Rationale for HRT 2010

Recent query from a concerned patient:

1) I read an article in USA Today that quoted some new study saying that estrogen did not help prevent heart problems and that AMA was no longer supporting HRT for heart disease risk reduction….can you tell me anything about this?

2) Is there any increased risk of breast cancer if I only take HRT for one or two years? And when do I start cycling with Progesterone after taking the estrogen?

My answer:

The recent spate of confusing public reports of research regarding HRT and heart disease risk point out how hard it has been for us to design a study that eliminates the positive healthy behaviors of women who are taking estrogen from those who do not. Meaning, not that the heart disease was not effectively reduced in incidence in the estrogen users, but that the women who were using the estrogen also had more positive health promoting lifestyle behaviors which invalidated the strict assumption that it was the estrogen that rendered them less likely to have a heart attack.

There is a huge body of observational data to support the use of ERT to promote maximal wellness into old age for women. This includes powerful data on decreased hip and spine fractures, less colon cancer, decreased risk for Alzheimer’s disease, less weight gain over post menopausal time frames, and better outcomes and survival if a woman is taking estrogen when a breast cancer is diagnosed. It is also of interest that, compared to women after age 50, men have higher levels of estrogen circulating in their bodies (and brains) until about age 75 when their testicular production of estrogen wanes. This correlates with the delayed onset of osteoporosis and dementia we observe in men. This supports the more evolutionary biological view of having a critical minimum level of estrogen in one’s body to protect essential metabolic and immune functions in brain, bone and liver (where lipids and clotting factors are made). I am of the strong view that the recent JAMA article, as with so many of them, fails to show a statistically significant effect of estrogen alone because we have not yet designed a good enough study to factor out the confounding influences of mood, energy to pursue one’s good intentions (nutritionally, fitness/exercise plan, psycho-spiritual goals, etc) and other potential enhancements that are observed in women who are taking estrogen compared to those who do not. Yes, we can always find exceptions to this general observation, but the strength of the observational data is huge, as is its relationship to the observed fact that we have very little mammalian company for human females in menopause and beyond. Virtually all of the other animals are already dead by the age of menopause. The more I observe women in my clinical practice, over 24 years now, the more this evolutionary biological view seems to be powerfully true. This is essentially what I wrote in the article published last year, “Individualization of HRT.” (Ref. 1).

There will be studies forthcoming that again attempt to look objectively at this entire realm of estrogen and disease risks. But if one looks at the biology of post partum lactation and menopause the similarities are quite striking. I feel deeply that our physiology after cessation of ovarian function is a biologic constraint. Nature had to choose between physiology for reproduction (post partum lactation for the newborn baby’s care and feeding with ample calcium and fat for enriching milk) and the longer term health effects of prolonged low estrogen states (inexorable calcium loss contributing to osteoporosis, higher blood fats now leading to clogged arteries and blood vessel damage) in older adult females. Not that Darwinian evolution is all that influences our destiny. Rather I see us arriving at a time where we can separate out the basic biologic evolutionary forces from the evolution of our consciousness. As human beings this is our great gift beyond animals: the opportunity for a greater depth of consciousness, intellectual understanding and spiritual growth that come with older age and time for reflection and gathering wisdom.

The menopause wisdom that I seek in clinical practice is to find the lowest (but sufficient) levels of estrogen that are maintained in young girls, between about ages 10 and 12, before the menstrual period starts. These young females have adequate estrogen levels for supporting good bone development, brain function (cognition) and the growth of secondary sex characteristics.

The 0.3/day level of Cenestin (a plant derived slowly absorbed spectrum of estrogens) is about that minimal level, as is 0.375 estradiol patch, 0.5 estrace/day, etc. Individual levels may vary as each of us has slight variations in the absorption, metabolism as well as distribution of hormones. Tests are done to monitor the effects of levels of hormones in each individual woman’s system.

In answer to your question about when to begin the progesterone opposition, it is also a matter of life style and follow through. At the 0.625 a day level the first “progesterone challenge cycle” is usually done about three months after starting the estrogen daily, with a 200 mg a day for 12 day Prometrium cycle. If the 0.3 Cenestin dose is used, then it is fine to check at 6 months with a 200 mg a day for 12 day Prometrium cycle, as the incidence of any stimulation of the uterine lining at that dose is very rare. Bleeding can be a sign of an awakening endometrium (healthy but annoying spotting during the first few weeks of taking estrogen) but if it is heavy I always want you to call so we can discuss it. My office nurse, Shannon, wrote up a great patient education piece on this and I’ll ask her to send it to you if you would like.

