Estrogen Matters: A Fresh Look at Postmenopausal Hormones

Rose is a 49-year-old woman who was in her usual excel­lent state of health when she began to experience episodes of heart skipping and racing. These palpitations, as we cardiologists call them, occurred randomly without warning and were distracting for Rose, and caused her to worry about her heart.

She saw her primary care physician who prescribed metoprolol, which improved her palpitations. Yet, this medication - a beta-blocker - left her feeling depleted and depressed. When Rose saw me as a patient, upon questioning, she confided that in the past year her menstrual cycles had become quite irregular and she felt like she might be starting menopause. I stopped her metoprolol and suggest­ed that she ask her gynecologist (GYN) physician to consider starting her on estrogen with progesterone. The GYN doctor started Rose on these hor­mones, and her palpitations vanished for good about two weeks later.

Supplemental estrogen + proges­terone - known as hormone replace­ment therapy (HRT) or estrogen replacement therapy (ERT) was for years highly acclaimed as an effective therapy to help keep women youthful and healthy after menopause. Con­vincing scientific studies showed that without question HRT, when started around the time of menopause, could alleviate symptoms such as hot flashes, brain fog and palpitations. Moreover, among postmenopausal women, estrogen and progesterone were linked with reduced risks for de­veloping heart disease, osteoporosis and colon cancer.

Diffusing the WHI Bombshell

But then in 2002 the Women’s Health Initiative (WHI), a study funded by the National Institutes of Health (NIH) to the tune of $1 bil­lion, announced results showing a possible uptick in the risk of breast cancer among women taking HRT. The academic winds shifted abruptly, and estrogen was officially deemed a carcinogen. Physicians across America took their female patients off HRT and have been reluctant to prescribe estro­gen and progesterone for postmeno­pausal women ever since.

Now, 17 years after HRT was left for dead, Avrum Bluming, M.D., an oncologist, and Carol Tavris, Ph.D., re­veal the questionable science behind the flawed conclusions of that WHI study and present a compelling case for HRT’s resurrection in an important new book. They uncover the sweep­ing publicity campaign that a few of the WHI investigators waged, based on their own biased opinions, against postmenopausal estrogen.

Drs. Tavris and Bluming’s book, Estrogen Matters, is a compelling ex­posé that scrutinizes the vast body of evidence regarding HRT and presents a fuller picture of largely reassuring data which, in general, supports es­trogen use for many postmenopausal women. This landmark book sets the record straight on the unique and im­portant benefits of estrogen and pro­gesterone. The purported increased risk of breast cancer with estrogen was never statistically significant in the WHI, and many of the frighten­ing warnings turned out to be wrong. Estrogen Matters will likely be a long overdue turning point in the medical saga of HRT.

I was always skeptical of the WHI findings - they were so contradictory to a massive amount of data showing that estrogen was generally beneficial for post-menopausal women.

When a woman goes through menopause, the amount of estrogen and progesterone her ovaries are pro­ducing suddenly plummets from the normally high levels to virtually zero, often causing unpleasant symptoms. These can include hot flashes, palpi­tations, loss of sexual desire, urinary tract problems, insomnia, anxiety at­tacks, difficulty concentrating, depres­sion, weight gain around the abdo­men and fuzzy thinking. The usual medical response to these complaints is a menopausal cocktail of prescrip­tion antidepressants, anti-anxiety meds and sleeping pills.

Additionally, bone strength starts to erode promptly after the ovaries shut down hormone production. For exam­ple, my sister Maureen’s bone density was normal before menopause, and in just a few years she had developed osteopenia. By the way, this was not due to a disease - without estrogen a woman’s bone strength will predict­ably weaken, even in an otherwise active and healthy female. Although there are numerous prescription drugs to treat osteoporosis and osteopenia, many of them have common and sometimes serious side effects. What’s more, none of these prescription medicines for osteoporosis is as effec­tive as HRT for strengthening bones and reducing fractures.

Heart Disease: Public Enemy #1

Estrogen replacement not only re­lieves many of the menopausal symp­toms such as hot flashes, palpitations and an expanding waistline, it also may reduce the long-term risk of heart disease, hip fracture and colon cancer. Each year, heart disease kills eight times more American women than does breast cancer. HRT is linked to a 40% reduction in risk of atheroscle­rotic cardiovascular (CV) disease when the hormones are started shortly after menopause. Most studies indicate that estrogen is safer and more protective when it is initiated within three years of the onset of menopause.

Women tend to fear breast can­cer more than heart disease, in part because they think of CV disease as more of a concern for their mother or grandmother. Only 9% of women report that the disease they fear most is heart disease. Yet, in every decade of life starting at age 20, a woman’s risk of dying of heart disease is much higher than her risk of dying from breast cancer. Estrogen relaxes arteries by stimulating the vessels’ production of nitric oxide - an important natural vasodilator. HRT improves cholesterol levels by increasing the protective HDL cholesterol, and reducing bad LDL cholesterol. Additionally, estro­gen has potent antioxidant effects, which helps to keep a woman’s blood vessels soft and supple.

