When Emotion Trumps Science: the Latest on Hormone Therapy

Let’s imagine that there is a new medication available for post-menopausal women.  It is an effective remedy for hot flashes and osteoporosis and lowers the risk of diabetes and colon cancer.  In younger women, it may protect against heart disease.  One version of this drug can also diminish a woman’s risk of dying of breast cancer.  Potential downsides include a small increased risk of having a stroke (12 more per 10,000) or of dying of breast cancer (about 1 more death per 10,000 with the drug). 

This blog has a feature called “Should I Be Taking This?” in which the potential side effects of a particular medication are listed first, followed by ostensible benefits.  Often the first list is quite long and the second rather short and tentative.  Some of the medications have only been on the market for a short time so the full extent of the risks and benefits may not yet be apparent, a situation I discussed in “Statistics and the Twenty Year Rule.”  

Against this background hormone therapy seemed like a pretty good deal:  substantial and proven benefits associated with risks that amount to tenths or hundredths of a percent.  And some hormone medications had been around for decades.  I started taking Premarin, an estrogen-only version of hormone therapy, in 1979 after a complete hysterectomy at age 32.  The initial dosage of 1.25mg was too high and was later reduced by half.  I tried taking even less but started getting hot flashes.  Then in 2002 the Women’s Health Initiative study of estrogen-plus-progestin therapy was halted because of higher-than-expected rates of breast cancer and heart attack in women using the medication; the risks of the therapy were deemed to outweigh the benefits.  When this news was released, widespread panic ensued among women using hormone therapy.  Many abandoned it altogether.  WHI was taken as a blanket rejection of hormone therapy by the medical community, whether researchers intended it or not.

The women who discontinued taking these medications avoided risks but they also lost substantial benefits.  Many undoubtedly experienced hot flashes which disturbed their sleep and interfered with their ability to concentrate.  People tend to joke about hot flashes but insomnia is a big deal.  Sleep is right up there with air, water, and food among the essentials for survival.  That’s why sleep deprivation is used as a form of torture.  These women were also more likely to get osteoporosis.  Sometimes their doctors prescribed bisphosphonates to protect from bone loss but these have been related to a rare type of femur fracture and, in a few cases, with osteonecrosis of the jaw (disintegration of the jaw bone), although the nature of the association is not yet clear.   

Women with a higher risk of breast cancer or stroke may not want any additional risk, however small.  My situation is different.  The Cleveland Clinic’s online calculator of stroke risk puts mine at 3.6% over 10 years, about half the average for women my age.  Taking estrogen may increase that risk to 3.60432%, an increment too tiny to worry about.  Decisions about medical treatment should be made on an individual basis: one size does not fit all.  The hormone therapy saga is a good illustration of this point.  

For those of us on hormone therapy, the medical discussion of this issue has been like an extended good news/bad news joke.  In a recent issue of the Wall Street Journal the invaluable Melinda Beck brings us up to date on the most recent findings.  The current notion is that for younger women the benefits may outweigh the risks.  Did doctors overseeing WHI anticipate the extreme reaction to their study? Did they consider what the consequences would be for women who stopped taking hormones?  Some of them, when quoted, sound a bit defensive.  In the WSJ article Rowan Chlebowski, a WHI investigator, asks:  “Why would anyone want to double their risk of dying from breast cancer?”  If the additional risk is tiny and the benefits include protection from hot flashes, osteoporosis, colon cancer,and diabetes, I’d say it was worth it.   

Women are still being advised to take these medications for the shortest time possible because of the risks, but how much is known about longer term use of these medications? I’ve met or read about many women like me who have taken them for decades and are doing fine.  When is someone going to study us?