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Pros and Cons of Hormone Replacement Therapy

Aired April 17, 2004 - 08:30   ET


RENAY SAN MIGUEL, ANCHOR: Here's what's happening at this hour. Two Japanese hostages released at the Japanese embassy in Baghdad today. Three other Japanese civilians, a journalist, an aid worker and a health researcher, were released on Thursday. They were taken hostage April 8.
The U.S. military is investigating mortar fire and explosions in Baghdad today. Two mortars landed in a busy commercial district, one hitting the roof of a house. They're also looking into the cause of a series of explosions. No more information available yet on that.

British Prime Minister Tony Blair backs Israel's plan to pull out of Gaza and part of the West Bank. Blair calls Israeli Prime Minister Ariel Sharon's plan an opportunity for creating a Palestinian state.


DR. SANJAY GUPTA, HOST: Good morning and welcome to HOUSE CALL. We're talking about the often confusing, sometimes controversial topic of hormone therapy.

For nearly 60 years, women were told taking hormones could have benefits, ranging from calming those raging menopausal symptoms to preventing heart disease and cancer.

But now another study seems to shatter some of those beliefs.


GUPTA (voice-over): You've heard for a couple of years now that combination hormone replacement therapy is not safe. And now a large- scale study looking at estrogen-only therapy shows no benefit at fighting heart disease or breast cancer.

Pretty conclusively now, hormones are not the answer to fighting chronic disease. In fact, this most recent study, published in "JAMA," was shut down early because of a 39 percent increased risk of stroke in women taking the estrogen-only therapy.

And there was no reduction in heart disease. The only chronic disease estrogen may help with is osteoporosis. Women did have a reduction in fractures when on estrogen replacement therapy.

The media attention on hormone replacement therapy has been intense. Still, according to the American Heart Association, 63 percent of women are confused and looking for alternatives. To ward off the symptoms of menopause, such as hot flashes, sleep disturbances and mood swings, the most promising alternatives may be antidepressants, which have their own side effects, low-dose progestin, phytoestrogens, which are plant derived estrogens, and Vitamin E, which nominally may work specifically on hot flashes.

Unfortunately, the studies on these alternatives are scant, and they're not widely prescribed.

For more chronic problems such as heart disease and breast cancer, the alternatives are more obvious. Be aware of elevated cholesterol levels. Monitor blood pressure. Tight control of diabetes, increase physical activity levels and, of course, never smoke.

Bottom line, taking hormones is like a balancing act. There are risks, but in your individual case, it might be worth it. Just remember, consult with your physician and opt for the smallest dose for the shortest amount of time.

And, if you've decided to stop, don't do it abruptly, but taper off.


GUPTA: What we know is this therapy fights osteoporosis and reduces menopausal symptoms but can also put you at increased risk of stroke.

And if you're taking the combined therapy of estrogen and progestin, there could be more risks, like heart disease, breast cancer, blood clots and dementia.

But don't count hormones out yet. For some women, hormone therapy may be their best option for getting through menopause.

And to help us get through all this, Dr. Steven Goldstein is here. He's a professor of obstetrics and gynecology at NYU. Also author of two books. Interesting books. One of them is called "The Estrogen Alternative" and the other one, "Could it be Perimenopause?"

First of all, welcome. Thanks for joining us. New study...


GUPTA: Thank you.

New study looking at estrogen, hormone replacement therapy. Are you telling your patients something different, based on these studies?

GOLDSTEIN: Well, when you say these studies, certainly the Women's Health Initiative, let's talk about that for a minute for a moment.

Because in July 2002, that was a huge bombshell. It was a huge prospective randomized trial with a placebo group. These are the kind of studies we should be using to talk to our patients about.

Ten years ago cardiologists were sending me patients to put on hormones who had new onset of heart disease, because we thought that hormone therapy would prevent heart disease. But that was based on what are known as observational studies.

