HRT Panic? -- Sorting Out the Facts: Christiane Northrup, MD -- 7/10/02
By Christiane Northrup
You've heard the news: Women in a national HRT study were suddenly told to stop taking the drugs. What does this mean for you? Should you stop taking estrogen? What are the facts behind the headlines? Women's health expert Christiane Northrup, MD, joined us to answer these questions and more.
The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician.
Moderator: Hello, Dr. Northrup. Thanks for joining us again on WebMD Live. Can you please explain the news about HRT that was released this week? How significant is this news?
Northrup: The news that was released was that a branch of the Women's Health Initiative [study] was stopped earlier than anticipated, because the women who were taking Prempro, a combo Premarin and Provera, were found to have an increased risk of invasive breast cancer. And also increased risk of heart attack, strokes, and blood clots in the lungs. The risk however, was minimal, in that out of 10,000 women, they'd expect eight more cases of breast cancer than in the placebo group.
This branch of the Women's Health Initiative was asking the question, "Does hormone replacement with Prempro decrease the risk for chronic disease in healthy women who have their uterus and ovaries?"
We have been waiting for decades to get definitive answers about whether hormone replacement improves the health of healthy women after menopause. This study looked at healthy women who take a standard dose of Premarin (made from the urine of horses) and Provera (a synthetic progesterone not found in the female human body).
Moderator: Who is funding the Women's Health Initiative? And how is this study different from earlier studies?
Northrup: The Women's Health Initiative is paid by the taxpayers. Most earlier studies have been funded by the pharmaceuticals that make the hormones. Wyeth-Ayerst, the makers of Prempro, provided the drug for the study. I've always felt uncomfortable with Prempro being the hormone of choice for this study on hormone replacement because it does not consist of bio-identical hormones.
Member: Should I stop taking Premarin cold turkey?
Northrup: It's never a good idea to stop Premarin cold turkey because often there's a rebound in menopausal symptoms as a result. It's far better to wean yourself off gradually over a period of one to two months and during that time, begin to include more soy foods in your diet, ground flax seeds, and women's herbs such as black cohosh, so that your body is getting safe hormonal support while you're coming off Premarin.
Another alternative is to switch from Premarin to another type of estrogen at the lowest possible dose. This would, of course, have to be a prescription from your doctor. If you were to do this, you simply stop Premarin one day and start the new estrogen the next. The main thing is there is no need to panic.
Member: How should I wean myself off of Prempro?
Northrup: What you do is take one tablet two days on and one day off, so you're one less tablet per week the first, the second week you take two less. The third week, skip Monday, Wednesday, and Friday, so that you're now on it every other day. The fourth week you take it twice a week. And the fifth week you are done. Some women will want to go slower than that, and some will go faster if they went through menopause three, four, or five years prior to Prempro. The main thing this study also showed was that to take hormone replacement for a couple years during the menopausal transition appears to be safe. The real long-term problems come when you take it five years or more.
Moderator: Was there any evidence that a woman's age had any relationship to risk using this form of HRT?
Northrup: Not particularly. It's more duration of use. The women in the Women's Health Initiative ranged from age 50 to 70.
Member: What types of HRT do you feel are safe?
Northrup: Any of the estrogens in high doses can increase the risk for blood clots and breast cancer. The best way to take hormones, which include progesterone, estrogen, and testosterone, is at the lowest possible dose that gives you relief of symptoms. The most physiologically natural way to take a hormone is the transdermal route through a patch or a skin cream. Many, many hormone preparations are available that can be taken this way. The dose can be monitored through measuring hormone levels in the saliva. You may need to change your dose regularly until you find the right combination of hormones. Many women work with formulary pharmacies that compound individualized hormone dosages in partnership with women and their physicians. This is the type of hormone replacement I consider ideal. Unfortunately, many women are cared for in HMO systems that have agreements with large pharmacies that limit the choices of hormones to just a few.
Bio-identical hormones are widely available and often quite inexpensive. No drug company can patent a naturally occurring hormone. And that is why they are not more widely used. Sometimes you can patent the delivery system of a bio-identical hormone. That is what's been done in the case of the various estrogen patches, which consist of the natural estrogen, estradiol.
Moderator: We have several members asking you to explain what "bio-identicals" are.
Northrup: Bio-identical simply means a hormone that matches exactly the hormone found in the human body. All hormones have a three-dimensional structure that has been designed by nature to fit the hormone receptors that are on every cell in the body. A hormone that is designed in a laboratory that is different from what is found in nature also has a different three-dimensional structure than that found in the human body. As a result, the biologic effect will be different. Premarin is often called a natural hormone because it is made from the urine of pregnant horses. But it is not a hormone that is natural to the female human body. Therefore, it is not bio-identical.
Member: Have there been any HRT studies using bio-identical estrogens? How do we know that the negative results from the WHI study aren't attributable to the "ingredients" in Prempro that are not natural to human women?
Northrup: Yes, there are studies of bio-identical hormones, particularly bio-identical progesterone, that do not show these adverse reactions. The point you make is exactly the key issue. I, for one, believe that the results of this study can be attributed, at least in part, to the fact that the study used hormones that are not native to the human female body.
Member: What if you've had a total hysterectomy -- does it apply the same?
