HRT -- Where Do We Go From Here?: Laura Corio, MD
Afterrecent news about HRT, women and their doctors will be weighing the risks and benefits of hormone replacement more carefully. Ob-gyn Laura Corio, MD, author of The Change Before the Change, was our guest on Thursday, July 11, 2002.
By Laura Corio
The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Hello, Dr. Corio. Thanks for joining us again on WebMD Live. What was your reaction to the news about HRT that was released this week?
Corio: I wasn't surprised. I've been saying all along that I don't like Provera. The product Prempro is a combination of Premarin and Provera. I have taken my patients off of Provera and placed them on oral micronized progesterone. The Provera has been shown to negate the benefits of the estrogen on the heart. And a research article in JAMA (The Journal of the American Medical Association) showed that women who took nothing or estrogen alone had a lower incidence of breast cancer compared with women who had been on HRT with Provera for over five years. These women had the highest risk of breast cancer. So to answer your question, I'm not surprised at all.
Moderator: There has been so much hysteria in the media. It sometimes sounds like the "Storm of the Century" reports every news station does when two snowflakes fall!
Corio: I have a difficult time with the way that info is given to the public. It can be a very small study and it gets placed on the front page of the New York Times and scares women out of their minds. The study that came out yesterday was so frightening to women. They have been saying for 10 years to go on Prempro, Prempro, Prempro. Six million women placed on it. And yesterday, they said to get off of it now. Women are very, very upset.
Member: Can Prempro be stopped abruptly? Do I need to take every other day for a while?
Corio: I tell my patients to taper it. Which means that they can take it every other day for two weeks and then stop.
Member: I stopped taking Prempro yesterday. What can I do now to prevent bone loss, flashes, dryness, and loss of sex drive? I am a healthy 57-year-young woman. I've been on Prempro five years.
Corio: If a woman is showing loss of bone (osteopenia), besides exercise and taking calcium and a good multivitamin, there are also medications such as bisphosphonates, which really are for treating and preventing osteoporosis. There is also Evista, which is a selective estrogen receptor modulator (SERM). It can also be used in post-menopausal women to reduce the risk of bone fractures.
Vaginal dryness can be treated locally with bio-identical estrogen cream or over-the-counter moisturizers.
Hot flashes can be treated with evening primrose oil, black cohosh, soy, and other phytoestrogens. And again, I have patients on bio-identical hormones, which I feel are absolutely safe. And you can do a very low dose and still get relief from your symptoms.
As far as libido, that's the toughest one because it's multifactorial. You have to delineate what exactly is going on. Is it a loss of interest in sex, difficulty reaching orgasm, vaginal dryness, or is it a blood test showing low testosterone? I have replaced testosterone in women with low libido and have gotten good responses.
Member: Is Premphase, which I've been taking, the same as Prempro?
Corio: Premphase is the same molecules. Prempro is just continuous Premarin and Provera. And Premphase is sequential Premarin and Provera, but I would recommend stopping that as well.
Member: What effects can be expected from stopping immediately for a 62-year-old?
Corio: She may not feel anything because she is older. She probably won't have many menopausal symptoms at this age. I would say that the majority of women who stop hormones at this age may feel fatigue or a change in well-being, but most women at this age are taking these hormones for their benefits and not for menopausal symptoms. So when they stop, they don't really feel that much of a difference.
Member: Will I start periods again if I quit taking my HRT? I am 53 and my periods have been very, very light for the past year.
Corio: Absolutely you may bleed. If you are still lightly bleeding and you're 53 years old and you stop your hormones, you may get a full-fledged bleed. Women get periods when hormones drop, so if you take someone off hormones and drop their levels, they will get a period. So yes, it is most likely you will get a period.
Member: I am a 47-year-old woman who had premature menopause starting at 30 years old. Are there any studies that look at the risks of HRT for women with premature menopause? Do you have any recommendations about how long women with premature menopause should take HRT? I am assuming that the risks for women on HRT are for women older than 50. Is this correct?
Corio: No. I think this study looks at the amount of time that a woman takes hormones, no matter how old she is. It's the cumulative years. So if someone is 30 and placed on Prempro versus 50 and on Prempro, it still will affect her if she takes it more than five years.
Member: What about estrogen keeping the walls of the skin sound? Are aging effects likely to be the result of not taking HRT?
