The Great Hormone Controversy
by Constance Young

Women nearing the age of menopause and older have been on a roller coaster ride since early 2000 when shrill headlines spread an alarming but confused message. The pronouncements were filled with half-truths--but what rang loud and clear was the message that hormone replacement therapy (HRT) could cause cardiovascular and other serious problems. In short, there were seven more cases of coronary heart disease, eight more strokes, eight more cases of pulmonary embolism, and eight more invasive breast cancers than expected in a group of women taking hormone replacement who participated in a major long-running study.

In the rush following the headlines, frightened women on HRT made urgent calls to their healthcare providers, or just dropped out. Others who had considered hormone replacement looked elsewhere. And of course the medical establishment went on red alert, reviewing the data, issuing reports, and prematurely putting an end to one segment of the study in question, the Women's Health Initiative (WHI), lest the effects of the study expose the study subjects to increased risk of disease.

I will try to make some sense here of this very complex issue.

The widely promoted findings were one interpretation (as you will see, there are others) of one part of the WHI study of over 16,000 postmenopausal women. In this segment, women free of the negative symptoms of menopause (problem 1) were given the most-prescribed HRT, Prempro, (problem 2) or another related drug produced by the same manufacturer (Wyeth-Ayerst). Prempro contains estrogen made from horse's urine plus progestin--which is synthetic progesterone. Both estrogen and progesterone are normally produced in a woman's ovary, gradually dwindling before and during menopause.

According to area practitioners Dr. Ira Jaffe, proprietor of Hudson Valley Women's Health Center, and certified midwife Susan Willson, of Woodstock Women's Health, there are several major limitations to the WHI findings. First, only one form of HRT was studied. Second, the only women who were given the drug were those who did not have symptoms. So the verdict is still out on how the results apply to women on other forms of HRT or who have symptoms.

Willson, who has a gynecology practice at Woodstock Women's Health, said, "The press only mentioned 'estrogen and progesterone' when they were blanketing the study across the media waves. In fact, there are no really large scale studies on what we call the 'natural hormones'--the bio-identical hormones that are synthesized from yam and soy, because there is no financial incentive for the drug companies to carry out those large-scale studies." Prempro has been widely promoted to physicians in multi-million dollar advertising campaigns by its mega drug manufacturer, Wyeth Ayerst.

There are also other synthetic types of estrogen. According to Dr. Lorraine Fitzpatrick, professor of medicine and director of the Women's Health Fellowship at Mayo Clinic in Rochester, Minnesota, "There are many other estrogens and progestins available. There are hormone therapies that we don't know much about--that are absorbed differently, that women react to differently, [and that] have different affects on clotting proteins (important for cardiovascular health)."

Dr. Jaffe points out yet another factor restricting the applicability of the WHI study, namely that "It did not make a distinction between women who had been continuously on estrogen--either from their own body, by taking pills--versus women who had been without estrogen for a number of years, and then started on estrogen."

According to Dr. Jaffe, "Women have become more frightened by the potential negatives of HRT than by some of its demonstrated advantages." He points out that estrogen helps reduce the risks of osteoporosis and of colon cancer...and other less clear, yet strongly suggested benefits in terms of improved sexuality, a delay in the onset of Alzheimer's, and a delay in the onset of age-related diabetes.

Although there are still many uncertainties, most practitioners agree that, after weighing all pros and cons with a healthcare professional, a women who decides to go on HRT should generally stay on the therapy only on a short-term basis.

Mitigating Menopausal Problems

Another way to counteract some of the potential problems brought on by menopause was addressed by Willson, who recommends making lifestyle changes such as a program of weight-bearing exercise (see sidebar), and possibly using a tailor-made "natural" estrogen as an alternative to the synthetic drugs.

According to Willson, "The estrogen in Prempro consists of sixteen different conjugated estrogens that come from mare's urine . . . and the progestin is not the same molecule our body would make." She explains that since a drug company can't patent a naturally occurring hormone, the manufacturer adds chemical subgroups to it so they can patent it. Willson claims that because such drugs don't fit exactly into the cellular receptors in our body, they may produce side effects which bio-identical hormones--created in a laboratory from yam and soy and being an exact fit--do not.

