We are rightfully very concerned about the cost of medical care these days. A major and very useful suggestion has been to emphasize preventive care. I couldn't agree more. So why don't we consider much more seriously hormone replacement therapy for women?
CHARLESTON, W.Va. -- We are rightfully very concerned about the cost of medical care these days. A major and very useful suggestion has been to emphasize preventive care. I couldn't agree more. So why don't we consider much more seriously hormone replacement therapy for women?
To do that, we have to learn to think anew -- doctors and patients -- and that's never easy.
I know "hormone replacement therapy causes breast cancer." That's what everyone says, but it's not true. Still, that's all anyone remembers from the Women's Health Initiative report in 2002.
Any cancer deaths are unfortunate, of course, but the worst the report could show was an increase in deaths of 3 to 4 per 10,000 treated women. The second arm of the study reported later and using estrogens alone showed no increased risk of breast cancer at all, not even for women who had already been cured of a previous breast cancer. The 2002 study was so poorly done in many ways it is almost useless. We must get it out of our minds and look elsewhere for guidance.
Studies done around the world agree that hormone replacement therapy protects in a big way against osteoporosis and subsequent fractures. Did you know that a senior suffering a hip fracture is 70 percent likely to be dead within the following year? There's a biggy for you.
Furthermore, bisphosphonates (like Fosamax) are not an adequate substitute. By corrupting the bone building process, bisphosphonates make bones dense, but not strong. The bones look good on bone density studies, but that's a fooler. They do not protect against osteoporotic fractures, and after years of use bizarre and unusual fractures have begun to show up.
Women have ovaries that from puberty until menopause secrete three steroid hormones -- estrogen, progesterone and testosterone. They are active in the nucleus of every cell in the body, from the head to the toes. They support connective tissue, skin, muscle, glands, bone, heart and brain. Why doesn't your uterus fall down through your vagina? Actually it tends to do just that without estrogen. And your bladder tends to be incontinent. And your spinal discs collapse. And you are more likely to gain weight and have adult onset diabetes and have your blood pressure go up and have heart problems. That is what we are setting ourselves up for by not replacing our disappearing ovarian hormones. Remember, too, that nowadays with prolonged life span, women spend at least one-third of their lives in the menopausal state with ovarian hormone deficiency.
People don't like to talk about sex very much, but the fact is some people enjoy it. Definitely we know there is a market for Viagra and similar drugs. Who are those men having sex with? Could it be their wives? Maybe yes, if their wives are taking hormone replacement. Women can enjoy sex more if their vagina actively makes secretions and its tissues are stronger than wet toilet paper. That happens with hormone replacement therapy. A female appropriate dose of testosterone also stimulates positive sexual sensation and responses.
Recent national and international studies are pointing to the likelihood that hormone replacement therapy protects against Alzheimer's disease. How is that for preventive medicine? If only a part of that debilitating condition were prevented each year, we would save billions (with a "b") in health-care costs, not to mention the improved quality of life for the rescued people.
The only definitive downside is an increase in blood clotting which can involve veins or arteries, producing a stroke, if the blood vessels are in the brain. Bad stuff. But you know what? It occurs with only orally taken meds. There are other choices. The estrogens must go through the mouth, and the gut and ultimately the liver to become dangerous clotting agents.
CHARLESTON, W.Va. -- We are rightfully very concerned about the cost of medical care these days. A major and very useful suggestion has been to emphasize preventive care. I couldn't agree more. So why don't we consider much more seriously hormone replacement therapy for women?
To do that, we have to learn to think anew -- doctors and patients -- and that's never easy.
I know "hormone replacement therapy causes breast cancer." That's what everyone says, but it's not true. Still, that's all anyone remembers from the Women's Health Initiative report in 2002.
Any cancer deaths are unfortunate, of course, but the worst the report could show was an increase in deaths of 3 to 4 per 10,000 treated women. The second arm of the study reported later and using estrogens alone showed no increased risk of breast cancer at all, not even for women who had already been cured of a previous breast cancer. The 2002 study was so poorly done in many ways it is almost useless. We must get it out of our minds and look elsewhere for guidance.
