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Thursday, August 7, 2003
Like millions of other women, Donna Packard
quit taking hormones after hearing that they increased her
risk for heart attacks and breast cancer. But three miserable
months later, Packard was back on them.
"Within a week, I was having hot flashes during the day and
waking up four or five times a night," said Packard, 56,
of Ivy, Va. "I was cross, and unpleasant, and disagreeable
and irritable. I kept saying, 'It's going to get better. It's
going to get better.' But it didn't. Finally, I just said,
'I'm not living the rest of my life this way.' "
Women across the country have had the same experience over
the past year, as they tried to wean themselves off estrogen
and progestin after a landmark federal study concluded that
the hormones' risks outweighed their benefits.
The findings of the Women's Health Initiative shocked doctors
and women, who had been using the hormones for decades -- not
only to alleviate hot flashes, moodiness and other symptoms
of menopause, but also to protect women's hearts. The study's
final results, published in today's issue of the New England
Journal of Medicine, confirm the preliminary findings: that
the hormones used in combination do not protect the heart,
and may increase the risk of a heart attack or stroke.
Hormone sales plummeted when the initial results were announced
last year as millions of women stopped taking the drugs. But
interviews with doctors, women's health advocates and experts,
and women around the country indicate that a significant minority
of those women suffered severe symptoms of menopause -- sometimes
more severe than before they started taking hormones -- when
they tried to stop.
"What's the definition of an addictive drug? It's
a drug that if you take it you feel good and if you don't take
it you feel
bad," said Deborah Grady, a professor of epidemiology
and medicine at the University of California at San Francisco. "I
don't think it's really the right terminology to use. I think
it's an inflammatory word. But there are some parallels."
There are no estimates of the number of women who have gone
back on hormones. But obstetrician-gynecologists around the
country report spending a significant part of their day counseling
women who want to resume hormone treatment.
Many doctors estimate that 10 percent to 25 percent of their
patients on hormones decided to keep using them or went back
on them, and some say it could be as high as 40 percent.
"It's without a doubt one of the most common problems
women are dealing with right now," said JoAnn V. Pinkerton,
director of the Women's Place Midlife Health Center at the
University of Virginia Health System in Charlottesville.
The phenomenon is putting doctors in a difficult position:
having to decide whether to allow women to take drugs that
increase their risk for serious diseases to alleviate menopause
symptoms that are annoying, perhaps even incapacitating, but
not life-threatening. Many express frustration because there
has been no research to guide them on how best to get women
off the hormones or whether lower doses are safer.
"I don't discourage or necessarily encourage women," said
Chasheryl Leslie of Premier OBGYN in Bowie. "It's something
that patients need to evaluate for themselves and make a personal
decision."
After several months of trying to live without hormones, Susan
Sentrulla, 56, of St. Peter's, Ind., chose to start taking
them again.
"It's wonderful. I feel like I'm back 20 years. I
am in such a good mood. I can sleep. I'm active," Sentrulla said. "You
know, I'll probably die at 65. But why would I want to live
dysfunctionally? It affects your marriage, your work. I really
think that if you need it, you need it."
Because the increased risk for heart attacks, stroke, blood
clots and breast cancer appears to be relatively low, many
doctors say they will put patients back on hormones as long
as they understand the risks, especially if they have no family
history of heart disease or breast cancer.
"I assess each patient individually," said Marilyn C. Jerome
of Foxhall OB-GYN Associates in Washington. "When I have
a patient who has some serious risk of cardiovascular disease
or breast cancer, I will encourage them to go off the hormones.
If I have somebody who really wants to be on hormones because
their symptoms are very bothersome, I don't discourage them
if they understand the risks."
Some women's health advocates worry that criticism of the Women's
Health Initiative may have created undue skepticism about the
risks, fueling a backlash.
"I've heard reports from some doctors at medical education
meetings that the presentations being given are putting out
a lot of
criticisms that are misleading," such as assertions that
the women in the study were too old or tended to be sick, said
Amy Allina of the National Women's Health Network.
Adriane Fugh-Berman, an assistant professor in the department
of physiology at Georgetown University School of Medicine,
said she is concerned that many obstetrician-gynecologists
are too inclined to prescribe hormones.
"OB-GYNs still think that hormones are good," Fugh-Berman
said. "If they are telling women that the Women's Health
Initiative was a very flawed trial and they shouldn't believe
it applies to them, that's very worrisome."
The additional analysis of the Women's Health Initiative being
published today found no evidence that hormones protected the
hearts of any subgroup of women, as some doctors and women
had hoped and speculated. Researchers are still evaluating
the effects of estrogen used alone.
"A lot of women held on to the belief that there was
still might be some benefit," said Marcia L. Stefanick of Stanford
University. "This is very clear: There is no benefit."
Many women's symptoms will subside with time, according to
Margery Gass, a professor of obstetrics and gynecology at the
University of Cincinnati and president of the North American
Menopause Society.
"I think it's important to talk to people about the
transitory nature of this phenomenon," Gass said. "They're not
generally permanent problems or chronic problems. Most of the
time those symptoms will resolve. It's more like a phase people
go through and they reach a new plateau of comfort."
But Gass, along with officials at the American College of Obstetricians
and Gynecologists and the Women's Health Initiative, said it
is reasonable for some women to take the hormones for relief
of menopausal symptoms if they understand the risks.
Federal health officials recommend that if women continue using
hormones to alleviate menopausal symptoms, they take the lowest
possible dosage for the shortest possible time. This assumes
they will have less risk, but there are no studies that prove
that.
Most doctors recommend women first try alternatives for hot
flashes, such as soy products and black cohosh. Antidepressants
such as Paxil also help some women with mood swings. Vaginal
gels can alleviate dryness.
If nothing works, doctors will typically put women back on
hormones, although they usually try prescribing much lower
doses.
Many doctors encourage women who want to go off the hormones
to wean themselves off slowly.
"In my experience, that seems to be a more effective
way to go," said Isaac Schiff of Massachusetts General Hospital
in Boston, who chairs the American College of Obstetricians
and Gynecologists' task force on hormone therapy.
Grady, however, tells women to try stopping all at once. If
they have problems, they can go back on and try skipping their
weekend pills. If that works, Grady then advises them to drop
the Friday pill and continue that pattern until they are down
to two or three doses a week.
"It can take six months to a year," she said.
Grady is conducting a survey to get a better sense of how many
women are going back on hormones. The Women's Health Initiative
is conducting follow-up research to determine what proportion
of women experience severe symptoms when they discontinue their
hormones, what they did about it and what method of stopping
works best.
In the meantime, women such as Sentrulla and Packard are happy
to be back on their hormones.
"It's sort of scary," said Packard. "But when I tried
to live without them I said to my husband, 'Honest to goodness,
I'd rather live 10 years less than live the rest of my life
like this.' It was just awful."
© 2003 The Washington
Post Company
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Menopause