Northrup: If you have had a hysterectomy, chances are you are not on a synthetic progestin, such as Provera. The arm of the Women's Health Initiative for women on estrogen alone is still ongoing. This group is on Premarin only without Provera. In my opinion, it would be safer to use another type of estrogen besides Premarin. The results, however, of the Premarin only group are not yet available.
Member: Prempro has been said to possibly have a pro-inflammatory effect. What does that mean?
Northrup: Most diseases such as heart disease and cancer are actually felt to arise from inflamed tissue. We have a great deal of evidence that heart disease starts because of inflammation inside of blood vessels. We also have evidence that cancer starts as inflammation inside organs and tissues and blood vessels. Premarin is in fact associated with inflammation inside blood vessels. To some degree, all estrogens might have some inflammatory effect, but the bio-identical estrogens such as estradiol are also known to have an antioxidant effect, the same way that vitamin E and vitamin C have antioxidant effects.
The whole key to quelling inflammation in the body in general is to get enough antioxidants in the diet through eating colorful fruits and vegetables daily, and also keeping stress levels reasonable. Stress of all kinds -- environmental as well as emotional -- is also proinflammatory.
Member: I have been taking Prempro for five years. If I stop now, will the "increased" risks decrease, over time?
Northrup: Absolutely. Absolutely!! The body is self-healing. Just as when people stop smoking, their risk for lung cancer decreases with every passing day. The same is true for any potential risk with Prempro.
Member: What time frame do doctors consider as "long-term" for taking HRT?
Northrup: Five years. Anything beyond five years -- according to this study. In the past we have said seven.
Member: Does the five-year limit include bio-identical hormones?
Northrup: I don't believe that it does, necessarily. Especially if we use very low doses. We probably, however, will never have the kind of study that would show this definitively.
Member: Does the need to use hormones ever end -- that is, after menopause is complete?
Northrup: Yes. Many women need HRT only during the two- or three-year period that corresponds to the final two years after the last menstrual period, when the hot flashes and night sweats are at their peak. After that, the body normally settles down and hormones are not required for symptom relief thereafter. It's important to remember that healthy ovaries produce small amounts of hormone throughout a woman's entire life. And so do other organs in the body, such as the brain and the adrenal glands. The key to maintaining good health after menopause is making sure that your lifestyle is healthy enough to maintain the health of all of your organs and tissues. Thankfully, this can easily be done with minimal or no hormone replacement.
Member: Wasn't it just as risky for me to be on the birth control pill for so many years, as it is for me to be taking HRT?
Northrup: The long-term studies of the pill do not show any major risks. However, we do not have any government-funded studies of the pill that would be comparable to the Women's Health Initiative. The bottom line is this: We should always be careful about putting synthetic substances in our bodies. The Pill is right for some women and it's wrong for others. As a nation, we need to stop our habit of expecting a "pill solution" to every health problem.
Member: How can something (Prempro) that comes from a natural source (pregnant mare urine) cause so many side effects and problems?
Northrup: It's natural for horses and not natural for humans. It's Premarin combined with a synthetic progestin. It's the combination of these two things together that is not good. We also have data that the metabolic breakdown products of Premarin alone are biologically stronger than our own body's estrogen would be. And this can cause more of a hormone effect than is necessary or healthy.
Member: Should we be concerned about the connection between physicians and the pharmaceutical companies as this debate continues?
Northrup: Yes. Yes, we should. The practice of medicine in the U.S. (conventional medicine) is seamlessly interwoven with the pharmaceutical industry. Period. End of Story! It just is!
Member: How does the message about alternatives to Prempro get communicated? The media speaks of HRT and Prempro as one and the same.
Northrup: Fabulous observation. That's the entire problem. Prempro is one and only one type of hormone replacement, and in my opinion, it's not even close to the ideal.
Member: Where can I get a copy of the study results?
Northrup: Ask your local medical center or your librarian. It's in The Journal of the American Medical Association, July 17, 2002, No. 3, volume 288. This is easy to get from any library.
Moderator: You can also get a very good summary in an NIH (National Institutes of Health) press release at www.nhlbi.nih.gov/new/press/02-07-09.htm. Dr. Northrup, we are almost out of time. Before we wrap up for today, do you have any final comments for us?
Northrup: This study and the panic surrounding it is a reminder to all of us to start trusting our body's ability to get and remain healthy with minimal drug intervention. HRT using bio-identical hormones is a viable and important option for some women, but not all women. The human female body was designed to stay healthy for at least 100 years.
There is no reason for the body to deteriorate because of a normal menopausal transition. Far too many American women have bought into the notion that menopause is a disease requiring treatment. This simply is not true.
Make sure you are doing everything you can to take charge of your life and your health by exercising, eating well, enjoying chocolate regularly (in small doses), and living joyfully. That should be our response to this study.
One more thing: Don't hold your breath waiting for some designer estrogen to save you. They are not going to work either. As Jeff Goldblum said in Jurassic Park, "Nature always finds a way!" When it comes to the choice between something created in a laboratory versus the wisdom of Mother Nature, put your trust in Mother Nature.
Moderator: We are out of time. I'm sorry we couldn't get to all of your great questions. Our thanks to Christiane Northrup, MD, and thank you, members, for joining us today. For more information, please read The Wisdom of Menopause and Women's Bodies, Women's Wisdom, both by Christiane Northrup, MD. You can also visit Dr. Northrup's website at www.drnorthrup.com. 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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