So the WHI was really an attempt to look at, does hormone therapy reduce heart disease?

And they had two groups. They had women who took estrogen with progesterone because they had a uterus, because understand, the only reason for the progesterone is to protect against uterine cancer. And that was the study that came out two years ago in July that made a lot of media attention.

This new study was the other arm. In women who had ha a hysterectomy, who could take estrogen only and didn't need progesterone, because they're not going to get uterine cancer, that group was what was published on now.

GUPTA: It's confusing. We're going to work through this, a lot of what you said we're going to work through in a little bit more detail.

But right now, women are scared. They hear they're more likely to have a stroke if they take estrogen replacement therapy. They're not going to get the benefits that were promised, heart disease, breast cancer.

Are you taking women off of it?

GOLDSTEIN: Well, let's talk about what is the indication for taking hormones? It is and has been relief of disruptive transitional symptoms: the hot flashes, the night sweats, the sleeplessness.

You know, I have women who it's like -- arriving at menopause is hitting a brick wall. They can't put two intelligent sentences back to back. They can't conduct a meeting. They're more concerned about how do I get through today, tomorrow and next week, not what might happen to me in five, 10 or 20 years.

GUPTA: And we're going to give them some of these options. We're going to talk about some of the alternatives.

Lots of e-mails coming in on this topic. You get these questions all the time. Let's work through some of them for our viewers.

First one, Carolyn from Virginia wanting to know, "Do studies to date warrant a complete halt in the use of hormone therapy for all women? Have studies shown which women are more likely to be adversely affected?"

First part of the question, should women stop taking the hormone replacement therapy?

GOLDSTEIN: Well, totally depends. When you say stop, if you're on it now and you went on it for relief of disruptive symptoms, what we're advocating is you do a taper and wash out, because the recommendation is lowest effective dose, shortest period of time possible.

Well, if you stay on it, of course, you'll have no symptoms. But if you taper this over time and the symptoms don't recur, then you really don't need to be on it.

If you taper it, and the symptoms recur, well, then you will have identified the lowest effective dose for relieving your symptoms, and you can continue on that dose.

GUPTA: So sort of a trial and error. But the important point, don't stop these abruptly. That could be a problem.

Second part of the question, though, as well, are you able to identify those women who might be at the highest risk of developing these adverse symptoms of hormone replacement therapy?

GOLDSTEIN: Well, talking about the adverse events like the breast cancers or the blood clots, or the heart disease, I think the answer to that is sure.

If a woman is at risk for blood clots, if she's had a history of any kind of thrombosis or blood clot in pregnancy or on birth control pills, she's not a candidate for hormones.


GOLDSTEIN: If a women has a family history of breast cancer, she has other risk factors, she's a smoker, a heavy alcohol user, she's had previous abnormalities with her breast, that may color your decision as to who to give it to.

GUPTA: So it is possible to identify those women who are at the highest risk?

GOLDSTEIN: Well, sure.

GUPTA: OK. Let's try to get another e-mail in before the break.

Jennifer in Florida asking, "Is there substantial proof that taking hormones helps in preventing bone loss for those with osteoporosis?"

Osteoporosis, a major concern. One out of every two women over the age of 50 may have some osteoporosis-related fracture. Again, hormone replacement therapy, the big promise of protecting against that. Yes or no?

GOLDSTEIN: No, absolutely. There's really no better thing than estrogen at preventing bone loss.

And so if women are going to be on hormones for relief of their symptoms, while they're on those hormones, the estrogen is a very good protector of bone. But currently we no longer feel that if that's the sole indication, just concern about bone loss, there are many other drugs that are not hormone replacement that can address bone issues.

GUPTA: I think that's a very good point. There are other options out there for women concerned about bone loss, like taking calcium and Vitamin D.

Ask your doctor, also, about biphosphonates. These drugs can prevent a breakdown of bone. Another one that you may have heard about, raloxifene. That actually mimics the effects of these hormones, or calcitonin, which is a non-sex hormone that increases bone mass in the spine.

