Map of life expectancy at birth from Global Education Project.

Thursday, October 21, 2010

Stay with me . . .

This is a slightly complicated story. A few days ago I got an e-mail promoting a film called "Hot Flash Havoc." This is purportedly one woman's story of the horror, the horror, of menopause and her long search for relief. Finally she found the one doctor who could end her suffering. Okay, here's a link, but I warn you, it's a very slick advertising site with an annoying sound track. I found it interesting that it also seemed to promote a particular physician named Alan Altman, who, as it turns out, also has a a very slickly produced web site that promotes his practice and various products.

It turns out that Dr. Altman is a big-time promoter of hormone replacement therapy, and he claims that the Women's Health Initiative (WHI) Study, which concluded that HRT increases the risk of cardiovascular disease and breast cancer, is bogus. He apparently thinks that HRT will keep you young, sexy, horny and healthy and that anybody who says otherwise is part of some sort of conspiracy against womankind.

I thought this all rather odd so I wasn't going to say anything about it, but then along comes longer term follow-up analysis from the WHI, which concludes that HRT is even more dangerous than we used to think.

The WHI was halted after most participants had been receiving HRT for 5.6 years, because it became clear to the investigators that health risks were exceeding benefits, including an elevated risk of invasive breast cancer, cardiovascular disease and stroke, and pulmonary embolism. This was a major shock, because HRT had been heavily promoted for years as a fountain of youth. The elevated risk of breast cancer was in fact anticipated, but HRT was thought to be protective against cardiovascular disease based on observational studies. Since the consumption of HRT plummeted in the wake of these findings, so has the population-wide incidence of breast cancer, an association which many people believe is causal.

Nevertheless, some people continued to believe that even though HRT increased the incidence of breast cancer, it resulted in a higher percentage being of a less dangerous variety. Not so, as it turns out. The new findings are:

Results In intention-to-treat analyses including all randomized participants and censoring those not consenting to additional follow-up on March 31, 2005, estrogen plus progestin was associated with more invasive breast cancers compared with placebo (385 cases [0.42% per year] vs 293 cases [0.34% per year]; hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.07-1.46; P = .004). Breast cancers in the estrogen-plus-progestin group were similar in histology and grade to breast cancers in the placebo group but were more likely to be node-positive (81 [23.7%] vs 43 [16.2%], respectively; HR, 1.78; 95% CI, 1.23-2.58; P = .03). There were more deaths directly attributed to breast cancer (25 deaths [0.03% per year] vs 12 deaths [0.01% per year]; HR, 1.96; 95% CI, 1.00-4.04; P = .049) as well as more deaths from all causes occurring after a breast cancer diagnosis (51 deaths [0.05% per year] vs 31 deaths [0.03% per year]; HR, 1.57; 95% CI, 1.01-2.48; P = .045) among women who received estrogen plus progestin compared with women in the placebo group.

Now, it's important to understand here that while relative risk seems pretty substantial, the absolute risk we are talking about is indeed pretty small -- 2 additional deaths per year per 10,000 women. However, I should also point out that over the course of the follow up period the survival curves continued to diverge, so it is reasonable to suppose that over a longer time period the absolute risk will increase. And of course, you also need to remember that even at the observed rate of difference, over ten years we're talking 20 deaths per 10,000, and more over longer periods. This does not include the cardiovascular and other risks, which I don't have handy although I do know they are of comparable magnitude.

As Peter Bach argues in the same issue of JAMA, while many physicians still feel that a short course of HRT around the time of menopause presents little risk, we don't really know this. It's true that the cardiovascular risk does not seem associated with HRT initiated right at menopause, but unfortunately timing of initiation is not related to the other risks.

I'm not personally familiar with the symptoms of menopause, but I do know many women including of course my own mother who have gone through it. From what I could observe, it didn't seem to be hellish enough to justify increasing your risk of dread diseases and early death just to relieve the symptoms. While I do believe that women should make up their own minds, I do not like slickly produced promotion of such a highly dubious product. I also have no reason to believe that the results of the WHI have been in any way misrepresented; nor do I believe it does a disservice to women to tell them the truth about scientific findings.


kathy a. said...

i've never been interested in HRT, which is a good thing because my doctor would not prescribe it for me, given a family history of breast cancer. a number of my friends without that history strongly encouraged me to seek low-dose, short-term therapy, though, because it helped them cope.

my understanding is that symptoms vary from woman to woman, as does the duration. but for me and a number of friends, the symptoms really are disruptive and somewhat disorienting.

i have slept very poorly over the past couple of years -- part simple insomnia, and on many nights, i am awakened over and over by hot flashes, as many as 10 or 12 times. as a result, my ability to concentrate and get my work done is much less than it was. the hot flashes also strike during the day, some random and some triggered by too warm clothing, a too warm room, brisk walking, climbing stairs. so, at a time when i should be increasing exercize, that is a disincentive. it is also socially awkward to turn red and start dripping and fanning oneself in the middle of a meeting. between one thing and another, this isn't doing anything for my mood or sense of well-being.

none of that is fatal. i had occasional symptoms for years and thought them very manageable, but the incidence really spiked a couple years ago. a few weeks in, i felt exhausted and was anxious for some relief; it was terribly discouraging to learn that the symptoms might last at that level for years.

now, i guess i'm resigned to being less productive until this passes. i sleep with blue ice under my pillow and turn the pillow when needed, and on bad nights run a fan. etc. one friend carries folding fans with her everywhere. another uses antiperpirant on her face, which doesn't stop the flashes but does cut down on the dripping -- this has been going on 6 years for her.

anyway, HRT is not for me. but i can see why some women might turn to it despite the risks -- not as a fountain of youth, but so they can function in their daily lives.

Cervantes said...

As I say, people should make their own informed choices, but this slick, high intensity promotion is really inappropriate. Obviously the guy is making big bucks off his jive, and although I haven't looked into it deeply, it appears to be highly tendentious and inconsistent with the medical consensus. So its pretty much evil.

Hopefully they'll come up with something safer for the kinds of symptoms you are experiencing.

kathy a. said...

obviously, i hate the website and doctor you referenced, too. and i've heard of things like oprah pushing HRT on her show, without presenting the risks and stressing the need to weigh them. awful stuff.

kathy a. said...

ok, i watched the trailer, and have to say that one of the reasons a film like that would be appealing is that women end up in perimenopause without a huge amount of information or a natural support group. if distressing symptoms turn up, it is isolating unless one finds fellow travelers. sure, a good doctor will share clinical information -- but those are short visits of necessity, not a support system in the social sense.

the onset of menstuation is another big set of body changes, but young women take classes together on the topic, and thereafter share information amongst themselves, and hopefully there is parental support. pregnancy and childbirth are another body-changing set of experiences, and get a LOT of attention -- and there are books, lamaze classes, you name it -- and natural bonds and exchanges of information happen. it follows a defined biological path, with a beginning and an end. plus, everyone loves a pregnant lady.

menopause is not a disease; but i think we are trained to think anything going on in our bodies might be fixed with a medical intervention. HRT's risks are an example of how a medical approach might be harmful.

there is also a layer of stigmatism about women achieving menopause -- that they are crones, they are useless, they have lost their beauty along with reproductive capacity. hot flashes are not acceptable chit-chat topics in many settings.

to me, that film and the doctor are using unmet social needs for information and support to push therapy that presents actual dangers. so that sucks.

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