As a women's health care nurse practitioner of many years, prescribing and balancing hormones "came with the job;" it was natural and needed and I loved it. I still remember the fateful day I was bombarded with phone calls from my patients asking me if I had "heard the news;" the news about how horrible hormones are and how they cause heart attacks and death? It appears that "breaking news" was about a large clinical trial on Premarin (a synthetic estrogen) and Provera (a synthetic progestin). That was in 2002 and the trial was called the WHI (Women's Health Initiative). We are still trying to recover from that improper, extrapolated information.
It is my duty to understand the complexity of these clinical trials that I may filter it in a manner acceptable to my patients so they can make informed decisions. You see, many of these patients I consider my friends and all of them I treat like my sister or mother.
World-wide there are close to five decades of trials, reports and observations on hormones, many of which are bio-identical (meaning exactly identical to the female body) hormones of which this large clinical trial was not. The guidelines regarding hormone replacement therapy were driven by findings from a number of research studies like the Nurses Health Study, a 20-year study of 120,000 women. It found that HRT use was associated with significant reductions in cardiac events, as well as cardiovascular and total mortality. There's the PEPI trial in 1990 with 875 postmenopausal women proved the safety and efficacy of natural progesterone combined with estrogen for the best cardiovascular protection. Other health benefits from this trial were less weight gain with women taking hormones after menopause, an increase in the HDL (good cholesterol) and protection against endometrial cancer. Later studies with natural estradiol and natural progesterone have shown protection against cardiovascular disease, osteoporosis, Alzheimer's disease, urinary and genital aging, colon cancer, endometrial cancer and high cholesterol. Also, it helps to prevent depression, fatigue, incontinence, weight gain and the loss of feminity.
The Journal of Internal Medicine in 2004 published findings from researching 30 trials involving hormone replacement therapy. Within those 30 studies was the WHI trial and still concluded that the benefits of HRT outweigh the risks if treatment is begun in younger menopausal women (2-10 years of menopause) who do not have coronary heart disease or breast cancer. The report found that initiating HRT in younger postmenopausal women actually resulted in a 39 percent reduction in death!
World-wide research also reports estrogen has protective properties against cardiovascular disease in premenopausal women, and that the risk for atherosclerosis begins to rise as estrogen levels decline after menopause. Substantial evidence supports the use of hormone replacement therapy for primary prevention of atherosclerosis in women, but only if started during the early postmenopausal period and before the onset of atherosclerosis. Once atherosclerosis has already developed, however, HRT has no effect at reversing the process and may actually promote heart attack or stroke. This largely explains the different outcomes from the Women's Health Initiative compared to other studies. The average age of women in the WHI was 62 (and many already had heart disease); that is an average of 12 years beyond the onset of menopause.
What about an increase in cancer risk with hormone replacement therapy? Provera (synthetic progestin) appears to be the culprit regarding breast cancer risk, not estrogen. It should be noted that the WHI found no increase in breast cancer deaths or total cancer deaths in either trial. Other recent trials, the NHANES and USC study, did not find any evidence of an increased risk for breast cancer.
The conclusion from this and previous studies is that the synthetic progestin used in the HRT trial of the WHI increases a woman's risk for breast cancer.
When I ask my patients what they are most afraid of when it comes to diseases that they may suffer from, they say ... breast cancer. The truth is most American women will be afflicted by or die from heart disease. Then there is osteoporosis, a progressive bone disease, of which 40 percent will be affected by and ultimately die of. Estradiol (one of the natural estrogens found in the female body) is the No. 1 protectant of bone loss and cardiovascular disease and natural progesterone is one of the most protectants against breast cancer in my opinion and from world-wide studies.
As a health care provider I am compelled to look at the evidence both old and new. I am at the front line and desire to share the truth with women so that they become a partner in their health decisions for long-term disease prevention.
Patricia Faust, NP, is owner of Affinity Gyn Inc. in Tempe. Reach her at (480) 388-3666 or visit www.affinitygyn.com.