Another e-mail question, see if we can get this in. Rosemarie from Florida wanting to know, "Is there any harm in not taking hormone replacement therapy after menopause?" That's the other concern.

GOLDSTEIN: No. Not at all. If you're not having disruptive transitional symptoms, there's no need to go on hormones.

But I constantly tell patients, there are two arenas you must address, now that women are not routinely taking hormones. And those are bone health and vaginal health.

Because those are two things that estrogen is very good for, and used to ride the coattails of hormone replacement into the bloodstreams of women, protection of the bone and vagina.

But fortunately, we can address those issues separately without giving women systemic hormones that get to their brain, their heart, their breasts and other places that they may not want it.

GUPTA: And a lot of women are looking for those alternatives. The word is out, in fact, about natural hormones. How do they match up to the more traditional pills? We're going to talk about that later.

But first...


UNIDENTIFIED FEMALE: Are you experiencing your own personal heat wave? What causes hot flashes and how long will they last? We'll answer those questions.

Plus, are hormone patches and other estrogen products safe? We'll clear things up when we come back.

First, take this week's "Daily Dose" quiz. True or false: spicy foods may trigger a hot flash. The answer when we come back.


(BEGIN VIDEO CLIP) UNIDENTIFIED FEMALE: Before the break we asked you, true or false: spicy foods may trigger a hot flash. The answer is true. Other triggers include hot beverages, alcohol, hot weather and even a warm room.


GUPTA: The symptoms of menopause can make women feel miserable. And although they're different for each person, some of the most common are hot flashes, mood swings, vaginal dryness, which can lead to a low sex drive, insomnia, memory problems.

Society often jokes about these side effects, but for the women who live through them, it's not very funny at all.

We're talking with Dr. Steven Goldstein. He's a professor at NYU School of Medicine, written two books on this topic. You get questions about this all the time over the last couple of years. This is becoming a very important topic on medicine.

Lots of e-mails coming in. We want to get to as many of those as we can.

First one, Jackie in Wyoming. She asks, "Hot flashes are part of going through menopause and I've begun to experience them. Why do they occur, and what's really happening to my body?"

GOLDSTEIN: Well, what's happening to your body, Jackie, is that you are stopping the making of estrogen. Your ovaries are no longer making estrogen.

And your brain is putting out follicle stimulating hormone, trying to get the ovary to respond. But the definition of menopause is when the ovary doesn't respond.

So it's a combination of the low estrogen and the high FSH, or follicle-stimulating hormone, which is the culprit. Because women who just have low estrogen, not high FSH, don't seem to get the same hot flashes.

Now, hot flashes have been studied a lot and not all that well understood. It's a loss -- a temporary loss of some of the thermo regulation. And women get palpitations, their heart rate goes up. They sweat. Then they can get cold after the sweat.

But it is so noticeable for some women and disruptive, especially when it happens at night and it wakes people up.

GUPTA: It can be very disruptive. I have -- A lot of friends of mine have gone through this sort of problem. Interesting information.

Another question. Betty from Ohio, "I have taken Premarin for 22 years following a hysterectomy." You and I were talking about this. "Last year I was taken off of it because of recent precautions. The hot flashes have been very bad. Will they subside eventually? What can I do or take to feel better? I'm 65," she says. Will it go away?

GOLDSTEIN: Not necessarily. There are some women in whom they seem to last forever.

In my experience, about 80 percent of women by four years after menopause will no longer have hot flashes, even if they don't have medication.

But the study we're talking about that came out yesterday is really good news for this woman, because she can be on estrogen only. The estrogen only arm of the Women's Health Initiative showed a tiny increase in stroke but no increase in heart disease, breast cancer, blood clots.

GUPTA: You know, it's like anything else. It's a risk/benefit for her, right? If she thinks the risk, the small increased risk of stroke is worth getting rid of these symptoms of hot flashes, it might be worth allowing her to stay on the therapy.

