Here's more on ERT:
Hormone Therapy: Do Benefits Outweigh
Risks? (8/4)
By CAROLYN SUSMAN
c. 1997 Cox News Service
WEST PALM BEACH, Fla. -- Pills or patch? Breast cancer or
heart disease? Road to recovery or Russian roulette?
Medical professionals consistently offer conflicting advice about
menopausal symptoms and hormone-replacement therapy.
Does replacing the body's dropping levels of estrogen make women's
tissues younger and stronger? Or are the 40 million menopausal and
post-menopausal women in the United States merely potential lab rats
for the multibillion-dollar drug industry?
A study published recently in The New England Journal of Medicine
offered hope that hormone supplements may extend a woman's life
during the first 10 years of use. Menopause usually occurs naturally
from the late 40s to around age 52.
But the study also warned that taking estrogen for more than 10 years
increases the risk of dying of breast cancer.
The statistics showed that for the first 10 years a woman takes
hormones, her overall chance of dying from various causes dropped
37 percent, and 53 percent for heart disease. But that protection
decreased to 20 percent after 10 years because of the increased risk
of breast cancer.
Bottom line?
``It's up to (women) to look into all the ins and outs,'' says Dr. Susan
Love, outspoken critic of the ``medicalization of menopause'' and
author of ``Dr. Susan Love's Hormone Book.'' ``It's a complicated
business, and not all the answers are in yet.''
Here are common questions.
When should I consider starting hormones?
Some, like Love, feel hormone-replacement therapy should be the last
step you consider. When you start experiencing menopausal
symptoms such as hot flashes, vaginal dryness, painful intercourse,
decreased sexual drive and insomnia - and these changes are
disrupting your life - you might consider taking action, even if your
periods haven't stopped.
Those who favor alternative approaches suggest lifestyle changes such
as increasing exercise, dressing in layers, eating more soy products
because they mimic estrogen and using vitamin E or acupuncture for
hot flashes.
There is a blood test that can measure your hormone levels, but some
don't consider it a good indicator because levels can fluctuate.
However, you are usually considered menopausal when you've
stopped having periods for a year.
Dr. Holly Hadley, in family practice in West Palm Beach, gives some
patients the hormone progesterone for a week. ``If there was a
(uterine) lining in there, you'll bleed, and you're probably still making
estrogen. If not, you're plumb out of estrogen.''
If there still is disagreement on risks, why would I want to take
hormones?
Hormone therapy is used to relieve symptoms of menopause. If these
are out of control and ruining your life, and you can't find an alternative
way to deal with them, you might want to try hormone therapy.
Hormones also are being touted as a possible preventive for heart
disease, osteoporosis and Alzheimer's disease, and as a buffer against
tooth loss.
Says Dr. Steven Pliskow, a West Palm Beach gynecologist,
``Statistically, for the one patient who may get breast cancer because
the estrogen stimulates the growth of an already existing abnormal cell,
there are 8,000 who will die from heart disease or (complications of)
osteoporosis (without it). That's 1 to 8,000. The benefits far outweigh
the risks.''
What types of hormone supplements are available?
Hormones can be taken several ways. The leading estrogen
supplement (conjugated estrogen) is Premarin, produced by
Wyeth-Ayerst, and it is also the most widely dispensed prescription
drug in the country.
For women who don't have a uterus, estrogen alone is usually
prescribed. For women with a uterus, you must have both estrogen
and progesterone. The risk of uterine cancer increases with estrogen
alone, because the lining builds up and isn't sloughed off. Provera,
produced by Upjohn, is the most commonly used brand of
progesterone in the United States.
The hormones can be taken either in continuous or cycled therapy.
With cycled therapy, you take estrogen pills daily and take progestin,
a form of progesterone, in two of the four weeks of the cycle. That
allows the uterine lining to build up, and you have a period. With
continuous therapy, you take both hormones daily.
Last year, Wyeth-Ayerst introduced Prempro and Premphase, pills
that combine estrogen and progestin in one tablet. With Premphase,
you have cycled therapy, because the progestin is included in the
tablet only during the first two weeks.
Are the pills my only choice?
Hormones are also available in patches, injections, creams, gels and
nasal sprays. And you have alternatives to Premarin, a synthesized
hormone. Synthetics are made with the urine of pregnant horses and
additives.
There is another type of hormone on the market, which its supporters
refer to as natural. These ``bio-identical, plant-derived'' hormones are
forms of estrogen made from plants and are the same chemical
formula as your body makes. Premarin contains some of these
estrogens. The plant-derived estrogens are known as estradiol,
estrone and estriol. Estrogen patches such as Climara, Vivelle and
Estraderm contain this form of estrogen, as do the oral forms of
estrogen marketed as Estrace, Estratab and Ogen.
What form is the best for me?
Whether you should take synthetic or plant-derived hormones, and in
what form, depends on many factors. There is a new book, ``Natural
Woman, Natural Menopause'' (HarperCollins, $24) devoted to the
benefits of plant-derived hormones.
Author Love laughs at the use of the word ``natural'' in describing
these hormones. ``Don't let anyone kid you - these are all drugs,'' she
writes. What form to use may depend on how well you tolerate the
drug you are taking, or whether you have a condition that favors one
form over another.
Patches, for example, deliver the estrogen directly through the skin,
bypassing the liver and intestines. This is great if you have a lot of
stomach irritation, gallstones or high triglycerides. But because, to
date, the patches contain only estrogen, women with a uterus must still
also take a pill containing progesterone. And because there are no
long-term studies of patches, there is debate on its effectiveness for
reducing heart disease.
Is there a difference in cost?
Premarin, according to Wyeth-Ayerst, costs approximately 40 cents a
day. The approximate cost for Prempro/Premphase is 50 to 60 cents
a day. That works out to about $12 to $18 a month. A spokesman for
the Climara patch says an average monthly cost is in ``the low $20
range.'' Climara is the first once-a-week patch. Others have to be
changed every three or four days.
What about side effects?
In addition to the risk of developing breast and other forms of cancer,
side effects can include symptoms of pregnancy - tender breasts,
nausea and headaches. But these usually go away after about a month,
or dosage can be adjusted.
Hadley, the West Palm Beach family practitioner, says it's a myth that
hormones produce weight gain.
What's the normal course of treatment? How does the doctor
determine what types of hormones I need and how much I should get?
``Normally, we start with 1 milligram estradiol, or 0.625 milligram of
conjugated estrogen - that's the least amount necessary to prevent
osteoporosis or heart disease,'' says gynecologist Pliskow. ``If the
patient is still losing bone, or having hot flashes, we increase the dose
progressively. Some patients have decreased libidos and sex drive.
They benefit from the male hormone, testosterone. There are no side
effects as far as extra hair growth or deepening voice. Your ovaries
produce a small amount of testosterone naturally.''
Normal, however, is relative. Love writes that taking hormones for
heart disease prevention is a ``personal decision based on inadequate
information.'' She doesn't rule out hormone therapy for this purpose,
but believes when to start varies with the patient's risk of heart
disease. And, she writes, ``we know of other ways to prevent heart
attack.''
How do the hormones act in my body?
``In women, almost every organ has estrogen receptors,'' explains
Pliskow. ``The estrogen binds to the receptors. It triggers a response
in the cell to go in and change the cell in different ways. In the heart, it
strengthens the muscle, in the vagina, it helps lubrication and elasticity.
It helps bones reabsorb calcium. So it revitalizes all the organs of the
body. The old tissues are made younger and stronger. The skin,
memory, brain, all of those things.''
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NYT-08-04-97 1106EDT< |
