Abigail Trafford (The Post)

• Health Talk Archive • Recent stories by Abigail Trafford • Health Section • Talk: Health news message boards • Live Online Transcripts • Subscribe to washingtonpost.com e-mail newsletters • mywashingtonpost. com -- customized news, traffic, weather and more

Are you using some kind of hormone replacement therapy (HRT) to treat symptoms of menopause or to prevent disease? A federal study has concluded that as a disease preventive, the common hormone replacement therapy of PremPro does more harm than good. What's your response to this news? Do you want to continue on HRT or are you trying to stop?

Join Post Health columnist Abigail Trafford to talk about hormone research and therapy with with Cynthia Pearson, executive director of The Womens Health Network on Tuesday, July 23 at 2 p.m. EDT.

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Abigail Trafford: We're on! Hormones. Are you for them or against them? Tell me what you think. Send in your questions and comments.

Abigail Trafford: Hello and welcome. This is a hot topic. More questions than answers. but let's start with a simple statement: what is the bottom line message to women about HRT?

Cynthia Pearson: I think that the bottom line is that we don't know as much about HRT as we used to think we knew. Much of what we thought we knew was based on exaggerated marketing claims. Now that we're finding out some of those claims were over-blown, it's important for each woman to think carefully about why she is using or considering using HRT and find out as much as she can about whether HRT is effective for that condition and what the risks are.

Clinton, Md.: Does hormone therapy cause breast cancer?

Abigail Trafford: Cancer is a multi-step process. The study looked at home HRT increased the risk of breast cancer. An individual's risk is made of of many things--family history, age, for example. But cynthia--what is the link between HRT and breast cancer?

Cynthia Pearson: Thanks to the Women's Health Initiative we now know that this particular type of HRT, estrogen & synthetic progesterone taken together every day, increases the risk of breast cancer when taken for four or more years. The increase isn't very big, but it is real.

The final answer isn't in yet on other forms of HRT. We'll know more in a few years when the estrogen-only arm of the WHI releases its results.

Washington, D.C.: Clearly, there are still benefits and risks associated with HRT -- although the NIH study shows the risks are greater than previously known. Some women still depend on HRT for its benefits, however. It seems like many physicians, as well as patients, will be confused about what's "best" for patients now. Are the NIH or any or the medical specialty societies working to develop or update practice guidelines for physician that help them weight these risks and benefits in light of the new evidence? I worry that in the absence of standardized guidelines, the media frenzy around this could outweigh the science and result in practice decisions that are inconsistent and uninformed.

Cynthia Pearson: That's a great question. Unfortunately, the American College of ObGyns isn't acting very quickly to create new guidelines for their members, who are most likely to see women who have questions about hormone use. They've convened a task force, which is expected to release new guidelines in a few months.

In the meantime, the best source of information for individual women and physicians looking for guidelines is probably the National Institites of Health. The NIH gave very clear instructions -- don't take HRT to prevent heart disease, talk to your doctor about safer alternatives to prevent fractures, and the benefits may outweigh the risks for short-term symptom relief.

Montgomery Village, Md.: Did the study investigate only combined estrogen/progesterone HRT? What about other combinations? I have been taking monthly injections of Depotestadiol (estrogen and testosterone)for six years and love the benefits but am more confused than ever about long-term risks. Prior to this study, my gynecologist had been reassuring me that I don't need progesterone because the testosterone inhibits the growth of uterine cells but I never felt completely confident. Maybe he's been right...maybe not. Cynthia Gorney's article in Sunday's Outlook about medical research leaving us in the "gray zone" is right on target. Does the medical consumer ever have sufficient information to make an educated decision or will we forever react to conflicting studies? It's like following a ricocheting ball and it's making me dizzy.

Cynthia Pearson: You have good reason to feel dizzy from all the conflicting information & one study leading to even more questions.

The short answer is that there are many, many ways to take hormones and none of them have been shown to be more beneficial than harmful for long-term use in healthy women. That's not to say that individual women might not be helped by any of these hormone treatments for short-term symptoms, but the long-term data are really unknown.

Here's some of the combinations and/or approaches currently in use. Estrogen is taken by itself in women who don't have a uterus. It can be given through pills, patches, creams and vaginal rings. Women with a uterus need to add progesterone to estrogen therapy to avoid the uterine cancer caused by taking estrogen alone. But with progesterone come symptoms that many women dislike, including bloating, breast tenderness and vaginal bleeding. So there's been lots of experimentation with different doses & combinations.