Corio: Estrogen does keep the skin elastic, moist, and with fewer wrinkles. Some day we hope that estrogen can be applied directly to our skin, just as we apply estrogen to the skin of our vaginas. So women who are aging and not taking estrogen may find skin changes occurring but I have had patients who have specifically wanted to go on HRT to keep their skin looking young.
Member: Does Evista have any effect on skin elasticity?
Corio: Not that we know of. Remember, Evista has some properties of estrogen, but not all the properties of estrogen.
Member: How much oil of primrose, black cohosh, and soy are necessary to prevent hot flashes? What kind of soy? Where does one find bio-identical estrogens? What about transdermal estrogen/progestin patches?
Corio: For evening primrose oil -- anywhere between 1000 mg and 3000 mg a day, for black cohosh -- 20 mg twice a day, and for soy -- between 10 g and 25 g of soy protein a day.
Now, about bio-identical estrogen and progesterone and testosterone: The first time I ever dealt with this was 15 years ago and it was through the International Pharmacy in Madison, Wis. They still exist today and if a patient calls them, they have doctors, such as myself, as referrals. And they work with the patients, compounding bio-identical hormones.
There are no progesterone patches. As far as transdermal patches of estrogen, I use them every single day of the week on my patients. They are bio-identical, patients love them, they absorb through the skin, which is a great way to give hormones, and the patients do very well on them. They are available in regular drug stores. Some of the estrogen patches that are available at drugstores are:
And these really are available at drug stores and your doctors can prescribe them for you. Bio-identical progesterone is made by Solvay and comes in the name of Prometrium. It can be gotten at any drugstore and substituted for Provera. I think any woman who is going to take HRT should be on progesterone, which is different than Provera, which is a progestin.
Member: Do you feel that the patches do help prevent cardiovascular disease (since they don't activate many of the clotting factors that happen when estrogen is taken orally)? Do you see the bio-identical HRT as not applying to this recent Prempro study?
Corio: Absolutely. I do not feel that patches or pills of bio-identical estrogen are problematic. They definitely help decrease the risk of heart disease. And if you read the study, what is very interesting is that the women who were just taking estrogen alone because they've had a hysterectomy and do not need progestin to protect their uteruses are still being continued in the study. They have not found these women who are just on estrogen to have any of the increased risks or heart attacks, strokes, breast cancer, or blood clots with just estrogen alone. I think that is very important. It clearly, in my mind, points to the Provera or progestin taken by many women on HRT.
Member: Are bio-identicals safe if you have a family history of breast cancer?
Corio: Yes, absolutely. I can tell you, honestly, that in my practice I see a lot of breast cancer. And it is not in my patients who are taking bio-identical estrogen and progesterone.
Member: Are these bio-identicals quite a bit more expensive for the patient?
Corio: As I said before, drug companies are now making bio-identical hormones that can be gotten on drug plans. It is time for doctors to become familiar with the other types of HRT that are out there and not being used.
Member: Why doesn't the medical community (other than yourself) let us know this distinction? HRT is synonymous with Prempro to many doctors and the media.
Corio: I am totally frustrated that other women and men physicians are not doing what I'm doing. I can't understand why.
Member: Just to note, Christiane Northrup, MD, was with us yesterday and I'm sure she would agree with Dr. Corio. There are some doctors who know and care -- it's just a matter of finding them.
Member: Are long-term studies being done on non-oral estrogen and/or bio-identical HRT?
Corio: There are definitely studies on patches, there are definitely studies on progesterone, estradiol, and testosterone showing the benefits.
Member: Do transdermal patches of estrogen predispose the uterus more often to cancer because of no progesterone?
Corio: Whenever you take estrogen, whether it's a pill-combined progesterone, or a patch and a separate progesterone pill, if you have a uterus you have to take progesterone to protect the uterus against the estrogen. So, no.
Member: Do you prescribe Estratest with the bio-identicals? Testosterone was not considered in the study, I notice.
Corio: No. Estratest is synthetic estrogen and testosterone, and I don't use synthetics.
Member: Are prometrium and estrogel bio-identical hormones?
