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Hormone Hell
By Melissa Hendricks
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In responding to this news, some hormone users, including McKelvey, immediately stopped using the therapy. Others have vowed to remain faithful to a medication that eases unbearable hot flashes. Still others, like 58-year-old Pauline Tyer, are uncertain, and maybe even a bit jaded by the flip-flopping of medical research. "My initial reaction is we've heard so many of those contradictions I'm taking it with a grain of salt," declares Tyer. "I'm really not sure where I'm landing."
If you, too, have been uncertain about whether to stop HRT, don't worry that you've harmed yourself by not deciding right away. "This is not a medical emergency," says Catherine DeAngelis, a physician and editor of the Journal of the American Medical Association (JAMA). "These drugs are not poisons. They are, in fact, very good medications when used appropriately." The absolute risk of taking HRT is low. For example, WHI researchers found a 26 percent increase in the risk of invasive breast cancer for women on estrogen plus progestin. Translated into absolute risk, this means that during one year, 38 out of 10,000 women using HRT would have invasive breast cancer, compared to 30 out of 10,000 women not using the therapy. Likewise, in the same number of women, HRT would account for seven more heart attacks, eight additional strokes, and 18 more blood clots.
Moreover, the WHI assessed only one type of HRT: Prempro pills containing 0.625 milligrams of conjugated estrogens plus 2.5 milligrams of medroxyprogesterone acetate. Other hormone preparations, lower dosages of Prempro, and different delivery methods such as the transdermal patch, could have lower risks and greater benefits. (The FDA has asked Wyeth to rewrite its labeling for Prempro to reflect the risks revealed in the WHI study. Wyeth must also remove references to hormone "replacement" from the label, because it suggests that hormones lost in menopause need to be replaced. "HRT" is a misleading term, according to the FDA.)
Further, the WHI results do not necessarily apply to women using estrogen-only therapy, which is reserved for women who have had a hysterectomy, since it increases the risk of uterine cancer. (The hormone progestin in combination therapy eliminates this risk for women who have not had hysterectomies.) Researchers in the WHI are continuing to study estrogen-only therapy and have not found reasons to halt that study. But in July, researchers conducting an observational study of 44,000 women reported a 60 percent increase in ovarian cancer among women using estrogen-only therapy. The risk was especially high for women taking estrogen for 10 years or longer. Women on combination therapy did not appear to have an elevated risk.
In deciding whether or not to continue therapy, consult your doctor or nurse practitioner and weigh the facts about HRT's risks and benefits. On the list of what's "in" and what's "out" for postmenopausal health care, a blanket recommendation for HRT is out, and a plan that is tailored to each woman's personal circumstances is in.
Be aware that several new drugs are now available for protecting against heart disease and osteoporosis, although each has its own side effects. Many doctors, however, recommend healthy lifestyle practices as a first line of defense against chronic diseases: not smoking, eating a diet rich in fruits and vegetables, doing weight-bearing exercises to strengthen your bones and aerobic exercises to strengthen your heart, and getting enough calcium and vitamin D. That has been McKelvey's approach. DeAngelis, the JAMA editor, stopped taking HRT after reading the results of the WHI study and now relies upon diet and exercise to minimize her risk of heart disease.
Finally, whether or not you include hormone therapy in your personal plan, you should re-evaluate every year to see if you are doing everything you can to reduce your risk of disease. Your decision about HRT need not be final. You can always change your mind.
Prescribing HRT as broadly as many doctors did until recently was a mistake. But who is to blame—and whether the women who took HRT were "guinea pigs"—are questions we will debate for years.
In the meantime, science surges forward. Researchers develop more effective drugs for treating chronic illnesses. And scientists seek to understand estrogen's puzzling behavior. Why, for example, does it stimulate one type of cancer but protect against another?
One hypothesis researchers are pursuing: Some women are genetically predisposed to developing problems when they use hormones, while others are set up to reap its rewards. Researchers at Wake Forest University School of Medicine have identified a gene that may help some women benefit from HRT.
Perhaps the most salient lesson to come from all this is something cardiologist Wenger tells her patients. Paraphrasing H.L. Mencken, she says: "For every complex question there's a simple answer, and it's wrong."
Writer Melissa Hendricks of Annapolis, Maryland, frequently covers medicine, public health, and the environment.
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