GOLDSTEIN: You have to practice menopausal medicine one patient at a time.

GUPTA: Everyone's a little different.

GOLDSTEIN: Everybody is different. You cannot. You have to individualize.

GUPTA: Another question coming in. Barbara in New Jersey wanting to know, "I've been experiencing hot flashes during the day, night sweats at night, loss of sleep. I've tried to tough it out without HRT because of all the bad press. I've tried soy and over- the-counter remedies. No positive results. Finally went on the Vivedot patch. Now symptom free. However, I'm still concerned about the negative side effects. How long should I stay on this medication and is weight gain a side effect?"

A lot of women are going to be worried about this. Now you're going to hear about all these alternatives, including the patch. First of all, is the patch effective? It is in her case.

GOLDSTEIN: Well, the patch is just an alternative delivery system. Transdermal as opposed to taking it by mouth. It bypasses the liver, which sounds great, and you have perhaps a little less risk of the blood clotting, but you also don't get as much of the benefit in the cholesterols. So there's a trade off.

GUPTA: Is it less safe? More safe?

GOLDSTEIN: No, it's really about the same.

GUPTA: About the same?

GOLDSTEIN: It's about the same. And it's just for some women who don't want to take a pill. They're better off wearing a little band-aid that you change once or twice a week. It's just an alternative delivery system. You can even take it vaginally. There's a ring no.

GUPTA: Safety being a common theme here, many people think natural means safer. Do they have a point? Coming up.


UNIDENTIFIED FEMALE: Are natural or bioidentical hormones a good alternative for women not on hormone therapy? Can herbs and supplements help you through menopause madness?

We'll answer all of your questions when we come back. But first, here's a tip from our health conscious Bod Squad.

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J.B. BERNS, CREATOR, URBAN REBOUNDING: We did a study comparing treadmill jogging to the urban rebounding workout. And what we found, through the University of New Mexico study, is that it was equal as far as burning calories. But the urban rebounding workout was less jarring to the joints, and you're testing balance and coordination.

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As with other aerobic activities, be sure to warm up before getting started and take time to cool down and stretch after your rebounding workout.



GUPTA: Welcome back to HOUSE CALL.

As of last July, about 10 million American women were taking some form of hormone therapy, making the estrogen-alone drug Premarin the most prescribed drug in the country for a few years.

But now people are searching for alternatives. More than 30 percent of women are searching for natural options from acupuncture to herbs and natural estrogens.

We're back with Dr. Steven Goldstein, professor of obstetrics and gynecology at the NYU School of Medicine. We get lots of e-mails about this topic. An interesting one that I want to read to you. This one is coming from Jean in California, talking about bioidentical hormones: "There's been a lot of interest in bioidentical hormones recently. Do these hormones have the same risks as synthetic hormones? What your thoughts about bioidentical hormone replacement therapy?"

First of all, what are they? Are they the same? Are they synthetic? What are they?

GOLDSTEIN: Well, you know, once this stuff passes through your liver, and it's glucoronadated (ph), it's metabolized, I think your breast and your brain, your heart is seeing it as the same substance.

GUPTA: Is it man-made, this stuff?

GOLDSTEIN: Well, yes. Now having said that, there are now pharmaceutically available brands of natural progesterone, natural estrogen.

The problem I have with things that aren't made pharmaceutically is there's very little quality control. If something is compounded in the back room, sure, the pharmacist is licensed by that state. But they're not looking at every 10 batches to see that it contains exactly what it's supposed to contain.

A recent FDA publication, when they looked at some compounding issues, 34 percent of the things made on site didn't contain what they were supposed to.

GUPTA: That's interesting.

GOLDSTEIN: If you ever go and look at some of the pharmaceutical houses, the quality control is amazing.

GUPTA: So that's your biggest concern here? It's not so much...


GUPTA: ... that it might be any different than...

