While it is certainly encouraging to see the pharmaceutical giant acting
responsibly and not inundating women with confusing spin and theories
about prevention, there is still something bothersome about this new
approach. For one, there is a live, interactive session with a panel of
esteemed gynecologists who talk about symptoms, specific therapy
options, and actual risks (a good thing), but it just so happens that it
was mainly gynecologists in the past (specifically Donnica Moore MD
who's now part of this new web-based Wyeth campaign) who really "took
over" so to speak and started assuming multiple roles as CARDIOLOGIST,
NEUROLOGIST, or ONCOLOGIST to their patients, saying hormones help the
heart and brain and are unlikely to contribute to cancer risk.
Although women shouldn't be unduly worried about potential risks, it's
still hard to place a lot of trust in a drug manufacturer and its paid
panel of physicians who, in the not-too-distant past, really bent the
truth and emphasized the PRACTICE of medicine (drug prescribing) before
the PROOF of its real effects was in.
So who's likely to need hormone therapy? It depends on the individual.
If women are bothered by symptoms and truly cannot or do not want to
tough it out, nothing holds a candle to hormones' benefits for symptom
relief. Yet is there ever a time when estrogen should be a long term
option? Possibly, but only for certain women, such as those who have had
surgical menopause at an early age (such women should consider low dose
estrogen until what would be an average age of menopause, say 48 to 52).
These women on estrogen ONLY therapy can probably put their mind at ease
in terms of breast cancer, since estrogen without progestin seems to
take a good 15 years to have meaningful impact on risk. Unfortunately,
there is still a lot of guessing involved. Despite the crossfire of
opinions and theories about actual risk, hard data show that estrogen
therapy DOES pose a VERY slight heart attack risk within the first 2
years of use (a 16%-25% increase), although this is significantly
smaller than the early increased risk seen with combined
estrogen/progestin, which nearly doubles in the first year.
Blood clots and stroke are also a consideration, the latter which seems
to remain elevated as long as a woman takes hormones. Dementia or mild
cognitive impairment is a significant risk for women over 65; the
likelihood of this in younger women is unknown (WHI will be releasing
information this summer on a series CT scans and MRIs of the brains of
women taking active hormones vs. placebo). If a woman is not bothered by
her symptoms, just plain doesn't have them, has risk factors for heart
disease or cancer, or is overly concerned about the actual risks of
hormones, she should strongly consider steering clear of them. Women
should not turn to estrogen as a cosmeceutical; it MIGHT have some
benefit in preventing skin dryness, but will not have an impact in terms
of wrinkles, sun damage, or the effects of smoking, nor does it have an
effect on hair thinning.
All in all, though some specialists claim that the risks of hormone
therapy pertain only to progestin, this is quite inaccurate. Both
estrogen alone and combined therapy seem to pose equal risk in terms of
stroke and cognitive decline; estrogen alone poses an early small heart
attack and blood clot risk - for combined therapy, the risk is even
higher and remains elevated for 6 years, which was actually the entire
duration of WHI 1's evaluation of Prempro. As for breast cancer,
combined estrogen/progestin has been proven conclusively to increase
risk, and estrogen alone probably poses a small increased risk as well
but only among REALLY LONG TERM users.
Since women continue to get browbeaten by conflicting reports, a lot of
it coming from HRT proponents trying to lead them down the same road
that brought them to a bleak dead end, it may be a long time before the
dust settles. Experts will debate till they're blue in the face, but
women need to know what to do now. The good thing is that a large number
have already made up their minds, which hasn't boded well for Wyeth's
profits. And although the company may, for now, be taking an extremely
conservative approach to its class of hormone drugs, it is essential
that women remain informed and be cautious about supposedly
earth-shattering "positive" information that might fuel Wyeth's
(currently sundered) quest to have its female consumers visiting their
local drug stores every month with a lifetime prescription for hormone
therapy.
Jonathan Raymond
Correspondent
Books on Cancer
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