How menopausal hormone therapy saves lives
Written by Java Tunson, MD
When the largest study of women’s health in the United States, the Women’s Health Initiative (WHI), falsely announced at a press release that hormone replacement therapy (HRT) caused breast cancer in 2002, one of the most damaging misreporting of data in history had been unleashed leading to the unraveling of a generation of womens’ health. After the announcement, seemingly from one day to the next, women stopped HRT, physicians stopped prescribing it and what little existed in the medical curriculum was wiped away. An entire article about the specific missteps of the announcement, including the irresponsibility of the press for propagating it without confirming the data could follow but it boils down to a few key points:
First, the announced finding was not statistically significant, meaning, it was not significant enough to prove that the findings could not just have been due to chance. The study reported the relative risk as being a 25% increase in breast cancer in the group receiving HRT, which sounds incredibly high but is the wrong number to focus on. The absolute risk, the number that should have been focused on, was this: the women who were in the placebo group (not receiving estrogen) had a breast cancer risk of 4/1000 and the women in the estrogen + medroxyprogesterone acetate (MPA, a synthetic progestin) group was 5/1000. Which means that the absolute increased risk was 0.1%. Moreover, there were zero, increased deaths from breast cancer in the HRT group.
Second, the study arm that received only estrogen (because this group had hysterectomies and did not require progesterone to protect their uterine lining from increased growth) did not have increased risk of breast cancer. It was the arm who received MPA that had the non-statistically significant increased risk of breast cancer. This would make it more likely that MPA (which is rarely used anymore and has most commonly been replaced with a bioidentical micronized progestin) would have been the culprit if there were a significant increase, which there wasn’t. The message here is not to fear progestins. The message is that the logic in their announcement was flawed.
Third, the average age of the participants were more than a decade from menopause. Though not completely contraindicated, there is data to support the safety and increased benefit of starting HRT closer to the beginning of menopause and within the first 10 years after menopause rather than later. The trial was already biased towards complications in their study population.
Ultimately, in an announcement about the 0.1% possible risk of increased breast cancer from HRT that was not statistically significant and demonstrated no increased deaths from breast cancer, HRT nearly disappeared; a treatment that dramatically improves quality of life, decreases the risk of colon cancer, the risk of cognitive decline and Alzheimer’s disease, decreases insulin resistance which leads to diabetes, decreases heart attack risk and significantly decreases the risk of broken hips. As a single example, the lethality of hip fractures alone is grossly under-appreciated as 25% of people above 65 years of age will die within a year of their hip fracture. Compounding all of the aforementioned benefits of HRT including decreased mortality even if HRT had a small increased risk of breast cancer cases the benefit of HRT would eclipse it.
The decision to use HRT, when to use it and in what formulation is highly individualized. Women in remission from certain types of breast cancer are not excluded from using HRT for (peri)menopausal symptoms but the decision and management should be done with the guidance of their oncologist. There are certainly people in whom HRT is contraindicated and the risks will outweigh the benefit. The crisis is that there is a dearth of accessible providers that can have informed, accurate, evidence based and nuanced discussions with their patients about HRT as a result of the WHI. Today, only 20% of OBGYN residencies provide any menopausal training and even fewer physicians of different specialties know how to or feel comfortable managing (peri)menopausal hormone therapy. It is generally not covered in the residency curriculum much less the medical school curriculum. The undoing of one misguided announcement 23 years ago is moving at a glacial pace but it feels the energy of a movement towards informed comprehensive (peri)menopausal care is building and it is being fueled by women demanding better.
“The undoing of one misguided announcement 23 years ago is moving at a glacial pace but it feels the energy of a movement towards informed comprehensive (peri)menopausal care is building and it is being fueled by women demanding better.”
This demand includes physicians and providers to be educated and certified in evidence based (peri)menopausal care and for more high quality resources for self -education and supportive communities surrounding the (peri)menopause experience. If you are a practitioner interested in learning about and becoming certified in hormone therapy, The Menopause Society is a strong resource. For patients, the same site can help you to find practitioners who are certified in (peri)menopausal care by zip code. Many more incredible resources are rising up to address this incredible disparity in womens’ health and the pendulum is swinging back.
If this speaks to you and are looking for a physician educated in (peri)menopausal care to discuss your experience in a one-time consultation or help formulate a personalized care plan through a more comprehensive program, I’d love to work with you.
In the meantime, live vividly.
Java Tunson, MD
