Menopause and the Women’s Health Initiative

July 2004 will mark the two-year anniversary of the publication of the Women’s Health Initiative (WHI)—a landmark scientific article showing increased risks of hormone replacement therapy. Never has an article in the press produced such dramatic changes in patient behavior. As the WHI has been reviewed and analyzed extensively in the past two years, it is worth asking whether the health of American women is better or worse for these changes.

A scientific or medical fact is never established by a single study. Rather, the findings need to be confirmed and reconfirmed by independent investigators. Over time a medical fact or a recommended change in practice emerges. This has not yet happened in the case of the WHI. Only two facts appear indisputable - dementia cannot be prevented by hormones in a woman who is already elderly; and, hormones will not prevent further heart trouble in a woman who already has heart disease.

The fact that women were admitted to the study at age 63 is its most glaring deficiency. Amazingly, 25% of the participants were in their 70’s. In fact, only 10% of the patients were age 50-54, the age when we usually consider starting hormone therapy. American women and their gynecologists want to know if there are health benefits when hormones are started at the time of the menopause, not years later.

Many of the study participants already had risk factors. For example, 36% had high blood pressure and 49% were current or former smokers. Once again, the study sheds little light on a critical question: can a healthy menopausal woman benefit from hormone replacement therapy?

Only one drug at one dosage was studied in the WHI. It may be that other formulations, other dosages; other delivery systems (skin patches, skin lotions, vaginal rings) will prove effective and safe.

The WHI, however, produced some needed changes in our specialty. Hormone replacement therapy is now used in the lowest dose possible and for the shortest time possible. Patient’s individual risk factors are carefully evaluated. Caution is exercised in patients with a family history of heart disease, stroke and breast cancer.

Recently another part of the WHI, called the “estrogen only arm”, was released In women who have had a hysterectomy and who only took estrogen (without progesterone) there was no increase in breast cancer risk. This is good news for the thousands of women who have had a hysterectomy or who are planning to have one.

What about hormones and breast cancer? When breast cancer is first diagnosed, it is generally accepted that it has been present in the breast for 7-8 years or longer. There is no evidence that estrogen causes breast cancer but it is suspected that the hormones may accelerate the cancer’s growth and bring it into mammograpic view sooner. This would explain why women on hormones have highly curable breast cancers and generally have excellent results. On the other hand, HRT makes a mammogram look slightly hazy and may delay the diagnosis.

So the issue of hormones and breast cancer remains unresolved. It is not likely to be resolved in the near future. We know this for sure - if a patient’s outcome is worsened by taking hormones, it is only worsened to a very small degree and possibly could be overcome by a diligent mammography program.

After 25 years of practicing gynecology, mostly with women in the middle years, I can report the following - hormone replacement therapy improves the sense of well-being in large numbers of women. Hot flashes and vaginal dryness improve, complexion softens, hair texture can become fuller, memory sharpens, and mood becomes less irritable. Even mid-life depression may begin to lift. These are my own personal observations

So, how can a women make sense of all this? Have a doctor you like and trust. Make sure he or she is well-versed and up-to-date on menopausal issues. Participate in your own health decisions. Don’t become frightened if your doctor suggests HRT. Ask for the lowest dose possible. Use it for the shortest time possible. Be cautions if you have risk factors for breast cancer, heart disease or stroke. Get appropriate lab studies and a bone density study.

There is a cartoon on a friend’s refrigerator showing two men at the bar, drinks in hand. One raises his glass and says, “Here’s to the truth as perceived by you!”

Until the truth about hormone replacement therapy is perceived with greater accuracy, we should read the WHI with a critical eye.

As Plutarch philosophized in the first century, “So very difficult it is to find out the truth of anything.”

© 2004 Allen Gregg South, M.D.