The Framingham Study showed that HRT was also associated with a 50% lower risk of osteoporotic hip fractures in postmenopausal women. Multiple studies show HRT cuts the risk of dying from colon cancer in half. And in contrast to the WHI findings, most studies show that for women without a prior history of breast cancer, estro­gen therapy does not increase the risk of being diagnosed with breast cancer, even among women who have been taking HRT for 10 or 15 years. Finally, women taking estrogen tend to live longer than women not taking HRT. A JAMA study estimated that HRT may increase overall life expectancy by about three to four years.

The Last Half of Life As a Second Prime

Dr. Bernadine Healy, a cardiologist, and the first and only female direc­tor of the NIH, the same organization that sponsored the WHI, wrote that hormone replacement therapy helps women stay healthier longer. She said, “The benefits of HRT are compelling. The total health of a woman as she gets older is largely what determines her quality of life; what allows her to view the last half of her life as a bless­ing and second prime.”

Women during their childbear­ing years are protected from many diseases, and that protection largely disappears after menopause. However, when the WHI investigators claimed the HRT was paradoxically danger­ous, and that it could increase the risks of breast cancer, heart disease, stroke and dementia, and shorten life expectancy, millions of women soon stopped taking their hormone therapy.

Even today, most doctors and medi­cal centers advise women not to take estrogen after menopause, or if they do start estrogen or HRT, they should be on it for the shortest period of time. Again, this is based on unproven biases against HRT, with no real evi­dence to support this recommenda­tion. What we do know is that women who stop their estrogen tend to lose the brain and bone benefits that were being conferred by HRT.

If you want to know how I person­ally feel about this crucially important topic, my wife, Joan, is on HRT, as are my mother, Leatrice, and sister, Maureen. Now to be clear, I don’t prescribe estrogen for them or for any of my patients. But I did advise my female family members, as I do for many of my postmenopausal patients, to ask their primary care physician or GYN doctor if they could be started on HRT. It is essential that postmeno­pausal women on estrogen therapy are followed appropriately with mam­mograms, GYN exams, etc.

Risks of Estrogen and Progesterone

There is a widespread assumption based on inconclusive data that estro­gen causes breast cancer. Decades of contradictory evidence indicate HRT is not only safe for most women - it’s beneficial in many respects. However, estrogen when prescribed as the lone female hormone in a postmenopausal woman who still has her uterus can increase the risk of uterine cancer. For­tunately, adding progesterone to the estrogen, which is referred to as HRT - the standard hormone therapy for a postmenopausal woman who still has her uterus, will completely eliminate the increased risk of uterine cancer posed by estrogen monotherapy.

Estrogen and progesterone carry other risks as well. When taken orally, estrogen increases risk for gallstones, and blood clots - such as deep venous thrombosis (clots in the leg veins) and pulmonary emboli (clots in the lungs). These risks are magnified in women taking higher dose estrogen, in smok­ers, and those with obesity.

On the other hand, these risks of gallstones and blood clots are mini­mized when estrogen is supplied via a skin patch or a vaginal cream. Also, older women with existing atheroscle­rotic plaque can be at increased risk of complications like heart attack and stroke if they start estrogen 10 years or more after going through menopause. Progesterone can trigger resumption of menstrual periods in postmeno­pausal women, and also can cause headaches and fatigue. Progesterone may marginally increase risks of ovar­ian cancer and breast cancer as well.

Still Dancing ...

Some women feel that taking estro­gen after menopause is not natural. But it is also not natural to live to age 90 or 100. Our ancient ancestors often perished from starvation, infections, trauma, exposure or even while giving birth, and thus died decades before succumbing to heart disease, osteopo­rosis or Alzheimer’s disease. A woman may not have serious problems with hormone deficiency for a decade or two without estrogen, but many women today live almost as long after menopause as they did while their ovaries were still producing hor­mones. HRT can help to maintain bone strength, skin elasticity, heart health, and mood as the decades go by.

Marie Griffin, M.D., is a smart en­docrinologist who I’ve always turned to for advice on the issues related to hormone therapy for women. Dr. Grif­fin said after the WHI study publicized its scary conclusions about estrogen, many of her patients who had been on HRT stopped their hormones. Subsequently, when those women came in for their annual visits, Dr. Griffin noted that the aging process had seemed to accelerate for many of them. One 74-year-old lady told Dr. Griffin that she quit dancing because she felt weaker and less steady on her feet, and just wasn’t in the mood to dance anymore. Those kinds of inter­actions prompted Dr. Griffin to think, “I want to still be dancing when I am 90, so I’m staying on my HRT.”

Joan is also big believer in the ben­efits of HRT based on her own experi­ence. She says, “How can a hormone that was flowing through my body for the first 50 years of my life turn sud­denly dangerous if I continue to use it after my ovaries stop making it?” For women like Joan, Marie, Leatrice and Maureen, the benefits of HRT out­weigh the risks of these hormones.

Importantly, each woman should talk her specifics over with her physi­cians and decide if HRT is right for her. Many women, including Carol Tavris, stay healthy and happy after meno­pause without the need for HRT. The decision about whether HRT should be started is a complex one that should be made only after thoroughly discussing the risks and benefits for each individual woman.

One-size-fits-all recommendations cannot be made, but women and their doctors do have a great deal of information to bear on the topic. This new book by Drs. Bluming and Tavris is a real treasure for any woman who wants state-of-the-art information to help her make decisions that are right for her regarding HRT.

In Good Health,
James O'Keefe, MD