISKS OF ESTROGEN HORMONE REPLACEMENT THERAPY (HRT)
b. Breast Cancer
The main concern about estrogen replacement therapy that worries me the most for which we still don't have enough data is whether or not estrogens are associated with breast cancer.
As far as I'm concerned Jean, I tend to be a little more conservative than some of my colleagues. I am concerned that estrogens might increase the risk for breast cancer after many years of use. Somewhere after 5 to 7 years of estrogen, the risk of breast cancer goes up in some women. We don't know who those women are, and have no easy of identifying them.
The 'cancer-meter' starts ticking after age 50. If a woman goes through premature menopause at age 40, using estrogen for 5 years does not increase the risk. After age 50, more than 5 to 7 years of use, I believe the evidence suggests that the risk goes up.
If you look just at the numbers and statistics without any emotions, then it's a no brainer. You would see that the number of lives saved from heart disease or osteoporotic hip fractures completely outweighs lives potentially lost due to breast cancer or endometrial cancer, assuming you're not using a progestin.
If you look at the emotional aspects of this dilemma, because breast cancer becomes a major problem for patients and a major concern and it happens at a different age, then the numbers change quit a bit.
Now, Jean, all the hype in the lay-media began in January 26, 2000 with the controversial article in the very respected and prestigious Journal of the American Medical Association (JAMA). This study showed a slight increased risk of breast cancer associated with long-term use of estrogen, as well as somewhat greater risk of breast cancer diagnosis with combination estrogen-progestin use compared to estrogen alone. Unfortunately, the results as presented in this study only add to the complexity and uncertainty surrounding the issue of breast cancer and hormone replacement therapy (estrogen). Because the subjects were surveyed over the past 20 years, they could have been on higher doses and different regimens of estrogen-progestin than are commonly prescribed today. These results, therefore, may not be reflective of current low-dose therapies."
At this time, the Society of Obstetricians and Gynecologists of Canada (SOGC) believes it is essential to restate the facts on the risks of hormone replacement therapy within the appropriate context.
In 1998, the Society of Obstetricians and Gynecologists of Canada (SOGC) published a consensus on Menopause and Osteoporosis, which was based on the best scientific evidence available. This study shows that, based on a then recent meta-analysis of over 50 epidemiological studies published on the risk of breast cancer with hormone replacement therapy, current users of estrogen, or those who ceased one to four years previously, had a small increased relative risk of breast cancer. The combined analysis reported no increased risk for estrogen users of less than five years. For women who had used estrogen for five years or longer, the average relative risk of breast cancer increased by approximately two percent per year of use. This reported relative risk for breast cancer with estrogen would account for an excess of two, six or 12 cases per 1,000 estrogen users after five, ten or 15 years of use, respectively. Within five years of discontinuation of estrogen use, the increased relative risk virtually disappeared.
There is a greater risk of developing breast cancer due to excessive alcohol consumption or by failure to exercise regularly than that attributable to estrogen.
In fact, the risk of developing breast cancer increases by 60% if alcohol consumption exceeds 2 drinks per day, by 60% if a woman does not exercise, by 2.8% for each year menopause is delayed and by only 2.3% by year of use of hormone replacement therapy. Age is also a risk factor.
It is therefore important to note that the increased risk as reported is therefore extremely small, particularly when compared with other known risk factors.
Canadian women who have reached menopause are at a greater risk of developing other diseases, such as cardiovascular disease, if they don't take hormone replacement therapy. Heart disease is the number one killer of women in this age group. Hormone replacement therapy not only protects women after menopause from developing heart disease, but also provides protection against osteoporosis (which afflicts one in four women over the age of 50), as well as colorectal cancer.
The SOGC recommends that women should discuss the potential benefits and risks of hormone replacement therapy with their health care provider based on their individual health needs and personal risk factors for such things as cancer, osteoporosis and heart disease. The SOGC further states that a woman may not need to take hormone replacement therapy indefinitely, and should reassess her needs with her health care provider on a regular basis.
Firstly, let me address your question as to the beneficial effects of estrogens and heart disease. The point I've been trying to make above, Jean, with all this is that I have always told my patients when they say they want to take estrogens to prevent heart disease that there are so many studies in the literature suggesting that estrogens prevent heart disease, that I actually believe it. But, I also tell these patients that there are no randomized trials and that we may be dealing with self-selection and with physician bias. I never promise my patients that estrogens will actually prevent heart disease. Rather, I say the data is suggestive of it but we have to wait for the National Institute of Health: Women's Health Initiative Study (W.H.I.S), a randomized, double-blind, clinical trial which is studying benefits or risks of estrogen and progestin on the bone, heart, breast and other tissues. This large study along with its definitive answers to these controversial questions will be completed by 2006.
There are so many studies, that I truly believe estrogens cut down the risk of heart disease. I don't know if it cuts it down as high as 70%, as some studies suggest, but even if it cuts it own to 10% which the most scrutinous studies suggest, then this is still very significant in that heart disease is the number one killer of both men and women.
Now, Jean, let me respond to your more important question as to the current evidence-based medical risks of estrogens and breast cancer.
What you have to consider, Jean, is that you must ask yourself the following paramount question:
"Do I continue taking estrogens at age 54 to prevent a hip fracture at age 75 or a heart attack at age 77, but might increase my risk of breast cancer at age 62?"
Jean, you and many similar women are faced with that decision -- it's so personal, that you alone must make it for yourself. All we doctors can do is give you the information and help you put it all together in some meaningful manner to help you make the decision for yourself.
Now, Jean, if you do decide to stop your estrogen, don't stop the estrogen cold turkey, because the hot flushes will promptly occur. Rather, wean them down slowly over time. I would recommend cutting them down to 6 pills a week for 2 weeks, then 5 pills a week for 2 weeks, and so on.
If on the other hand, you decide to remain on estrogen, then you must perform regular breast self-examinations and also have a regular annual mammogram. This is good preventative advice regardless of what you decide.
There is no right or wrong answer, rather I have attempted in keeping with the health coach philosophy to gather, organize and present to you the relevant evidence-based studies and guide you to ask the right question. I look forward to revisiting this question again with you in 2006 after the anticipated W.H.I.S. study is completed.
Until then I wish you a "private" peachy Norma-Jean life and hope you never become a Blue-Jean baby.
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