Studies done around the world agree that hormone replacement therapy protects in a big way against osteoporosis and subsequent fractures. Did you know that a senior suffering a hip fracture is 70 percent likely to be dead within the following year? There's a biggy for you.
Furthermore, bisphosphonates (like Fosamax) are not an adequate substitute. By corrupting the bone building process, bisphosphonates make bones dense, but not strong. The bones look good on bone density studies, but that's a fooler. They do not protect against osteoporotic fractures, and after years of use bizarre and unusual fractures have begun to show up.
Women have ovaries that from puberty until menopause secrete three steroid hormones -- estrogen, progesterone and testosterone. They are active in the nucleus of every cell in the body, from the head to the toes. They support connective tissue, skin, muscle, glands, bone, heart and brain. Why doesn't your uterus fall down through your vagina? Actually it tends to do just that without estrogen. And your bladder tends to be incontinent. And your spinal discs collapse. And you are more likely to gain weight and have adult onset diabetes and have your blood pressure go up and have heart problems. That is what we are setting ourselves up for by not replacing our disappearing ovarian hormones. Remember, too, that nowadays with prolonged life span, women spend at least one-third of their lives in the menopausal state with ovarian hormone deficiency.
People don't like to talk about sex very much, but the fact is some people enjoy it. Definitely we know there is a market for Viagra and similar drugs. Who are those men having sex with? Could it be their wives? Maybe yes, if their wives are taking hormone replacement. Women can enjoy sex more if their vagina actively makes secretions and its tissues are stronger than wet toilet paper. That happens with hormone replacement therapy. A female appropriate dose of testosterone also stimulates positive sexual sensation and responses.
Recent national and international studies are pointing to the likelihood that hormone replacement therapy protects against Alzheimer's disease. How is that for preventive medicine? If only a part of that debilitating condition were prevented each year, we would save billions (with a "b") in health-care costs, not to mention the improved quality of life for the rescued people.
The only definitive downside is an increase in blood clotting which can involve veins or arteries, producing a stroke, if the blood vessels are in the brain. Bad stuff. But you know what? It occurs with only orally taken meds. There are other choices. The estrogens must go through the mouth, and the gut and ultimately the liver to become dangerous clotting agents.
Instead, let's give them through the skin or through the vagina for women at particular risk. Preparations are available for all alternative routes, all of which avoid the liver and decrease blood clotting risk.
So again I ask, why don't we give more women hormone replacement therapy, essentially as a routine, unless there are specific reasons not to? Right now, no more than 20 percent of post-menopausal women in this country take hormone replacement.
If low thyroid were the issue, a doctor would prescribe, and the patient would take, supplemental thyroid hormone. If diabetes were the issue, a doctor would prescribe insulin (or a substitute drug). There would be none of this dithering and bargaining. The same should be said for ovarian hormone deficiency
When menopausal female patients have insomnia, and depression, why do doctors prescribe sleeping pills or anti-depressants when hormone replacement works wonders for these complaints?
Another clear fact shown by all studies is a definite deadline by which hormone replacement must be started. It is absolute that to be significantly effective the hormones must be started with menopause or very soon after. Do not wait. Start with the hot flashes and keep going. Women, who don't do this, will have time for regrets when it is obvious their body is weakening, but in all likelihood it will be too late by then. Remember, it is preventive medicine.
The main reason for the low usage of hormone replacement therapy is that it is "not natural." Of course, it doesn't help that the results are in the future, and one has to be in the plan-ahead mindset. We're not talking about instant gratification except in eliminating menstrual irregularities and hot flashes.
Here is what is natural: A hundred years ago (and for all time before that) women died routinely in childbirth and of all the rampant diseases and traumas of past history. At that time pneumonia was almost always fatal, tuberculosis was rampant, and any significant trauma was likely to be deadly because sterility and anesthesia were unknown. There's a reason why stepmothers were famous in fairy tales. So few women reached old age it didn't matter if hormone replacement therapy was unknown and unavailable.
If that makes you nostalgic, forget about hormone replacement therapy. But if you think you might want to be a healthy oldster, consider the information I have shared and please don't wait until you're 70 to begin. Talk with your provider about starting hormone replacement therapy when your periods really get irregular, continue it thereafter, and enjoy your old age.
Haning is physician in Charleston.
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