Corio: Yes. Estradiol and progesterone are bio-identical hormones. Bio-identical hormones are hormones that women made when they were menstruating. They are the exact hormones that we made during our menstrual cycle. Premarin is a conjugated estrogen from horse urine and is probably made from 10 different types of estrogen, five of them horse estrogen, which our body cannot identify. Provera is a synthetic progestin, which is not anything our body can identify, and the by-products of it could be the problem.
Member: I am almost 53 years old and have been taking Premarin and Prometrium for about a year and a half. Prior to that, for about a year or so, I was taking Premphase. My last period was almost two years ago. I called my gynecologist's office and was told that the press was only telling half the story, and that there was really nothing that urgent to worry about. My mother died of a heart attack at 77, seven years ago. What do you advise?
Corio: The Premarin is not the culprit. The Prometrium is very good for you. I would say to stay on it and relax.
Member: Should those of us who are past childbearing have our uterus removed and take straight estrogen? Is it safer?
Corio: No, absolutely not. You can take Prometrium and not take Provera.
Member: I use a patch that I believe is called "Combi." Does that have progesterone in it?
Corio: Combi patch has estradiol, but a progestin. So the progestin is synthetic and I would take a pure estrogen patch and take progesterone at bedtime, by mouth.
Member: Do you think synthetic estrogen and progesterone will be taken off the market?
Corio: Progesterone is not synthetic and I would say, I hope so. There is a place for Provera. But there are some women who need it to menstruate and so I would say I hope it's taken away as a choice with HRT.
Member: I am currently taking HRT and will visit my doctor next week, what types of questions are appropriate to ask him in regard to the HRT issue?
Corio: First of all, why are you taking the hormones? Discuss with your doctor the reason you're on HRT. If the reason that you're on it is substantial, then stay on the HRT, but switch to natural bio-identical hormones so you don't have to worry about the recent results of the study. Women take HRT to control menopausal symptoms and if that's not the issue, then are you taking it for prevention of osteoporosis. The way I look at HRT is as preventive medicine. Once a woman has osteoporosis, heart disease, Alzheimer's -- these drugs are not the drugs of choice.
Member: So, it's your feeling that natural bio-identical hormones can be taken long term, or do I have it all wrong?
Corio: No you have it right. I want to repeat, I look at the patient and say first, "You should be on a good diet, exercising, taking vitamins and minerals." We shouldn't be taking HRT to substitute for all these other things. A woman can age beautifully without hormones.
Member: I've been on the study with Women's Health Initiative for about 6 years now. I'd like to stop taking the pills. I stopped once before and within a couple of days I got my period. It was a very heavy flow. I'm afraid it might happen again. Should I slowly stop taking the hormone pills or go "cold turkey?"
Corio: If you slowly weaned off the hormones instead of cold turkey, taking it every other day for two to four weeks you may still bleed, but it won't be as dramatic.
Member: What about birth control pills with the same problematic synthetic combination -- are they dangerous for young women, too?
Corio: No, it's not the same thing. It's medroxi-progesterone and it's not the same thing. It's not in birth control. There was a recent study in The New England Journal of Medicine that studied women on birth control and did not show an increased risk of breast cancer. And I just want to say that all these different chemicals don't act the same way.
Moderator: Dr. Corio, we are almost out of time. Before we wrap up for today, do you have any final comments for us?
Corio: A woman needs to weigh the benefits versus the risks of taking any medication. Women can take HRT especially for menopausal symptoms and should ask their doctors about taking estradiol and progesterone instead of synthetic hormones such as Premarin and Provera. I would tell the patients who have been taking Prempro for many years not to be hysterical and to not worry. This is one study, the number of women who did get into trouble are small. They need to speak with their doctors and decide with their doctors whether the benefits of hormones outweigh the risk. We all look forward to more information and more studies to give us information to help us decide what's right for each one of us.
Moderator: We are out of time. I'm sorry we couldn't get to all of your great questions. Our thanks to Laura Corio, MD, and thank you, members, for joining us today. For more information, please read The Change Before the Change, by Laura Corio, MD. Please check out our news stories, features and archived interviews with experts -- visit the Menopause Center and Living Better: Healthy Women on WebMD. And be sure to visit the message boards: Menopause, with Joan Starker, PhD, MSW, Women's Health: Common Conditions, with Jane Harrison-Hohner, RN, RNP, and Women's Health: Friends Talking.
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