Ralph W. Moss, Ph.D. Weekly CancerDecisions.com
Newsletter #35 05/07/02
Hormone Replacement Therapy
When my wife entered menopause a few years ago she
went to a prominent New York gynecologist for
help. This doctor, until then sympathetic to
alternative ideas, suddenly became a hard-liner.
She dismissed alternative treatments with the wave
of her hand, demanding proof of their safety and
effectiveness. She insisted that my wife
immediately begin hormone replacement therapy
(HRT). She showed scary pictures of a woman with a
"widow's hump" and predicted this would happen to
my wife if she didn't follow her advice. When my
wife asked about the increased risk of endometrial
cancer with estrogen, she replied, "Cancer, that's
nothing. We can cure cancer. Heart disease is what
will kill you."
She also claimed that any health risks of estrogen
drugs, such as Premarin, were counteracted by the
inclusion of another hormone, progesterone, in
modern formulas. The health benefits of HRT, she
said, went way beyond the relief of hot flashes
and night sweats. They included the prevention of
broken bones, strokes, urinary incontinence,
severe depression, Alzheimer's disease and even
heart attacks. This persistent gynecologist
wouldn't let my wife leave the office without a
paper bag full of cheerfully colored samples and a
prescription for more pills.
This sort of high-pressure salesmanship could not
have hit us at a more vulnerable moment. My wife
was suffering with alternating hot flashes and
chills. (I got my exercise opening and closing
windows.) She had night sweats and insomnia, which
left us both tossing and turning all night. Over
on the dresser were the candy-colored pills that
promised to take all her troubles away. Despite
her suffering, she decided against taking them and
in fact threw them away when we moved last year.
Something in her gynecologist's frenetic manner
gave us pause. When unconventional practitioners
promise to cure multiple diseases with a single
pill they are called "snake oil salesmen." When
they offer medicines made from urine, they are
hooted out of town. But when conventional doctors
tout the multiple wonders of pregnant mares' urine
(how do you think Pre-mar-in got its name?), well,
that's just "scientific medicine."
Or is it? Lately, HRT has fallen on hard times. An
international panel of experts last month
concluded that rigorous clinical trials provided
no evidence that estrogen could prevent or treat
urinary incontinence, major depression, or memory
loss in Alzheimer's disease. And although it may
prevent bone loss there is no proof that it
actually prevents fractures.
It's no secret that estrogen, without
progesterone, significantly increases the risks of
uterine cancer. But it turns out that HRT also
increases the risk of breast cancer by 30 to 60
percent in those who take it for more than five
years. And, as an article in the Journal of the
American Medical Association recently made clear,
getting off HRT may not be easy. Sometimes women
suffer terrible hot flashes when they try to quit.
They have only delayed, but not overcome, their
HRT also increases the risk of uterine bleeding
and breast soreness. It causes a 40 percent
increase in the incidence of gallbladder disease,
a disease that already affects one in ten
Americans and is particularly prevalent in older
women. And remember the gynecologist's claim that
HRT prevents heart disease? In fact, it triples
the risk of blood clots, especially in women who
have preexisting cardiac problems. Three studies
have suggested that HRT increases women's risk of
heart attacks and strokes.
The New York Times, which has been a staunch
defender of the medical status quo, has changed
its tune. In a recent editorial, it called the use
of HRT "questionable," a word it once reserved for
alternative medicine. This follows the Times'
recent conclusion that the data supporting
mammography are similarly flawed. Welcome to the
What to substitute for HRT is unclear. My wife
used sage tea, evening primrose oil, and natural
progesterone cream, all of which she found very
Many women use soy protein, although it may not
reduce the severity of hot flashes. In a recent
clinical trial among postmenopausal women with a
history of breast cancer (who therefore could not
use HRT), there was no significant difference
between soy protein and a placebo in the number
and severity of hot flashes. Both groups got some
benefit, probably because of a strong placebo
effect. Mild gastrointestinal side effects
occurred more frequently with soy.
Articles in alternative medicine magazines claim
that the herb black cohosh, in formulas such as
Remifemin, is a safe and effective treatment for
menopausal symptoms. Perhaps it is. German doctors
gave my wife samples of Remifemin the way American
doctors pushed HRT. But I cannot find any clinical
trials to support such usage. Black cohosh and
some other "women's herbs" contain plant forms of
estrogen (phytoestrogens). As Fredi Kronenberg,
PhD, of Columbia University has said, "It is
unclear whether these herbs are safe for women at
risk for breast cancer or its recurrence."
Many women rely on natural progesterone cream.
This is advocated by Dr. John R. Lee in his book,
"What Your Doctor May Not Tell You About
Menopause." Medical opinion on natural
progesterone is sharply divided, but it has not
been rigorously studied. Dr. Lee has been
criticized for advocating an "unproven method" and
doctors have been warned of legal consequences if
they follow his example:
"We would ...caution clinicians against the use of
such products as alternatives to HRT for any
current or future indication," two British doctors
wrote in The Lancet. "The real danger is that
patients may be denied active treatment to prevent
the long-term diseases associated with the
menopause by the inappropriate substitution of
compounds with unproven efficacy. Such patients
who subsequently develop these diseases would
rightly have access to legal redress against the
This ominous pronouncement would give any
doctor pause. However, today the boundary between
"proven" and "unproven" treatments has blurred.
Talking not of alternative treatments but of
orthodox HRT, a doctor at Massachusetts General
Hospital told the Times:
"What is sad is, here's a drug [HRT] that's been
around for so many years, and we know so
relatively little about it. It was used and
introduced without really being studied in a
rigorous scientific way. We're learning as we go
along. We really suffer from a lack of
information, a lack of good science."
"Learning as we go"...Why didn't they tell us this
before? We, the consumers, are supposed to be
docile guinea pigs in a vast but uncontrolled
experiment with powerful hormones. That's quite a
commentary on "scientific medicine."
---Ralph W. Moss, Ph.D.
Grady, Denise. Weighing Risks and Benefits of
Hormone Therapy. New York Times, April 30, 2002.
Grady D. A 60-year-old woman trying to discontinue
hormone replacement therapy. JAMA 2002 Apr
Lee JR. Is natural progesterone the missing link
in osteoporosis prevention and treatment? Med
McKenna DJ et al. Black cohosh: efficacy, safety,
and use in clinical and preclinical applications.
Altern Ther Health Med 2001;7:93-100.
New York Times [editorial], Rethinking Hormone
Therapies. April 28, 2002.
Stevenson JC and Purdie DW. Use of Pro-Gest cream
in postmenopausal women. Lancet 1998;352:905-6.
Van Patten CL et al. Effect of soy phytoestrogens
on hot flashes in postmenopausal women with breast
cancer: a randomized, controlled clinical trial.
J Clin Oncol 2002;20:1449-55.
Wade C, et al. Hormone-modulating herbs:
implications for women's health. J Am Med Womens
The news and other items in this newsletter are
intended for informational purposes only. Nothing in
this newsletter is intended to be a substitute for
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