Issue Date: November 17, 2002
My best advice on hormone therapy
Recent study findings were frighteningly convincing. But women have to judge what's best for themselves.
Earlier this year, a massive federally funded study on the benefits of treating menopausal women with estrogen plus progestin had to be halted before its expected completion because of disturbing findings. Many doctors, like me, were left just as confused as our patients.
This study indicated our previous belief that this kind of hormone replacement therapy (HRT) would decrease the risk of cardiovascular diseases and strokes was completely wrong. Further, our concern that it might raise women's risk of breast cancer looked justified -- alarmingly so. On a positive note, the study showed that women taking the therapy had fewer hip fractures and less colon cancer.
For doctors, the negative findings run so contrary to our clinical experience -- and our gut -- that they are almost unbelievable. My experience with patients on HRT has been so very positive. My patients seemed to have fewer strokes and less dementia in old age. And HRT certainly appeared to have a positive effect on heart disease.
Many of my peers, still incredulous, are reserving judgment. They're not telling patients to do anything differently. Yet the study was a good, large one, and it's difficult to deny the data and the conclusions. Studies like this have been done before, but this was supposed to be the ultimate one, the one with all the answers.
Sometimes studies have negative outcomes in the short term; when a study is followed out far enough, the results may become profoundly positive. So some people are saying, "This study just wasn't long enough. They terminated it before it turned around." But I feel confident in these results, as do many experts. (The results of a continuing study of estrogen-only therapy are pending.)
The situation poses a great scientific conundrum. Medicine is supposed to be empirically based. As a physician, you're supposed to do what the science says, and the science here says we definitely should not keep women on this kind of combination HRT. Yet I know the misery that discontinuing the therapy can cause -- the return of hot flashes, headaches, vaginal dryness, libido problems and mood disturbances, among other side effects -- and I believe we may be doing a grave disservice to millions of women by advising them to stop taking it.
I tell my patients that given the data, it would be irresponsible of me to recommend they keep taking HRT. But I also tell them that if I were a menopausal woman, I would stay on it. I try to hold their hands and help them make the decision. Some decide to stay on the therapy. Some stop and have no bad side effects. Some stop and feel so awful they go back on it.
The results of the study were confusing, and the news media made matters even more confusing. This highlights the importance of having a clinician with whom you can communicate. A good doctor can help you sort out all the issues.
You can't base medical care on headlines -- so let's not allow the media to make our health decisions for us.
Contributing Editor Drew Pinsky, M.D., hosts the nationally syndicated radio show "Loveline".
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