And combining testosterone with estrogen is even newer. Testosterone may have some risks -- it can raise cholesterol levels in women, for example. The studies that show a benefit of testosterone have been very small and mostly in women who have no ovarian function.

Reston, VA: What is your opinion of Estrace cream? My doctor said that very little gets into the bloodstream and it is safe. Do you agree?

Cynthia Pearson: Estrace cream is one of several types of estrogen cream available through prescription. Most women who use estrogen cream are interested in getting "just a little bit" of estrogen, which is a good approach to take. This method is also very effective for women who have had trouble with vaginal dryness & haven't been helped by non-prescription remedies. There's a little bit of debate about exactly how much estrogen gets into the system. It's probably safest to assume that women's bodies do absorb some of the estrogen, but it's definitely a much lower dose than pills or patches.

Gaithersburg, Md.: Thanks for the chat on HRT! I am a 32-year-old who's been on HRT for the past four years due to a hysterectomy at the age of 28. As a long term user of HRT do you believe there will be consequences to my continued use for the next 20-30 years?

Cynthia Pearson: You know, one way to think of your question and others like it from young women who have started hormones after a hysterectomy or treatment for cancer is that our bodies were built to have & work well with high levels of estrogen and progesterone in our 30s and 40s. Nature intended us to have these hormones & it makes a lot of sense to replace them via pills when the ovaries have been removed. (Although women who have been treated for cancer need to talk with their oncologist about their diagnosis & any possible impact of HRT.)

I think using HRT in your 30s or early 40s to replace the hormones that would have been produced by your ovaries makes sense. It's completely different from encouraging women who have already gone through a natural menopause in their 50s to start taking hormones for prevention of disease.

You could certainly consider creating your own menopause around the age of 50 by tapering off the hormones.

McLean, Virginia: What do the recent findings mean for a 30 year old diagnosed with premature menopause?

Cynthia Pearson: I think this is a very similar question to the previous one. A woman who is 28 or 30 when she loses ovarian function is in a much different situation than a 50 year-old whose menopause has come about naturally.

By the way, the Women's Health Initiative only included women who were at or past the age of natural menopause. So I think it's fair to assume that the increased risks found for breast cancer, heart disease and other conditions are risks that were created by adding hormone treatment on top of a lifetime of exposure to the body's own hormones.

Washington, DC: Based on the findings of WHI should/will the FDA make changes to the labeling of HRT products?

Cynthia Pearson: Boy, I love this question. The group I work with is especially concerned about the FDA's role in the HRT issue. The FDA "saved" us from a decade of ads in women's magazines telling us that estrogen prevented heart disease by turning down a request to give formal FDA approval back in 1990. The FDA is also responsible for creating a nuetral source of information that every woman who receives an ERT prescription -- called the patient information leaflet. The current version mentions possible risks, but now that we know what conditions are more likely among women using HRT and exactly how often they occur, that information should be included in the FDA approved label. Women deserve no less!

Sterling, VA: Concerning the recent HRT study that was halted early------was prevention of Alzheimer's studied, or was the study too short? Also, what are the implications for prevention of skin wrinkling and drying, and also prevention of hair loss?

Cynthia Pearson: Great question about Alzheimer's. We really all want to know that information, right? Yes, the WHI is studying Alzheimer's disease. Originally the researches thought that it would take 9 years of treatment to determine if HRT had any effects. When the results of the "combination" trial were announced on July 10, the government said that the Alzheimer's data were being looked at. So maybe we'll know more soon.

Laurel, Md.: Ms. Pearson, do you think many women know when they start taking hormones for symptom relief, that, when they stop taking the pills, it is more likely than not that all the symptoms they originally took the drug for will return? Do you think they are usually told this by their doctors when they are given the prescription? Do you think that this aspect of using hormone drugs for symptom relief has been explored adequately in the media in the past two weeks given that symptom relief seems to be only "benefit" left for these drugs?

Cynthia Pearson: Another good question. I think not enough women are told that their symptoms may rebound & start all over again when the stop taking HRT. However, that doesn't need to last forever, nor does it always need to be so uncomfortable. Symptoms from natural menopause are gone in about 3 years for most women (some women longer, though). If HRT has been taken all that while, the symptoms that occur when it's stopped are being caused by the drug, not by the body's own natural processes.