Willson explained that manufacturers can create the actual estrogen (estradiol, estriol, or estrone) that we make in our own body. Most manufacturers then add subgroups to the estrogen, because they cannot patent a natural product. By changing the chemical structure of the estrogen it can then be patented as a medicine. "In contrast, the makers of patches usually use the natural estrogens because they patent the delivery system (the patch) instead of the estrogen to make their profit," Willson explained. Patches release the estrogen into the bloodstream when they are applied to the skin.

She also recommends a natural progesterone called prometrium, but claims that a better choice is to tailor-make a compound estrogen designed for one's individual needs. These can be made up as pills, drops, or creams exactly as the provider prescribes. She claims that some of the natural estrogens are higher risk than others. Therefore she says, "One approach is to start with the lowest dose of the lowest risk estrogen, then continue tailoring it until you get to something that works for you and carries the least amount of risk. But that takes time."

The Cancer Risk

Add to the confusion created by the WHI study are the long-known effects of estrogen on some cancers, which are not as clear and simple as the public believes. Dr. Jaffe explains, "If there is a continuous source of estrogen in a woman's body without opposing progesterone-like hormone, then the lining of the uterus can start to grow abnormally and create a risk for becoming cancerous." He adds that by including a progesterone-like drug to HRT, the risk is eliminated. Studies have also tried to measure the risk of breast cancer associated with hormone replacement. He says, "These studies often don't take into account the fact that it takes about ten years from when a cancer starts to grow in the breast until it is big enough to feel on an exam or to see on a mammogram." He says that studies that claim to show an increased rate of breast cancer in women on hormone replacement may be basing that claim on occurrences of cancer that were already there but had not yet manifested themselves.

What's a Woman to Do?

According to Dr. Fitzpatrick, one of the biggest dilemmas facing women with menopausal symptoms (hot flashes, problems sleeping, mood swings, and vaginal dryness) is what to do when hormone levels drop and symptoms go haywire.

In fact, there is a shopping bag full of choices. A woman can go on HRT with estrogen and progestin, or women who have had hysterectomies and have no uterus can go on estrogen replacement therapy (ERT). HRT helps relieve symptoms that are uncomfortable, or even dangerous, such as weakened bones, and reduces the rate of bone loss after menopause, but it is not the best treatment for all women.

It is difficult to compose a list of women who might do well on hormone replacement, but there are at least two types of women who generally should not go on HRT. Dr. Jaffe says that "People with a demonstrated estrogen-sensitive cancer in their body are generally not good candidates to take estrogen. Likewise, people who have a history of stroke or deep vein thrombosis or pulmonary embolism--clotting problems--also probably should not start taking estrogen."

Willson says that she looks "at the whole piece" together and tries to tailor a treatment that fits with a person's belief systems, history, and with what's safe. "Many women do very well on different alternatives that do not involve hormones at all. Other women may need a bit of the hormone to address their symptoms." Willson says that she takes an hour with a woman on her first visit. "There is not one easy answer that fits everybody."

Rhinebeck homeopathic practitioner, Dr. Ronald Whitmont, has an arsenal of alternative remedies that he recommends (see sidebar). "Above all, there is good, solid evidence against the use of HRT in menopause," he claims, "...and strong evidence supporting the use of many 'alternative' lifestyle approaches to these risks of aging."

Dr. Ronald Whitmont's Safer Way To Treat Menopausal Symptoms and Prevent Against Disorders of Aging

Osteoporosis: Reduced estrogen occurring during menopause affects bone density. Good solutions to prevent osteoporosis include: weight-bearing exercise; a diet rich in calcium and vitamin C (mainly from fruits, vegetables, grains and nuts); plenty of sunshine to assist in the physiological conversion of cholesterol into vitamin D in the skin.

Heart Disease: Aerobic exercise; a diet low in animal products and cholesterol and high in antioxidants and bioflavinoids (found abundantly in fruits and colored vegetables).

Cancer: Same as for osteoporosis and heart disease, plus emotional expression, peer support and stress reduction. (see Signs & Symptoms of Menopause).

Alzheimer's disease: Regular lifelong physical exercise; a diet high in antioxidants from fruits and vegetables; continued mental and emotional challenges, including mental calisthenics, changing one's routine and setting continual intellectual and mental challenges.

Signs & Symptoms of Menopause: Regular physical exercise throughout life; a diet high in fruits and vegetables and low in animal products; emotional expression and stress reduction techniques including (but not limited to) t'ai chi (and other martial arts), medi- tation and relaxation techniques.