Oge Young, MD is a retired Concord Ob/Gyn.
One month ago in the New York Times Sunday Magazine (2/5), author Susan Dominus, wrote a piece titled “We Have Been Misled About Menopause.” Her article dispels the myths of menopause, including the dangers of menopausal hormone replacement.
She dramatically writes, “Imagine that some significant portion of the male population started regularly waking in the middle of the night drenched in sweat, a problem that endured for several years. Imagine that those men stumbled to work, exhausted, their morale low, frequently tearing off their jackets or hoodies during meetings, excusing themselves to gulp for air by a window… Imagine that their doctors had received little to no training on how to manage these symptoms and when the subject arose, reassured their patients that this process was natural.”
Menopausal hormone therapy was once the most commonly prescribed treatment in the United States. It effectively treated these “hot flashes” and many other menopausal symptoms. In the late 1990s, fifteen million women a year were receiving a prescription for it. Unfortunately, a single study, the Women’s Health Initiative in 2002, suggested there were elevated health risks for women of all ages taking hormone replacement therapy (HRT).
Panic set in and the number of prescriptions for hormone replacement plummeted. Within six months insurance claims for hormone therapy had dropped 30 percent, and by 2009 they were down by more than 70 percent. JoAnne Manson, chief of the division of preventive medicine at Brigham and Women’s Hospital and a chief investigator in the study, described the fallout as “the most sea of change in clinical medicine she had ever seen.”
The message took hold then and has persisted since. In recent years, the W.H.I. study has been found woefully flawed. The misinterpretation of the data is one of the great tragedies in modern medicine, an appalling disservice to healthy middle-aged women.
The study was stopped in 2002 because it gave evidence of a slight increase in breast cancer (less than one more case per thousand women) on estrogen and a synthetic progesterone compared to women on no hormone therapy. What did not make headlines in the media was that the data also showed there was a lower risk of breast cancer in women who were taking only estrogen.
Also, the W.H.I. suggested HRT increased the risk of heart disease. It is thought that women rarely experience a heart attack before menopause because estrogen (produced by her ovaries prior to menopause) protected the blood vessels of her heart. This turns out to be true.
The major problem with the study was that the average age of the women in the W.H.I. was 63, at least 10 years post-menopause. In a reanalysis of the data, women were divided into age groups. HRT was found to significantly reduce the risk of heart attacks for women in their 50s.
Only the women in their 60s and 70s, well past menopause, who had never been on HRT, experienced an increased risk of heart disease. There seems to be a 10 year “window of opportunity” after menopause when estrogen replacement will prevent the formation of atherosclerosis (fatty plaques) on a woman’s arteries.
The W.H.I. revealed a significant reduction in osteoporosis at all ages for women on hormone replacement, an extremely important benefit of HRT. The study did not show a clear decrease in Alzheimer’s disease or other dementias with HRT, but it is well documented that short-term memory markedly improves on HRT.
Sadly, the author of this article reports that many care providers have little knowledge of menopause, and do not know about the safety and benefits of hormone therapy. In defense of these practitioners, “corporate” medicine today is not allowing time for providers to explain to patients the complexities and nuances of menopause and the Women’s Health Initiative.
I urge women to read Susan Dominus’ New York Times Sunday Magazine article and consult a care provider who is knowledgeable about menopause and HRT. An informed decision about the replacement of estrogen, at least for the first 10 years post-menopause, appears to be in keeping with women living longer and healthier lives.