The way to minimize these uncomfortable effects of stopping -- no one has ever proven this in a stop, but lots of women report good success with tapering off, rathering than stopping suddenly. We'd love to see more research on this.

Bethesda, Md.: What are women's groups doing or what should they be doing to educate their members about this issue? How do we get them to engage in public discussion on the issue when so many are funded by pharmaceutical companies like Wyeth?

Cynthia Pearson: I think women's groups & others interested in these issues should press for more government-funded research. And it wouldn't hurt if women's groups started a "disclosure" campaign to insist that their groups & the experts called on for their opinion disclose any financial ties to the pharmaceutical industry.

Alexandria, Va.: Where can I found out more details on the NIH study? Were there any controls for diet and exercise? I am currenlty on a regime alternating Estrogen and Estratest(conjugated estrogens plus a small dose of methyl testosterone) as a reuslt of a hysterectomy and removal of overies at age 42. As surgeons and doctors don't seem to care or talk about the sexual implications of hysterectomies, they certainly won't consider those implications with discontinuing HRT. I am currently doing all I can for heart health and bone density (vigourous exercise, a diet high in complex carbohydrates and lean protein and good fats). If the surgical menopause study comes up with similar results, I don't plan to give up hormones on the basis of an MD's interpretation of a study of which he has very limited knowledge.

Abigail Trafford: You bring up a really good point about sexual function. Doctors don't want to talk about it. Certainly federal officials are holding news conference on sexuality. But sexuality is a key issue for women--and for many, it's a prime reason to take hormones--either as pills or as vaginal creams. Cynthia, what is the evidence on HRT's effects on vaginal health? What do the hormones do to the vagina? Did the NIH study address sexuality? How would you advise women who are concerned about maintaining vaginal health in light of the NIH study?

Cynthia Pearson: Thank you for sharing your experience. Sexuality is such an important part of life for most people and you're right, it's often not discussed or researched.

I don't know exactly how much the WHI looked into sexuality, but I'm sure that it wasn't enough!

As for the specific question about vaginal health, Our Bodies Ourselves said it best many year ago "use it or lose it". Not to sound too flip, women participating in menopause support groups have reported that orgasms are important & finding ways to continue to be sexual seems to be an important part of maintaining vaginal health. Lubricants can be helpful for women who find vaginal intercourse to be uncomfortable. And very small doses of estrogen creams also provide relief .

Somewhere, USA: Why don't the media give this pharmaceutically well known and reliable information? A woman can have excellent and
safe HRT by taking: estriol, estradiol, and micronized progesterone (1/2 the month only). The much-debated study used the most common pill for HRT, then equated prempro with HRT. Prempro and the other convenient pills use (a) progestin instead of actual progesterone and (b) give it every day instead of half the month, as in a natural cycle. Progestin has been known for years to raise triglycerides, so of course heart attacks would be expected.

Does it make sense to anyone why the hormones that until yesterday supported women in their natural form and mix became toxic today? It may be because the drugs sold in the US are not the same.
There are pharmaceuticals much closer to the real thing, but they are hardly sold in the US. These are:
- micronized progesterone (sold as
utrogestan, prometrium), only since 1999. It's the same molecule as women't progesterone and does not have the side effects of progestin. Women should take this 1/2 the month, as their body once did.

- Estrogen: estradiol makes up only 15% of women's normal estrogen, but that's all the pills give. Instead women can take:

- estriol: NOT sold in the US except through expensive compounding pharmacies, but sold in Europe (e.g. produced by the Dutch Organon) for about $2 per month. Estriol makes up 80% of estrogen in women's bodies, and was found in Sweden NOT TO CAUSE CANCER. (citation available). But estriol may or may not stop bone loss.

- a mixture of estriol and estradiol for best control (sometimes estrone also).

- Sold in the US through compounding pharmacies as tri-est and very expensive.I never understand why this pretty common knowledge is not given out. The most likely explanation is that the usual drug companies would not benefit. But the consumers should know.

Abigail Trafford: Cynthia, what about this. Is the estrogen formula used in Europe safer than PremPro, which is so common in the U.S.

Cynthia Pearson: Unfortunately, we don't get enough good research on alternatives, espeically those that can't be patented. Right now, natural hormones are tantalizing, but unproven.

Abigail Trafford: Our time is up. sorry not to get to all your questions. This was a great discussion. Thank you Cynthia, thank you all!

   |      |