To Your Health
By James N. Dillard, M.D.
(01/21/2010) It’s not fair. It seems that we expect women to work hard to always look good, to look young. For most men, getting ready to leave the house means just putting on a baseball cap, and as the years go by men become distinguished. But it’s not so easy for women. There’s always unfair pressure to stay youthful.
According to legend, the natives of Puerto Rico told the Spanish conquistador Ponce de Leon of a miraculous fountain of the waters of Bimini that would cure illness and restore youth to whoever could drink of it. Ponce de Leon sought after the fountain and discovered Florida.
Though the fountain of youth was never found, Florida has been easing our stiff muscles and arthritic joints ever since. Still, the search for the fountain has continued, sometimes in unfortunate ways.
The two dominant sex hormones in a woman’s body are estrogen and progesterone. They cycle monthly, and eventually wane into the change of life, or menopause, when periods cease at an average age of 51. This is a natural process and carries with it symptoms such as hot flashes, sleep disturbance, mood changes, fatigue, and others.
As early as the 1940s, doctors began giving estrogen to ease hot flashes. In 1966, Robert Wilson wrote a national best seller called “Feminine Forever,” in which he declared that by replacing the waning sex hormone estrogen, women could not only avoid all the symptoms of menopause, but also remain young and vibrant forever.
This trend caught on like wildfire, and by the 1970s women were taking hormone replacement therapy by the tens of millions. Drug manufacturers touted their products as the cure for everything from wrinkles to heart attacks and Alzheimer’s disease.
By the mid-1970s, some less than rigorous studies suggested that hormone replacement therapy protected women against heart disease and improved quality of life. Better-quality research showed that estrogen did help with osteoporosis. At the same time, evidence was mounting that giving estrogen by itself without progesterone increased the risk of endometrial cancer.
Though some experts called for caution, citing growing evidence of risks for breast cancer, leg clots, and heart attacks, drug manufacturers spent hundreds of millions of dollars promoting hormone replacement. By the last decade of the 20th century, combined estrogen and progesterone was the most prescribed drug in the country.
Then, in August 1998, the Journal of the American Medical Association published the landmark Heart and Estrogen/Progestin Replacement Study of 2,763 post-menopausal women. It showed that hormone replacement therapy did not protect against heart attack, and that it increased the risk of blood clots.
This news tended to dampen some of the enthusiasm. Still, many women and doctors stuck to their guns. They liked the way hormone replacement therapy suppressed menopausal symptoms, and they hoped the research data was still too preliminary.
In July 2002, the National Institutes of Health prematurely halted a prospective trial part of the 15-year Women’s Health Initiative study of over 68,000 women ages 50 to 79, because it was becoming clear that estrogen and progesterone therapy was increasing the rates of breast cancer, stroke, blood clots, and heart disease.
Since 2002, two-thirds of the women who had been taking menopausal hormone replacement went off the drugs by themselves. Rates of breast cancer, which had been steadily rising since 1945, suddenly fell 15 percent after 2003 in women 50 years and older. These decreased rates have continued to drop slightly since that time.
The hormones used in the original hormone replacement therapy products are not the exact same molecules that are manufactured by the human body. There is a recent interest in using “bioidentical” hormone replacement instead. Though the body’s original hormones are now commercially available, there is little to no substantive research to support the claims that this therapy avoids the same risks as non-identical hormone replacement therapy. The Endocrine Society, the American College of Obstetricians and Gynecologists, and the American Cancer Society have not endorsed the superiority of bioidentical hormone replacement.
A friend recently told me she was on hormone replacement therapy. When I asked her why she said, “My doctor told me to.” This was the wrong answer, as it’s way too passive. The other answer is, “Oh, I’ve been on that forever. It makes me look young.” This was my mother’s answer, and it was wrong too.
The right answer is that you have discussed with your doctor all the risks and benefits of hormone replacement in light of all the research and relative to your health status, risks, and family history, and that together you have agreed that it is worth the risks, for you.
Getting older is not a disease, and the change of life is not a disease, despite our culture’s biases. But being on hormone replacement therapy for a few years for bad hot flashes is not the worst thing in the world, as for many women the risks are slight. Hormone replacement does strengthen bone, though we now have several other medications for thinning bones. And there are many alternative ways to treat symptoms associated with menopause. I know this answer is not as exciting as searching for the fountain of youth, but there’s always Disney World.
Questions can be directed to Dr. James Dillard at jdillard@ehstar.com.