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Recent Newspaper & Online Columns by Kate Scannell MD

A Halloween tale: More chilling news about hormone replacement therapy

By Kate Scannell, MD, Contributing columnist Bay Area News Group
PUBLISHED IN PRINT 10/31/2010

THE ONGOING saga about hormone replacement therapy is as scary and unsettling a Halloween tale as they come. A sobering new study published Oct. 20 in the Journal of the American Medical Association should end that tale -- though on a chilling note.

The new study comes from researchers with the Women's Health Initiative (WHI). It adds to our trove of disturbing data about the potential hazards of combination hormone replacement therapy -- or "HRT" -- for postmenopausal women. It shows for the first time that, compared to postmenopausal women given placebos, women receiving combined estrogen plus progestin not only experienced a greater incidence of breast cancer, they were also more likely to die from their cancer.

The finding is noteworthy because it sufficiently dispels the prevailing myth that breast cancers occurring in women on HRT are relatively benign and easier to treat.

It exposes this myth as a falsehood that can no longer be used to hearten women who are considering HRT initiation. Because it brings doctors and patients closer to the truth about HRT, it allows them to make more accurately informed medical decisions concerning postmenopausal hormone replacement.

How could this have happened?

But it's both stunning and unconscionable to realize that it has taken us this long -- so many decades -- to evaluate whether HRT might actually harm women and promote their deaths. Really, how could this have happened?

In the not-too-distant past, U.S. doctors routinely offered hormone replacement therapy to many postmenopausal women. Initially, in the 1930s, estrogen alone was prescribed to treat hot flashes and night sweats. But in the 1970s, after estrogen use was linked to an increased risk for uterine cancer, doctors began adding a second counterbalancing hormone -- a progesterone compound -- for women who still had a uterus. This "combination treatment" HRT became de rigueur.

The wildly successful marketing of HRT to postmenopausal women and doctors was furthered by a highly influential and best-selling book published in 1966: "Feminine Forever" by physician Robert A. Wilson. Through his book and popular lecture circuit, Wilson claimed that "menopause is completely preventable," and, with estrogen treatment, "Every woman alive today has the option to remain female forever." It did not matter that Wilson's claims constituted little more than his opinion -- or that his book and lecture tours were allegedly financed by estrogen manufacturing companies.

Over time -- but without good scientific evidence -- HRT was promoted as a panacea that could lessen women's risks for heart attacks, strokes, depression, generalized aches and pains, Alzheimer's dementia, and osteoporosis, as well as night sweats, wrinkles, and hot flashes.

In fact, HRT became so fashionable that by 2002 doctors were prescribing it for about 6 million American women who hoped to stay healthy and "feminine forever."

But 2002 also proved to be a watershed year in which the WHI published another paradigm-shifting study. Its researchers showed that combination HRT was associated with both an increased risk of invasive breast cancer and a delay in cancer diagnosis that resulted in more advanced-stage disease. They also demonstrated that, contrary to hopes and expectations, combination HRT significantly increased a woman's risks for heart attacks. And strokes. And blood clots in the lung.

In the eight years between the two WHI studies, we also learned that combination HRT did not protect against dementia, and it increased a woman's risk of dying from lung cancer.
A precipitous global decline in postmenopausal HRT use followed WHI's 2002 publication. Annual sales of Prempro by Wyeth -- now owned by Pfizer and the leading U.S. manufacturer of combination HRT -- ultimately fell by almost half, to about $1 billion. And the good news -- no, the great news -- is that we've subsequently witnessed a marked reduction in breast cancer incidence.

Taking the "pause" in menopause to reflect on other options

It's startling to realize that millions of women have been exposed for decades to an untested medical "treatment" that, in the long run, has no legs. It's sobering to wonder how many women may have died or been harmed by a pharmaceutical product that was peddled to promote femininity and a view of menopause as a "disease."

Moreover, it's humbling to acknowledge the degree to which medical practice can be shaped by fad and convention, by anecdote and commercial marketing. It's dreadfully ironic that an influential book titled "Feminine Forever" could so easily promote a medical practice that actually shortened many women's lives.

For the moment, unless the serious side effects of combination HRT can be ameliorated, doctors and women should take the "pause" in menopause to reflect on alternative symptomatic treatment options for night sweats, hot flashes, and insomnia.
Women currently taking HRT should confer with their doctors about an individualized risk and benefit assessment in light of the newer studies.

The Women's Health Initiative -- along with the women who volunteered for its research -- should be commended for their groundbreaking and lifesaving work. For reminding us, yet again, that medical practice sometimes need a dose of science to get in touch with reality.
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Kate Scannell is a Bay Area physician and syndicated columnist. Her new novel is "Flood Stage."

Copyright Kate Scannell 2010