The Demise of HRT
By Dr. Ralph Moss
from CancerDecisions.com Newsletter (8/6/02)You've probably heard the astonishing news about hormone replacement therapy (HRT). A recent study in the Journal of the American Medical Association reported that women who took a combination of estrogen and progestin had more, not fewer, health problems than those who didn't. This federally funded study of over 16,000 women was supposed to prove, once and for all, that HRT was beneficial. Instead, HRT turned out to do more harm than good: there was a 29 percent increase in coronary heart disease, a 26 percent increase in breast cancer, and a 41 percent increase in stroke, all of which overpowered a decrease in the incidence of hip fractures and colon cancer.
These adverse findings on HRT were so important, in fact, that the study had to be stopped three years short of its scheduled completion. "The bubble has burst," exclaimed Dr. Isaac Schiff of the Massachusetts General Hospital in Boston, who is chairing the American College of Obstetrics and Gynecology task force that is rethinking its guidelines on HRT.
The JAMA findings also prompted the president of the American Heart Association to declare that women should neither start nor continue HRT for the prevention of coronary heart disease. Not surprisingly, news reports of the JAMA article have sent the six million women who take estrogen and progestin (often sold under the brand name Prempro) into a tailspin. "How could so many physicians get it so wrong for so long?" Emily Joffe asked plaintively in the online journal Slate (7/11/02).
HRT: Science or Religion?
As I wrote in an earlier newsletter (May 7, 2002), when my wife entered menopause her gynecologist badgered her to take HRT. When my wife asked her gynecologist about the opinions of Susan Love, MD, a well-known physician who has urged caution in the use of HRT, she called Dr. Love a "murderer" for even questioning its safety. I wonder what the women dying of hormonally induced breast cancer would say to that!
In fact, despite (or perhaps because of) the zealous loyalty of physicians to these drugs, hormone replacement therapy has always seemed more like religion than pure science. Whenever you run into the sort of furious contentiousness exhibited by my wife's gynecologist, you can bet that the speaker is on shaky ground.
Resistance to criticism is nothing new in medicine. "Cancer research has…become so isolated and so entrenched that, without being aware of it, the researcher now almost instinctively regards those who criticize his opinion, question his authority, or adopt other methods of working, not as fellow workers, but as amateurs, as 'outsiders,' or even as positive enemies," the researcher Dr. William H. Woglom wrote in the early 1930s. Not much has changed since then.
An All-Purpose Rejuvenator
So how did the allopathic medical profession become so enamored of hormone replacement? About 40 years ago, a New York gynecologist named Robert Wilson, MD, preached the doctrine that estrogen could be "an all-purpose rejuvenator for women of a certain age," to quote a recent Time magazine article. In his best-selling book, Feminine Forever, published in 1966, Wilson called menopause a "living decay" during which women descended into a "vapid cow-like" state. By giving estrogen, Wilson claimed, he could magically transform a "dull cow" into a supple, younger-looking wife. As Time magazine summarized Wilson's argument, "She would not only feel better herself but also make those around her feel better -- especially, it was implied, her partner in bed."
The hormone's chief manufacturer, Wyeth Pharmaceuticals, next launched an aggressive marketing campaign. A 1975 ad read, "Almost any tranquilizer might calm her down…but at her age, estrogen may be what she really needs." Over the next two decades, the patronizing tone that characterized Wilson's book and the drug company's advertisements was replaced by scientific-sounding arguments for the virtues of hormone replacement. Doctors used these arguments to convince their menopausal patients that taking estrogen and progestin would not only decrease their hot flashes but also reduce their risk of heart disease and cancer, and millions of American women believed them.
But as Susan Love, MD, noted in a recent New York Times editorial, there was a lot of scientific theorizing about the benefits of HRT, but very little scientific research. "What happened is that medical practice, as it so often does, got ahead of medical science. We made observations and developed hypotheses -- and then forgot to prove them."
How the Mighty Have Fallen
The fall of HRT from its secure position as one of the pillars of conventional medical thinking is only the latest in a string of reversals that call into question the wisdom of the medical establishment. In recent months, research has cast doubts about the effectiveness of bone marrow transplantation for stage IV cancers, challenged the usefulness of mammography as a screening tool, and demonstrated that arthroscopic surgery for osteoarthritis of the knee is no more effective than a placebo. In December 2001, a highly touted cancer drug, Erbitux, failed to receive FDA approval, sending its stock (and its major stockholders) into a tailspin, while just last month the low-carbohydrate diet promoted by Dr. Atkins (and reviled by the medical establishment for the past 30 years) was vindicated.
There is a growing feeling of skepticism among Americans concerning official medical pronouncements, which parallels and sometimes intersects with doubts over the country's financial and political leadership. The public is confused, disoriented and distrustful.
I hope the recent findings about HRT and other seemingly sacrosanct medical practices do not lead to a new era of "medical nihilism," in which it is assumed that no one is honest and nothing works. If, on the other hand, these reports lead to a healthy skepticism about all medical pronouncements, a willingness to consult primary sources, and an even-handed approach towards alternative and conventional medicine, then they could turn out to be a salutary "correction" in the marketplace of ideas.
Note from Chet: Be sure to sign up for Dr. Moss's excellent newsletter at his website.
References:
Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002;288:321-33. Available at http://jama.ama-assn.org/issues/v288n3/ffull/joc21036.html
Gorman, C and Park, A. The truth about hormones. Time Magazine, July 13, 2002. Available at http://www.time.com/time/covers/1101020722/story.htmlLove, S. Preventive medicine, properly practiced. New York Times, July 16, 2002. Reprinted at http://www.susanlovemd.com
Moseley, JB et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee.. N Engl J Med, 2002;347:81-8.
Quote from Dr. William H. Woglom in: Stefannson, V. Cancer: Disease of Civilization? NY: Hill & Wang, 1960, p. 132.
My earlier column on HRT: http://www.cancerdecisions.com/050702.html
On ineffectiveness of screening mammography: http://www.cancerdecisions.com/071602.html
On the Erbitux scandal: http://www.cancerdecisions.com/052902.html and http://www.cancerdecisions.com/061802.html
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