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Read "The Estrogen Dilemma" With Caution

Posted Apr 16 2010 5:27am
There is a piece in the New York Times called " The Estrogen Dilemma " which many women will read with great interest. I would urge women to read this with great caution before jumping to any conclusions.
The article is a well written piece by journalist Cynthia Gorney, who discusses both the controversy of hormone replacement and possible benefit with memory and mood, simultaneously with her own personal medical history. I would imagine many women readers will identify with both Ms. Gorney's depression (since it is so common) and her struggle with the decision whether or not to stay on hormone replacement (since there is so much confusion around the issue).
The article pokes many holes in the landmark Women's Health Initiative (WHI). Prior to this study, many physicians, myself included, were prescribing hormone replacement to perimenopausal and post-menopausal women like candy. We did this because the data on the purported benefits seemed robust, and the data on risks seemed minimal. The WHI proved that making routine decisions without large, randomized clinical trials was not necessarily a good idea. The WHI showed that, at least in the population studied, the risks of hormone replacement (breast cancer) outweighed the benefits (heart attacks turned out to be a risk not a benefit). More importantly, many doctors stopped prescribing hormone replacement because alternatives to protect against heart attacks (statins, aspirin) and osteoporosis (bisphosphonates, calcium, vitamin D) existed and didn't carry the same risks. However, this doesn't mean that the risks/benefit ratio for hormone replacement applies to every women equally. Women who suffer from severe symptoms of menopause, especially with a low risk of breast cancer, would certainly have a risk/benefit ratio favoring hormone replacement.
Gorney's article suggests that perimenopausal mood issues such as depression, memory/attention, as well as prevention of Alzheimer's disease can all be linked to estrogen deficiency, and estrogen replacement just might be the solution. These facts coupled with very real holes in the WHI data regarding women in their late 40's and early 50's (who weren't in the study), suggests that hormone replacement may in fact be just what many women need.
However, the key is the lack of data. Though studies are underway, we do not know whether or not estrogen can help with perimenopausal mood disorders, or even if it does, whether it is any better than other treatment such as anti-depressants. In addition, though there is reason to believe that the dangers found in women in the WHI might not apply to younger women, we do not have data to prove that it is safe. Absence of evidence is not the same thing as evidence of absence (harm).

Bottom Line: Medicine has to be individualized. Every therapy and test, including screening tests like PSA's and mammograms, have risks and benefits. Balancing those risks and benefits is important, and is not the same for every patient. Age, individual risk for disease, personal preference, and symptoms are all important factors. Estrogen may have an important role in mood disorders and memory for women, and may be safe if started in the late 40's and early 50's, but we simply don't know for sure. Estrogen, especially when given with progesterone is definitely linked to breast cancer, and given later in life, increases the risk for heart attacks. If you are a perimenopausal women that identifies with Ms. Gorney, and you think that estrogen replacement may be the miracle cure you are looking for, proceed with caution. Weigh all the available data, risks and benefits before jumping to conclusions from a very well written and emotionally impactful article. Your physician can be very helpful in guiding this decision.
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