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Reprinted from the Miami Herald article

FOR WOMEN, WHAT NOW!

Millions who take hormones face a tough choice; Increase health risks, face pain of menopause, or try untested alternatives.
Janis Young’s first instinct after a large, national study of hormone-replacement therapy came to an abrupt halt last week was to flush her pills down the toilet.
Her second instinct; Call my doctor.
The bombshell by the Women's Health Initiative, the largest study to date of hormone-replacement therapy. Threw Young and six million women into a quandary; should they cease taking their estrogen/progestin pills and endure hot flashes, thinning bones and mood swings or increase their risk of breast cancer, blood clots and stroke.
“It’s a very complex issue,” said dr. Paul Gluck, an obstetrician/gynecologist at Baptist hospital. “You can’t read a headline and say, ‘Yes, Imam at an increased risk so I should throw this poison pills out. The benefits still on balance for most women outweigh any risks.”
Physicians have been inundated with calls from women trying to determine what to do. And why some suggest alternative therapies such as acupuncture, herbal supplements and antidepressants, non of these have been put through the kind of long-term scrutiny given hormone-replacement therapy (HRT).
While the study, which involved 16,608 healthy women, advises against using estrogen and progestin supplements for the long term, many doctors recommend patients talk to them before deciding.
Young, 47, is following that advice. The Miami art teacher decided to continue with the therapy until she could reach her doctor. She is not eager to return to the mood swings and sleepless nights she experienced before starting the hormone therapy.
“My quality of life on hormone replacement has improved so much that I don’t want to jump out without preparation or speaking to my doctor,” Young said. “I don;t want to be irrational about the whole thing.”
Rationality also guides many physicians’’ interpretation of the statistics behind the researchers’ decision.
The study projected that out of every 10,000 post menopausal women ages 50 to 79 who take estrogen/progestin pills, eight more would have breast cancer, seven more would have a heart attack, eight more would have a stroke, and eighteen more would have blood clots. On the plus side, there would be five fewer hip fractures and six fewer cases of colorectal cancer. The National Institutes of Health had concluded in the 1980s that estrogen reduces bone loss and fractures in post menopausal women.

BENEFITS VS. RISKS

In stopping the study, the researches said that the benefits in terms of bone health and colorectal cancer did not outweigh the risks.
To many physicians, the news came as little surprise Hormones have long been implicated in an increased risk of breast cancer and blot clots. Estrogen alone, can cause uterine cancer, although the addition of progestin mitigates that.
But some physicians find the numbers less than persuasive when they take a close look.
“It’s a little bit of an Arthur Anderson problem. You can massage the statistics and I think it was a bit of a knee-jerk reaction,” Dr. Arthur Shiparo, a professor of endocrinology at the University of Miami School of Medicine.
Because this study looked at a specific combination with a specific kind of progesterone, some doctors question whether the culprit here is not hormone-replacement therapy in general but this particular mixture.
“It’s not as if the FDA has issued a warning,” said Gluck of Baptist. “The reason that the FDA has not done that is that the whole story is not in. If the FDA says there’s a problem with these drugs, that’s big time.”
Still, it’s a complicated call and some women believe that doctors have long been too supportive of the hormone supplements. Marilyn Gardner, a Miami resident who gives her age as “60-plus,” has seen four gynecologists over the years, each of whom recommended hormone-replacement therapy. Each time she refused politely.
“I had done a lot of research, and didn’t like what I was reading,” she said. “I think more women should stand up and realize it’s their bodies and their lives and they have a perfect right to wonder.”

ALTERNATIVE ROUTES

Other women peruse health-food stores for supplements like black cohosh, dong quai, and phytoestrogens, or turn to nontraditional practices for aid.
Barbie Levine, 50, has undergone periodic acupuncture treatments for the past twelve years, since she started experiencing early menopause symptoms. With a family history of cancer, Levine knew hormone replacement was out. So the Miami Beach massage therapist tried acupuncture.
“I truly believe that acupuncture is what’s keeping me going,” said Levine, who said last week’s announcement strengthened her support of the eastern medicine. A few years ago when Levine felt her heart racing - another symptom of early or perimenopause - one acupuncture treatment restored her normal rhythm.
Acupuncture is based on the theory that blocked energy sources in the body lead to imbalance and the uncomfortable symptoms. Miami Beach acupuncturist Sachi says that in many instances one treatment will help restore the flow of energy and end hot flashes.
“I can’t say that it works 100% for every woman all the time, but neither does hormone-replacement therapy, because each of us is unique,” Sachi said.
Other women prefer to pursue a natural therapy more akin to traditional HRT> Biscay Park resident Mary Cochrane was on HRT but the early reports of increased breast cancer risk concerned her. She asked her doctor about natural alternatives. He gave her a prescription and pointed her to Ramon Moreno, a compounding pharmacist in Hialeah.
Mereno mixes estrogen and progesterone derived from yams or soy to make a pill to match each women’s hormonal levels. Moreno says about 65% of his business at Universal Arts Compounding Pharmacy focuses on this, called bioidentical hormone replacement therapy. Running between $45 and $65 a month, this treatment is more expensive than standard therapy, but also more natural, Moreno says.
“This is something that your body recognizes as being not foreign, It’s something that your body can detoxify in a more efficient way and still get relief from hot flashes,” he said. “This is like going to a tailor and having a dress made to fit you like a glove.”

‘BETTER OPTIONS’

for Cochrane, a nurse, it’s worth the extra cost. “I do feel secure that this is a better option,” she said.
Few of these alternative treatments, however, have the scientific evidence to back them up, rendering many doctors reluctant to endorse them. Many natural alternatives have performed no better than placebos on what few studies have occurred.
“I think that I would caution women to be careful,” said doctor Wulf Utian, executive director of the North American Menopause Society. Basically what these women are doing is just experimenting on themselves because there’s no monitoring and no real study of the safety and efficacy of this.”
The American College of Obstetricians and Gynecologists and the North American Menopause Society, two professional associations for doctors who treat menopause, have each formed a task force to determine new practice guidelines.
To provide solid data on one herbal pill that purports to treat menopause symptoms. University of Miami researchers are conducting a trial of a supplement whose primary ingredients are black cohosh, kava kava and isoflavones. Thus far, the study has excepted 30 women. Eventually, the investigators hope to enroll about 175 but they will allow as many as 250 to join. To participate in the placebo controlled study, women must not have taken traditional hormone-replacement therapy for at least three months.

‘ A LITTLE UNFAIR’

“I think this makes women more open to alternative treatment for menopause,” said Arlette Perry, a clinical physiologist at UM’s School of Education and the principle investigator. “Quite frankly, the primary treatment for menopause is and always has been hormones. It’s a little unfair to only give women one option.”
For now, however, Susan Fix, a real estate agent in South Miami, is not making any drastic decisions. A few months ago, Fix, 56, started on the medication at the urging of her doctor, who offered an impressive list of reasons to take the therapy. She’s decided she’ll stay on the drug until she sees her doctor.
That strategy sits well with doctor Wayne Whitted, director of gynecology at the University of Miami School of Medicine, who recommends to every worried caller and e-mailer that they consult him in person.
Said Whitted; “You can’t make life-altering decisions over the telephone.”

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