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Thursday, August 12, 2010

Estrogen: the pendulum swings again

The following essay addresses the present tendency of scientific medicine to rely heavily on studies which address the effects of treatments on populations rather than individuals.  It has been clear, always, before and after various large scale studies of the effectiveness of estrogen, that hormone therapy is good for some people and not good for others. Nevertheless, at great cost to patients in money and time and quality of life, we have at various times pronounced estrogen to be good either for everyone or for no one.

When the Woman's Health Initiative study was stopped in 2002 due to increase heart attacks and breast cancer in the women treated with estrogen and progesterone the non-medical press circulated the story extremely effectively, and within a year very few women did not know that the estrogen they had been prescribed and told would save them from all sorts of misery was actually toxic and evil.  It was a bad year for estrogen.

In the 8 years since then doctors, researchers and menopausal women have gradually processed much of the information that came from that large, double blind multi-center trial, and recommendations have matured. It is clear that conjugated estrogen plus medroxyprogesterone is not good for preventing dementia and leads to an increased incidence of breast cancer, heart attacks and strokes.  Statistically the combination of hormones does not lengthen a woman's life, but then it doesn't shorten it either. It does reduce hip fractures, colon cancer and diabetes. Some women feel better on hormones and some feel worse, but statistically quality of life is a wash.

But WHI was a huge study, involving over 160,000 women over more than 12 years. The amount of data from this group of women is tremendous and it is potentially powerful enough to answer questions like "which women experience which side effects?" and "who should take estrogen and who should not?" As an individual person navigating the shoals of menopause, these are the questions that are most relevant.

This issue of Internal Medicine News reports on Dr. Richard Santen's conclusions as part of a task force from the Endocrine Society on hormone therapy.  Apparently when one analyzes the subgroup of women in their early 50s and those within 10 years of menopause, a significant 30-40% reduction in overall mortality was seen in estrogen users, with or without progesterone. This is, of course, just the group of women who would be likely to want to use estrogen for treatment of the hot flashes, mood changes and sleep disorder so common in early menopause.

As a physician who sees many women as they experience the end of regular menstrual cycles along with the joys of waking up multiple times each night in puddles of sweat and being unable to remember what it was that they were supposed to be doing right now, I will again have to adjust my recommendations regarding the use of hormones. I will continue to struggle with answering questions about which forms of hormones are safest, how long to take those hormones, when and how to stop them. The WHI will be unable to answer many of these questions due to its study design. I will, however, have a new piece of information to support the women I treat who feel they really want to take estrogen.

Here is a link to the Internal Medicine News article.

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