Chapter 96
Risks and Benefits of Menopausal Hormone Therapy
The news that women treated with hormone therapy had higher rates of breast cancer, cardiovascular disease, and overall harm “shook women and physicians across the country.” Before the study, estrogen was the most commonly prescribed drug in the United States, but after its publication the number of prescriptions immediately fell, and within a year so did the incidence of breast cancer worldwide. The Women’s Health Initiative hormone study had cost about a quarter of a billion dollars, but given the number of lives saved by the decline in hormone use (including more than 100,000 fewer breast cancer cases in the following ten years alone), the net economic return was estimated at 37 billion dollars, a 140-fold return.
Big Pharma did not withdraw gracefully. Even after the findings were published, millions of prescriptions continued to be written. Appalled by how much cancer his colleagues were causing, one doctor wrote: “When will we stop striving only for financial gain, admit that we are harming many of our female patients, and finally start changing our prescribing behavior?” Many physicians continue to cling to the “non–evidence-based view” that hormone therapy is beneficial for health despite overwhelming evidence to the contrary, which is attributed to “decades of carefully orchestrated influence by pharmaceutical companies on the medical literature.” Lawsuits by breast cancer victims unearthed internal documents showing that drug companies had hired PR firms to write dozens of slanted reviews and commentaries for medical journals. It is said that the “currently prevailing culture in gynecology supports health advice based not on science, but on advertising.”
After the truth came to light, Big Pharma continued trying to use purchased articles in medical journals to distort the evidence, downplay the risks, and promote unproven benefits. Only 6 of the 110 published biased polemics disclosed their financial ties to hormone manufacturers. Pharmacology professor Adriane Fugh-Berman put it this way: “Doctors served as clueless dupes for pharmaceutical companies and harmed women.” If physicians really wanted to prevent heart attacks in women, instead of allowing themselves to be made into pawns of the pharmaceutical industry, they could recommend simple lifestyle changes that reduce heart attack risk by more than 90 percent.
Risks and Benefits of Menopausal Hormone Therapy
Where do we stand today on menopausal hormone therapy? The U. S. Preventive Services Task Force, joining other organizations such as the American Academy of Family Physicians, the American Geriatrics Society, and the American Heart Association, now advises against hormone therapy to prevent chronic diseases in postmenopausal women with and without a uterus. However, this does not include hormone therapy to treat severe menopausal symptoms, for which the American College of Obstetricians and Gynecologists recommends that “the gynecologist should help the patient weigh risks and benefits.” To make an informed decision, let’s take a look at the numbers.
Estrogen is very effective at reducing the frequency and intensity of hot flashes, by 80 percent more than a placebo, with no difference found between pills and patches. Hormone therapy also reduces the risk of osteoporotic fractures. If 200 women with a healthy uterus take hormones for ten years, overall that should mean nine fewer bone fractures. Those are the benefits: symptom relief and fewer fractures. In the same scenario, you would have to weigh those benefits against four additional heart attacks (fatal or not), two additional strokes, four additional cases of dementia, two additional cases of breast cancer, one additional case of fatal lung cancer, four additional cases of gallbladder disease, and ten additional blood clots. I can hardly imagine a woman accepting that risk-benefit ratio if she knows all the facts, unless she is completely debilitated by menopausal symptoms and has already tried everything else unsuccessfully.
Younger women (newly menopausal) are at lower risk, and the same is true for women at lower risk for cardiovascular disease, blood clots, and breast cancer, and for those who no longer have a uterus and can therefore take estrogen-only preparations. (Otherwise, the risk of uterine cancer is too great.) Estrogen-only offers the same symptom relief, and over ten years, in 200 women, eleven bone fractures are prevented, and there are no additional heart attacks or dementia and two fewer breast cancer cases, but six additional cases of gallbladder disease, only one additional case of blood clots, and likewise two additional strokes. In any case, the FDA recommends prescribing estrogens only “at the lowest effective dose and for the shortest duration,” although it is unclear whether lower doses are actually safer.
What’s the deal with “bioidentical” hormones?
The Women’s Health Initiative used Premarin because it was the most commonly prescribed form of estrogen; and in fact, in the United States more than a million prescriptions are still written for this drug each year. It is a mixture of more than 50 different estrogens from horse piss. (“Premarin” comes from pregnant mare urine, “urine of a pregnant mare.” If you don’t believe it, crush a tablet and sniff it.) The grim results of the Women’s Health Initiative (in combination with high-profile celebrity promotion) led to a shift of interest to bioidentical hormones from plants rather than from horses. As I explain at see.nf/bioidentical, there are now urine-free and FDA-approved bioidentical hormones, but they presumably carry the same risks.
So how can menopausal symptoms like hot flashes be treated with something harmless? The American College of Obstetricians and Gynecologists recommends getting relief by, for example, “drinking something cold.” Turning down the thermostat, dressing more lightly, and switching on fans helps somewhat, but is there really no way to treat hot flashes without risking cancer, blood clots, and coronary thromboses? Fortunately, there is.
Risks and Benefits of Mammography
Since we’re talking about informed decisions about one’s own body that are made harder by the corrupting financial interests of multibillion-dollar industries sowing confusion: What about mammograms? There are conflicting recommendations—for example, mammography starting at age 40 versus 50, annual screening, screening every two years, or no routine screening at all. Nine-tenths of women surveyed greatly overestimated the benefit of mammography or had no idea how helpful it is. One survey found: “If women knew how little breast cancer screening helps prevent deaths from breast cancer, 70 percent would not put themselves through it.” But perhaps you are among the 30 percent, and you have every right to decide for yourself.
Decisions with completely clear-cut consequences—only risks or only benefits—are easy. Should doctors, for example, instruct women to examine their own breasts? The answer is no. That has been tested. Out of hundreds of thousands of women, some were randomized to examine themselves and others not to. The researchers not only found no benefit, but also found harms, including that twice as many women had to undergo a biopsy. It could not be shown that self-exams reduce the risk of developing breast cancer, dying from it, or discovering tumors at earlier stages. For this reason, in 2015 the U. S. Preventive Services Task Force explicitly advised against instructing women in breast self-examination.
To be clear, the USPSTF did not speak out against breast self-examination, only against teaching it to women. That’s because reminding women to examine themselves led only to harm without benefit. If you discover something unusual, by all means go to the doctor with it, but exhorting women to examine themselves causes more harm than benefit. Nevertheless, most doctors continue to show women how to do it. Why? Simply because they have always done it. Medical inertia wins out over women’s health, even without a multibillion-dollar industry lobbying to keep this practice in place. Which brings us to mammography.