February 1, 2009
MY TAKE ON OPRAH AND THE HRT DEBATE
 The public have followed Oprah through the many phases of her life - the ups and downs, the weight losses and the weight gains - and now we are witness to the turmoil she is facing as she passes through another crisis: mid-life and menopause. The hot spot in this crisis appears to involve the question of whether she, or any of the millions of baby-boomer women, should use hormone replacement therapy (HRT) to help offset the troubles that menopause brings. Please allow me to provide my strong opinion on this subject.
First of all, it is not easy "getting into" the life of the fertile female. Remember how difficult life was when you first got your period? Do you remember those tumultuous years? Have you ever lived in the house with a teenage girl as she is passing into the lifecyle of the fertile female? It is rough, to say the least. But in the end it is very worthwhile. After the hormonal storms have passed a young fertile woman is born.
It is rough getting into the fertile lifecycle, and (no surprise) it is rough getting out of it. And it takes about as long to get out as it did to get in - several years. Personally, I think it is a very worthwhile life on the other side of fertility, a gloriously less-complicated life for the wise woman.
The advantages of getting out of it the life cycle of the fertile female is that once you have reached your new non-fertile "steady state" there are no further cyclical waves to endure, no further hormonal swings and arrows. After the post-menopausal storms have passed, the seas are quiet and the sailing much smoother.
Taking estrogen, or estrogen and progesterone, after your ovaries have shut down and no longer make these hormones is referred to as "hormone replacement therapy" - HRT. It is replacement because there is a loss of hormones (estrogen and progesterone) that is "replaced" by the ingestion of these substances - either synthetic or naturally made. HRT is dangerous business. Even though some of the symptoms of menopause may be relieved by HRT, a woman who uses HRT puts herself at risk, a specifically unknown but generally documented increased risk for cancer and stroke and blood clots. HRT is a dangerous business for many reasons, but before I get to that, let me first define and describe exactly what a hormone is and what it does. Neither of these important distinctions was made in any of the material offered by Oprah in her recent, sensational discussion on the use of HRT. I think it is always helpful to define the terms before you discuss the concepts that relate to them. So, let's begin at the beginning and define and describe them, and then take it from there.
A hormone is a substance that is made in the cells of one tissue in the body, like the ovaries, and then released into the general circulation. The hormone circulates until it finds its "receptor" - a kind of "lock" that sits on the surface of other cells in the body. The hormone is like a "key" and the mechanism of a lock-and-key works nicely to describe what the hormone does. It circulates until it finds its "lock" and then it open's the lock, enters the cell, moves into the central command center of the cell and delivers a message: DO THIS...... In the case of the hormone, estrogen, made by the ovaries (and also in fat cells and in the adrenal glands) the message DO THIS specifically causes breast cells to grow and divide, it causes cells in the uterus to grow and divide, and it cause a whole host of other changes in many other cells and tissues in the body. (It makes blood clot more quickly, which is useful when a woman is in a "bleeding" state, like menstruation and when delivering a baby - but less useful when she is not.)
When you are young and healthy, the hormone messages that cause growth make sense. When you are older, when your biologic clock has moved toward the "evening hours," when fertility and child-bearing are no longer on the "menu," the estrogen message to breast cells that trigger them to grow and divide is hazardous to your health.
You do not want breast cells, especially those older breast cells that have been exposed to many years of accumulating carcinogens from the environment, to "grow or divide" when the rest of your body is winding down it's work as a reproductive factory. This is one of the reasons that estrogen is particularly hazardous in older women - it pushes abnormal cells over the edge and accelerates change to cancer formation. Multiple studies have shown that women who use HRT have an increased risk of breast cancer. If they use HRT that contains only estrogen, they have an increased risk of uterine cancer. There are no studies that show that using hormones of any kind is not associated with an increased risk of some form of cancer, or other problems. Keep in mind, your entire body is closing down the fertility factory as you pass through menopause, and some parts of your body are getting older no matter what you do. Using HRT pushes cells to do things that are really unnatural, given the rest of the aging process underway all around them.
To summarize:
- HRT is associated with either an increased risk of breast cancer (if it contains progestin) or an increased risk of endometrial cancer (if it does not).
- HRT is associated with an increased risk of stroke.
- HRT is associated with an increased risk of blood clots.
- HRT does not protect against Alzheimer's disease.
- HRT does not protect against heart disease.
Now, here is some good, if not easy, news:
- There are other ways to offset the troubling symptoms of menopause. Diet and exercise are the two most beneficial. And since the symptoms of menopause tend to eventually pass, they do not last forever, it seems imprudent to exchange a reduction in menopausal symptoms for an increased risk of cancer and stroke.
I cannot support the use of HRT for women. I appreciate the difficulties associated with the change of life, but I cannot condone the use of HRT because I do not think the increased risks of cancer and stroke are worth the benefits. I am willing to take a stand on this. I am prepared to be wrong about this in the future: but I do not think I am wrong about this now. Given the preponderance of the accumulated data collected from thousands of women, I think HRT is hazardous to your health.
When, just a few years ago, a study showed unequivocal evidence that HRT increased the risk of breast cancer, millions of women stopped taking the pills. A few years later the incidence of breast cancer, for the first time in decades, began to decrease. Most investigators believe that the reduced use of HRT explains the reduction in new cases of breast cancer.
In 2005, the World Health Organization declared that, after a thorough review of the world's literature by a host of international experts, exogenous hormones, in the form of birth control pills and HRT were Group I carcinogens: known to cause cancer in humans. Lead, benzene and HRT - all grouped together. The 2005 WHO report is little known in the USA. More women should be made aware of this report and should examine the report themselves. It is available on the WHO website.
I AM VERY CONCERNED THAT OPRAH'S TAKE ON HRT WILL INCREASE THE NEW CASES OF BREAST CANCER AGAIN, AS WOMEN RETURN TO HRT BECAUSE OPRAH THINKS THEY MIGHT BE USEFUL "FOR SOME WOMEN - CONSULT YOUR DOCTOR."
When the advice is, invariably, "Ask your doctor" this is just a way to punt the problem back into the patient's lap, for her to bring to her doctor. In my humble opinion this advice doesn't really help women make the informed decision. They want advice: my advice is this = don't use HRT.
As a doctor, as a breast cancer surgeon, as a woman who has successfully passed through menopause into a new, post-fertile steady-state — this is what I tell my patients: avoid HRT. Find other ways to deal with the symptoms. They won't last forever. You will get through it. You will be glad you did. The post-fertile steady state is a fine, calm place to be - even if it takes a few years to get there.
And, by the way, if you choose to take HRT and you get a breast or uterine cancer, or have a stroke, or get a blood clot, you will be stopping HRT anyway: why not avoid it altogether. If you get a breast cancer, or have a stroke, at least you won't feel guilty, you won't wonder whether you gave yourself a cancer that you could have avoided.
This is my opinion. I know it is a strongly worded opinion, and I know it differs from others. But, nevertheless, it is my considered opinion - as a breast surgeon and as a post-menopausal female who would like other women to be as healthy as possible, in as natural a way as possible, free of regrets and remorse down the road. I have had too many patients on HRT who have developed breast cancer and they will never know if they gave it to themselves or not. Don't go there. It is not a peaceful place to be.
Regards,
Kathleen T. Ruddy, MD
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