A new study came out about hormone replacement therapy (HRT) and from the headlines you would think that women can use hormones with no worries at all:
The Australian, 9/14/2017
L.A. Times, 9/12/2017
The Today Show, 9/12/2017
NBC News, 9/12/2017
Can this be true? Didn’t the groundbreaking Women’s Health Initiative (WHI) in 2002 show that hormone therapy came with serious risks to women’s health? Yes, indeed it did. So what happened? Is it really okay to take hormones now? Well, to understand this recently published study, let’s review the story of the prescription of hormone replacement therapy for menopausal women.
The Medical View of Menopause
Prior to the 1800s, menopause was known but rare because most women simply didn’t live long enough to get there. By the late 19th and early 20th century, doctors understood menopause as a milestone in a woman’s reproductive life, but one that came with no serious health problems. By the 1930s and 1940s, menopause began to be discussed in nursing and medical journals, but they reported that most women didn’t experience symptoms troubling enough to require medical attention.
However, by the 1950s a different undercurrent was found in medical commentary on menopause. Doctors warned that menopause brought “emotional turmoil” and could “threaten a family’s tranquility,” citing examples of menopausal women getting annoyed with their husbands and complaining about doing housework. This was clearly not acceptable, and the popular advice literature told women—not to figure out why they were dissatisfied—but to get a hold of themselves and control their feelings. If they found that to be impossible, one female physician recommended that they simply pretend they didn’t feel that way.
The myth that menopause made women sick, ugly, and unpleasant was ultimately legitimized and popularized by gynecologist Robert Wilson’s book Forever Feminine (1966). Psychologically, Wilson thought menopause could push women into two very different, but equally undesirable states. First, he recounts many stories of husbands who find their menopausal wives to be crabby and refusing to make dinner. Wilson concurs, attesting that decreased estrogen can make a woman become a “dull-minded, sharp-tongued caricature of her former self.” But on the other hand, he warns that a menopausal woman “eventually… subsides into an uneasy apathy that is indeed a form of death within life.” They “acquire a vapid cow-like feeling” where the “world appears as though through a grey veil, and they live as docile harmless creatures missing most of life’s values.” Not an attractive picture either way.
Big Pharma Steps In
In 1943, The pharmaceutical company Wyeth had figured out how to produce stable estrogens by extracting them from pregnant mare’s urine, and sold it as Premarin. It was primarily prescribed to help decrease hot flashes, for which it was very effective.
To save women from the fate of becoming either a crabby witch or a near-dead zombie, Wilson argued that all menopausal women (even those without troubling symptoms) should take hormone therapy for the remainder of their lives. He said it would keep them attractive, pleasant, and youthful.
At the same time, many doctors observed that their patients who took hormones seemed to be healthier than those who didn’t: they seemed less likely to get heart disease, dementia, or osteoporosis.
From the 1960s to the early 1990s, the medical field and pharmaceutical companies strongly suggested that all postmenopausal women should take HRT until death to protect themselves from these illnesses. This recommendation was shocking for two reasons: by 1975 HRT was already known to increase the risk of endometrial and breast cancer, and no randomized controlled studies had been conducted to establish that hormone replacement therapy did in fact reduce the risk of heart disease, dementia, or osteoporosis.
This is important because a randomized, controlled, double-blind study has been the gold standard to test whether a drug or treatment actually produces the desired outcome for decades. And here, doctors and pharmaceutical companies were encouraging a treatment for which the health risks and benefits were not established by the most reliable kind of research.
The widespread recommendation for HRT also produced a financial windfall for pharmaceutical companies. By 1990, Premarin became the most commonly prescribed drug in the U.S., which is especially remarkable since only half the population (women) was eligible to take it. By 1997, hormone replacement therapy accounted for one billion dollars in yearly sales revenue for pharmaceutical companies. HRT had become a humongous cash cow.
The Women’s Health Initiative
Eventually, after many years of lobbying by women’s health activists, a high quality national study was funded by the government to evaluate the effectiveness of HRT. It was called the Women’s Health Initiative (WHI), where 27,000 women were enrolled from 1993-1998. They were randomly assigned to either HRT or placebo to see how hormone replacement therapy affected risk of heart disease, dementia, and hip fracture. Neither the women nor the experimenters knew who was given HRT or placebo, providing the kind of scientific rigor to examine the effectiveness of HRT that had been lacking.
They Had to Shut the Study Down
By 2002, the study had to be shut down. Why? Because in their preliminary analyses, researchers found that not only didn’t HRT prevent women from getting heart disease or dementia, HRT INCREASED the risk of these diseases, as well as the risk for strokes, breast and uterine cancer. For decades, physicians had prescribed a drug to millions of women that threatened their health rather than improved it.
As you might imagine, the number of women taking HRT dropped substantially. Since that time, the prescription use of HRT has remained at levels similar to those when it was only prescribed for the physical symptoms of menopause. Physicians generally recommend a short-term course of HRT to alleviate hot flashes and the like for women who find them disturbing.
So What Did the Most Recent Study Actually Find?
The study that has recently been in the news is a follow-up with the women in the WHI. The researchers reported that the women in the study who took HRT for five to seven years did not die any earlier than the women who took placebos. This is most certainly good news. Getting to be alive is good. But does it mean that HRT is safe like the headlines said? It depends on how you define safe.
The women who were assigned to HRT were still somewhat more likely to develop breast cancer, strokes, pulmonary embolisms, dementia, and gall bladder disease than those who were not. So, the women who took hormone replacement therapy may not have died sooner, but their quality of life was more likely to suffer. The treatment for breast cancer can be brutal and cause many other health problems, and it is hard to imagine a condition that more negatively impacts your daily life than dementia.
Women should make decisions about whether to go on HRT with a full awareness of the risks and benefits, not patted on the head and told there’s nothing to be worried about. We need a full understanding of this issue, not misleading soundbites.