The Other Side Of The Hormone Controversy

April issue 2009
Copyright © 2009. MORE Magazine.

Most experts say women should take hormones for only a few years after menopause, and only if their symptoms are severe. Now, in a new book, biologist Winnifred Cutler claims that HT is safe for long-term use and highly beneficial - as long as you do it right. Here, she makes her case...

By Stephanie Young, Contributing Health Editor

Page 146 - 152.

Could doctors have been wrong about hormones - again? In 2002, the authors of a large-scale study, the Women’s Health Initiative,  set off panicky newspaper headlines, by proclaiming that the risks incurred by women taking hormones outweighed the benefits. Many women and their doctors concluded that it was best to discontinue hormone therapy or use it only in the short-term if menopausal symptoms were unbearable. 

But that conclusion was wrong, insists biologist Winnifred Cutler, Ph.D. Like the study’s many other critics, she points out that the average age at enrollment in the WHI was 63; the study undersampled the younger women (ages 50-54), who, later analyses showed, may actually experience a lower risk of heart disease while on hormone therapy. Cutler also notes that women in the study who still had their uteruses (some had undergone hysterectomy) were given only one drug, Prempro, which combines conjugated equine estrogen (supplied by pregnant horses) and progestin (synthetic progesterone); other drugs composed of different ingredients, may not present such risks.

In addition to her examination of the WHI, Cutler spent five years analyzing data from many other international studies to parse out what’s really going on with HT. The controversial result, Hormones and Your Health: A Smart Woman’s Guideout next month, argues that hormones are not only good for you, it helps turn back the clock. Not every expert in her field agrees, but here she presents her reasoning.


Q: Tell us why you think hormones are so great.
A: Some are not! But combined with a healthy lifestyle, appropriately prescribed HT regimens can lengthen the span of your life, enhance your sexuality, build better bones, improve your posture, preserve your memory, help you sleep more soundly, sharpen your thinking and ability to learn, even out your moods, lower your odds of developing urinary tract infections, reduce your risk of Alzheimer’s and promote a healthier cardiovascular system.

Let’s consider heart health.  Among the 120,000 women followed for 20 years in The Nurse’s Health Study, hormone users were 40 percent less likely to develop heart disease or to die.  Or look at diabetes. A 2003 report from the HERS trial, conducted at 20 US clinical centers found that hormone users had a significantly lower risk of developing Type 2 diabetes. What’s more, hormones can make you look younger. Estradiol or estriol {variations of human estrogen} in a face cream significantly reduced crow’s feet in as little as six weeks in a University of Vienna Study and similar research conducted at Yale University School of Medicine.

With demonstrated benefits like these, why take HT for only a few years after menopause? That advice does not withstand my scrutiny.


Q: One argument for limiting hormone therapy to short-term use is that it has been shown to increase the risk of breast cancer, right?
A: It is dangerously wrong to throw all hormone regimens into the same category when discussing breast cancer. For instance, the multicenter Women’s Contraceptive and Reproductive Experience study, which started in 2002, examined breast cancer risk in relation to specific hormone regimens, and reported that taking continuous-combined HT -the Prempro type- for five or more years was the only routine that increased the risk of developing breast cancer. The danger increased the longer women used that form of drug. No other hormone regimen showed increased risk.

In addition, European studies often support the safety of hormones that are chemically identical to human estradiol and progesterone in regimens where estradiol is taken every day and progesterone is added during the last half of the month.


Q: But the Women’s Health Initiative study did find a connection between Prempro use and elevated breast cancer risk. In fact, the study was halted prematurely partly because it was feared that the women taking the hormone were increasing their risk.
Yes, but even in the WHI study, the risk of breast cancer on an individual basis was low.  In the WHI, of the 8,506 women taking Prempro, 166 cases of invasive breast cancer occurred; in the 8,102 assigned to placebo, 124 cases were detected, that is, 1.95 percent vs. 1.53 percent, or a difference of 0.42 percent. So 99 percent of women will not be at increased risk of breast cancer regardless of which hormones they take.