I search the literature as well as my own heart for THE right answer to these critically important questions. Demographic estimates of the millions of Baby Boomers entering menopause give one pause. It is terrifying to me that there will be so many of us getting so very old with significant disabilities and (horror!) dependency! (all quite likely if we do not aggressively seek optimal life styles and maintain minimum hormone levels to support our aging brains, bones and blood vessels). I do feel a bit like Chicken Little as I watch the unfolding of significant diseases in the in this midlife and beyond age group. It is scary to age and to face threats to our quality of life and intact survival. No one knows this better than you. But our fear of breast cancer is far out of proportion to its actual occurrence at any one age as well as its incidence relative to the choice of taking estrogen or not. It saddens me, conversely, that it does not protect us from breast cancer to avoid taking estrogen. There are no studies that show a significant reduction in risk if women do not take estrogen, nor are there any that show a decline in risk for women who took estrogen and then stopped, both of which should be observed if a substance is etiologic in causing or promoting a cancer.

The truth is that ERT is an independent risk factor, and a very weak one at that, with regard to breast cancer. Its association with significant decrease in osteoporosis, hip fracture and overall cardiovascular disease is quite strong. But the fact that fear of breast cancer drives so many women away from ERT is of great concern to me. If diagnosed with breast cancer, women actually do significantly BETTER if they are on HRT when the cancer is diagnosed. They also have a more favorable prognosis in all categories of disease that impact the survival and quality of life indices. The recently published trial evaluating HRT after a diagnosis of breast cancer (Ref.2) revealed a significant reduction in risks for recurrence and mortality in estrogen users as compared to non-users. This may seem paradoxical but the biology of breast cancer depends upon multiple factors, many of which are improved by the presence of a minimum level of estrogen. Patricia Kelley’s book, “Understanding Your True Risk of Breast Cancer,” is a gem that I strongly suggest you buy. She also gives cancer risk consultations privately through her SF office at St. Francis Hospital, (415) 353-6119 for appointments. She has a Ph.D. in genetics and has specialized in cancer risk analysis and individual risk assessment and education for over 25 years. I know her quite well and cannot say enough good things about Dr. Kelly.

Lastly I want to say that it is lonely out here in Medical Doctor land. We practice medicine in a litigious culture that is inclined to sue for that which the doctor prescribes, not for that which we omit. So the bias is heavily on the “do not treat” side of the equation. It requires a lot of time to adequately discuss all of these ideas with women who are considering taking HRT short and long term. The office hours required to adequately cover this information is not positively rewarded by today’s system of reimbursement of physicians, nor does the medical legal climate incline one towards engaging in this dialog further as there are no individual guarantees. Our health care system is simply not set up to address individual women’s concerns within the managed care confines of today. But I do feel strongly that there is great wisdom in the profundity of evolutionary biology as regards menopause physiology. And it is for this reason as well as the overwhelming observational data, that I do consider ERT as the “natural” way to be optimally alive and well into our future. None of us has a great deal of past experience as to what it is like to be very old. Rather we anticipate the future with the knowledge we have gained from our past. In this regard I think that aging is a totally new experience for Baby Boomers who somehow felt it would be different for us as women growing older. Somehow we would beat the rap of getting old and frail as has occurred in former generations of women. And we will depart from that old mold if we take the necessary steps to give ourselves, one by one, what we need to be healthy and vital. What came to us so easily as younger women we must put forth more energy to maintain as we age. Of this I am personally and professionally convinced! It is a commitment in both time and money.

So much for my motivational speakers approach to menopause management! I do feel passionate about giving you the information you need, as thoroughly analyzed, carefully organized and simply as I know how.
With all best wishes to your health!

(Ref 1: Ricki Pollycove, San Francisco Medicine Journal, Sept. Vol.73 (8), 18-23, 2000)

(Ref 2: Ellen S. O’Meara et al, Journal of the National Cancer Institute, 93:754-61, 2001)