GOLDSTEIN: Quality is safety.

GUPTA: All right.

GOLDSTEIN: Patients seem to equate natural with safe.

GUPTA: We're going to talk a lot about the natural and safe.

GOLDSTEIN: We need to. We need to.

GUPTA: In fact, Bonnie from Pennsylvania asking, "Since most physicians do not want a woman to stay on hormone replacement therapy for more than two to three years, are there all natural or herbal supplements which may be just as good and safer for women to take to help with postmenopausal symptoms?" GOLDSTEIN: And I would ask Bonnie why does she assume that because it's natural it's safe? Some of the most powerful medicines -- digitalis comes from a plant. All of medicines have their origins in botanicals.

GUPTA: This is a public belief, though. If you can buy it over the counter, if you can buy it in an herbal store, it's safer.

GOLDSTEIN: It's not regulated. Black Cohosh is estrogen. It's metabolized through your estrogen. Sure it takes away your hot flashes. It's estrogen.

And you don't really know how much you're taking. It doesn't have the same kind of regulation in terms of quality control. I mean, don't delude yourself. You know, just because it comes from the health food store doesn't mean it isn't estrogenic and your body isn't seeing it as an estrogen.

GUPTA: Regulation can make things safer.

Same topic here. Let's keep on this, because it's interesting. Pamela in Texas, "I'm 49 years old and four years into menopause. I am symptom-free with the exception of debilitating hot flashes." You hear about this all the time, Doctor. "I've never taken hormone therapy but have tried many herbal remedies which only work temporarily. My doctor recommended Black Cohosh, which helped for awhile. Is it safe?"

Now Black Cohosh is estrogen.

GOLDSTEIN: Black Cohosh comes out of nature. It's a botanical, but it is an estrogenic botanical. In other words, you can buy that over the counter, but it's estrogen.

And yet, you don't know how much you're taking. You don't how it's affecting the lining of your uterus, unless that's being followed. It's -- You know, natural doesn't mean risk-free.

GUPTA: These are important points. Dr. Steven Goldstein, professor at NYU, answering a lot of our questions.

What kind of questions should you be asking your doctor about hormone therapy?



UNIDENTIFIED FEMALE: When HOUSE CALL returns, we'll tell you where you can go to get more information about hormone therapy and research what options may be right for you.

For some of this week's medical headlines in today's edition of "The Pulse."

The dietary supplement ephedra is now banned. A federal judge sided against two manufacturers Monday to stop the government action. The FDA announced in December it would block the sale of the supplement. The ban took effect on Monday.

Also, the average hospital stay after a heart attack has gone down from 12 days to six days over the past decade. The new report in the Archives of Internal Medicine also found that patients were just as healthy after their six-day stay as those who stayed longer.



GUPTA: To read more, click on these sites supported by the National Institutes of Health: Search for "hormone therapy," and you'll find up to the minute news on hormone treatments and menopause.

Plus, there's a place to find these studies broken down into plain English: On the right-hand side, click on post-menopausal hormone therapy, and you're going to find a list of resources to help you, from hormones to hot flashes.

Also important is to find out what's right for you as an individual. Get involved, do your homework, than talk with your doctor.

If you're on hormone therapy, start with this question: why? Other questions you may have: which hormone therapy am I on; should I stop taking it; and what alternatives do I have?

It's been a great show. It's all the time we have left for today. Thanks to you all at home for your e-mails. Thanks to Dr. Steven Goldstein, professor at NYU.

GOLDSTEIN: Thank you.

GUPTA: Really important, good information; shed a lot of light on this complicated issue.

And be sure to tune in next weekend. We're going to talk about organ donation. From the waiting list and the fear of donation to the sometimes controversial process. That's next weekend on HOUSE CALL, 8:30 Eastern. Remember to e-mail us your questions:

Thanks so much for watching. I'm Dr. Sanjay Gupta. Now, stay tuned to CNN for more news.


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