And remarkably, most studies show that postmenopausal women who develop breast cancer when they are on hormones are less likely to die from it than postmenopausal women who have breast cancer and are not on hormone therapy. This points to the complexity of the relationship between hormones and breast health.


Q:Cardiovascular risks like heart attacks were another reason that the WHI was halted prematurely. Can you shed some light on this?
A: WHI researchers tested the drug too late in the lives of women who already showed evidence of heart disease in the form of atherosclerotic plaques in their arteries.  However, if you’re in the early stages of atherogenesis some studies say that HT regimens may prevent or inhibit up to 70 percent of the progression of this disease.


Q: If the science shows that hormones are so beneficial, why do many doctors still seem leery of them? Why are we being told to take them in the lowest dose for the shortest possible time?
A: Many doctors understood the early termination of the WHI to mean categorically that the risks of taking combination hormone therapy outweighed the benefits.  Since then it has become clear that is simply not the case. In a sense, the WHI was helpful in disclosing that the drug it tested (Prempro) was more harmful than helpful to a group of older women who started hormone therapy years after experiencing menopause. However, this major study's findings about that one drug were then, erroneously, and unfortunately, applied across the board to all types of hormones and all women.

Suggesting that the best course of action for HRT is the “lowest dose for the shortest time” is a standard medical practice guideline; {Editor's note: This is the position of the Food and Drug Administration which regulates pharmaceuticals, as well as the North American Menopause Society }. That advice is designed to serve the needs of the medical establishment rather than the individual. It’s a recommendation that is generated to protect doctors from damaging costs of malpractice lawsuits. A doctor is relatively invulnerable to a lawsuit if his or her treatment follows practice guidelines, because they are the accepted standard of care.

Q: Given that other experts disagree, why should we believe your analysis of the various studies?
A: Well, I do favor skepticism! But my credentials are on the public record.  This is my eighth book on women’s health; I have also published two respected medical textbooks on hormones. As a scientist, I have the training to analyze scientific findings. My agenda is not influenced by malpractice fears nor have I ever received consultant fees, funding or stipends from any pharmaceutical company. Also, I am not employed by a university whose funding depends on the good will of a pharmaceutical company.


Q: So what would you recommend to women who are interested in hormone therapy?
A: Bearing in mind that new studies keep refining our understanding and that women taking hormones tend to live longer, I favor daily use of an estrogen, 17 beta estradiol, generally through a non-oral route (like a patch, suppository, cream or lozenge). This would be coupled for about 12 days in a row each month, with progesterone, not synthetic progestins. The progesterone would be taken in a non-cream form - via a pill that is swallowed or absorbed under the tongue.


Q: What if you or your doctor panicked about the news coming from the WHI, and you stopped taking hormones? Can you get back on then and still reap some of these life-enhancing benefits?
That is something you should decide with your doctor; I always encourage a respectful patient - physician partnership. You would need some careful monitoring during the first few months to make sure markers associated with increased cardiovascular risk (such as triglyercide and c-reactive protein levels in your blood) or breast cancer (increased density) do not occur. Hormone therapy cannot erase any existing damage, such as blood vessel blockage due to the plaques from atherosclerosis.

In your time off from hormones, if your health status has changed—you’ve become overweight, for example—some or all types of hormone therapy may no longer be appropriate. Being overweight is not good for your health, and in conjunction with hormones it may slightly raise your risk of stroke. But certainly, if you can follow a good hormonal regimen, then other body systems, such as your bones, will benefit.


Q: Hormones may be anti-agers, but they’re not a panacea. How else do you advise women do to stay healthy?
A: Hormones work best in conjunction with a healthy lifestyle: regular exercise, a diet rich in low-fat dairy, fruits, vegetables and whole grains, stress management. I also favor a rich spiritual life. Replace fear of hormones with knowledge--and enjoy the best years of your life!

 Read More on this topic from Dr. Cutler's book, Hormones and Your Health (click here).


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