HRT:
Hormone Replacement Therapy
By Dr. Ralph Moss
from CancerDecisions.com Newsletter (5/7/02)When my wife entered menopause a few years ago she went to a prominent New York gynecologist for help. This doctor, until then sympathetic to alternative ideas, suddenly became a hard-liner.
She dismissed alternative treatments with the wave of her hand, demanding proof of their safety and effectiveness. She insisted that my wife immediately begin hormone replacement therapy (HRT). She showed scary pictures of a woman with a "widow's hump" and predicted this would happen to my wife if she didn't follow her advice. When my wife asked about the increased risk of endometrial cancer with estrogen, she replied, "Cancer, that's nothing. We can cure cancer. Heart disease is what will kill you."
She also claimed that any health risks of estrogen drugs, such as Premarin, were counteracted by the inclusion of another hormone, progesterone, in modern formulas. The health benefits of HRT, she said, went way beyond the relief of hot flashes and night sweats. They included the prevention of broken bones, strokes, urinary incontinence, severe depression, Alzheimer's disease and even heart attacks. This persistent gynecologist wouldn't let my wife leave the office without a paper bag full of cheerfully colored samples and a prescription for more pills.
This sort of high-pressure salesmanship could not have hit us at a more vulnerable moment. My wife was suffering with alternating hot flashes and chills. (I got my exercise opening and closing windows.) She had night sweats and insomnia, which left us both tossing and turning all night. Over on the dresser were the candy-colored pills that promised to take all her troubles away. Despite her suffering, she decided against taking them and in fact threw them away when we moved last year.
Something in her gynecologist's frenetic manner gave us pause. When unconventional practitioners promise to cure multiple diseases with a single pill they are called "snake oil salesmen." When they offer medicines made from urine, they are hooted out of town. But when conventional doctors tout the multiple wonders of pregnant mares' urine (how do you think Pre-mar-in got its name?), well, that's just "scientific medicine."
Or is it? Lately, HRT has fallen on hard times. An international panel of experts last month concluded that rigorous clinical trials provided no evidence that estrogen could prevent or treat urinary incontinence, major depression, or memory loss in Alzheimer's disease. And although it may prevent bone loss there is no proof that it actually prevents fractures.
It's no secret that estrogen, without progesterone, significantly increases the risks of uterine cancer. But it turns out that HRT also increases the risk of breast cancer by 30 to 60 percent in those who take it for more than five years. And, as an article in the Journal of the American Medical Association recently made clear, getting off HRT may not be easy. Sometimes women suffer terrible hot flashes when they try to quit. They have only delayed, but not overcome, their menopausal symptoms.
HRT also increases the risk of uterine bleeding and breast soreness. It causes a 40 percent increase in the incidence of gallbladder disease, a disease that already affects one in ten Americans and is particularly prevalent in older women. And remember the gynecologist's claim that HRT prevents heart disease? In fact, it triples the risk of blood clots, especially in women who have preexisting cardiac problems. Three studies have suggested that HRT increases women's risk of heart attacks and strokes.
The New York Times, which has been a staunch defender of the medical status quo, has changed its tune. In a recent editorial, it called the use of HRT "questionable," a word it once reserved for alternative medicine. This follows the Times' recent conclusion that the data supporting mammography are similarly flawed. Welcome to the club.
What to substitute for HRT is unclear. My wife used sage tea, evening primrose oil, and natural progesterone cream, all of which she found very helpful.
Many women use soy protein, although it may not reduce the severity of hot flashes. In a recent clinical trial among postmenopausal women with a history of breast cancer (who therefore could not use HRT), there was no significant difference between soy protein and a placebo in the number and severity of hot flashes. Both groups got some benefit, probably because of a strong placebo effect. Mild gastrointestinal side effects occurred more frequently with soy.
Articles in alternative medicine magazines claim that the herb black cohosh, in formulas such as Remifemin, is a safe and effective treatment for menopausal symptoms. Perhaps it is. German doctors gave my wife samples of Remifemin the way American doctors pushed HRT. But I cannot find any clinical trials to support such usage. Black cohosh and some other "women's herbs" contain plant forms of estrogen (phytoestrogens). As Fredi Kronenberg, PhD, of Columbia University has said, "It is unclear whether these herbs are safe for women at risk for breast cancer or its recurrence."
Many women rely on natural progesterone cream. This is advocated by Dr. John R. Lee in his book, What Your Doctor May Not Tell You About Menopause. Medical opinion on natural progesterone is sharply divided, but it has not been rigorously studied. Dr. Lee has been criticized for advocating an "unproven method" and doctors have been warned of legal consequences if they follow his example:
"We would ... caution clinicians against the use of such products as alternatives to HRT for any current or future indication," two British doctors wrote in The Lancet. "The real danger is that patients may be denied active treatment to prevent the long-term diseases associated with the menopause by the inappropriate substitution of compounds with unproven efficacy. Such patients who subsequently develop these diseases would rightly have access to legal redress against the prescriber."
This ominous pronouncement would give any doctor pause. However, today the boundary between "proven" and "unproven" treatments has blurred. Talking not of alternative treatments but of orthodox HRT, a doctor at Massachusetts General Hospital told the Times:
"What is sad is, here's a drug [HRT] that's been around for so many years, and we know so relatively little about it. It was used and introduced without really being studied in a rigorous scientific way. We're learning as we go along. We really suffer from a lack of information, a lack of good science."
"Learning as we go"... Why didn't they tell us this before? We, the consumers, are supposed to be docile guinea pigs in a vast but uncontrolled experiment with powerful hormones. That's quite a commentary on "scientific medicine."
Note from Chet: Be sure to sign up for Dr. Moss's excellent newsletter at his website.
Sources:
Grady, Denise. Weighing Risks and Benefits of Hormone Therapy. New York Times, April 30, 2002.
Grady D. A 60-year-old woman trying to discontinue hormone replacement therapy. JAMA 2002 Apr 24;287(16):2130-7.
Lee JR. Is natural progesterone the missing link in osteoporosis prevention and treatment? Med Hypotheses 1991;35:316-18.
McKenna DJ et al. Black cohosh: efficacy, safety, and use in clinical and preclinical applications. Altern Ther Health Med 2001;7:93-100.
New York Times [editorial], Rethinking Hormone Therapies. April 28, 2002.
Stevenson JC and Purdie DW. Use of Pro-Gest cream in postmenopausal women. Lancet 1998;352:905-6.
Van Patten CL et al. Effect of soy phytoestrogens on hot flashes in postmenopausal women with breast cancer: a randomized, controlled clinical trial. J Clin Oncol 2002;20:1449-55.
Wade C, et al. Hormone-modulating herbs: implications for women's health. J Am Med Womens Assoc 1999;54:181-3.
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