Saturday, October 27, 2012

Hormone replacement - will it kill you or make you healthier? What the reports aren't telling you about HRT

"Hormone Therapy Whiplash: Say No to HRT! Say Yes to HRT! Which Is It?"

That's the headline of an article by Melanie Haiken on today's Forbes website. Haiken is  frustrated by conflicting recommendations about hormone replacement based on European and American medical studies.

In the new European study, women began using hormone replacement therapy at about the time of menopause and lowered their likelihood of getting a number of dread diseases. Take HRT, say European doctors.

In the 10-year-old American study, women began taking hormones some ten years after menopause and raised their chances of succumbing to heart disease, breast cancer, blood clots, gall bladder dysfunction, dementia ... well, you get the picture. Don't take HRT, say American doctors.

Aha! say some experts, examining both studies. Timing makes all the difference. Take those pills when you're relatively young. Don't wait until you're over 60 to start them. "If you’re within a five to ten-year window of menopause," Haiken concludes, think carefully about your own circumstances and then "see your doctor for a frank discussion."

Well okay. But somehow I'm still confused. Or would be, if I hadn't noticed something else about the studies.

Unfortunately, Haiken and Hwang - along with just about everybody else discussing conflicting studies on HRT - pay no attention to what may turn out to be the most important difference between the two studies: they used different types of estrogen. 

Participants in the American study took Prempro (a tablet containing conjugated estrogens made from horse urine along with a progestin) or Premarin (just the conjugated estrogens).

Participants in the European study took estradiol (a synthetic form of the principal and most potent human estrogen) plus a progestin if they still had a uterus.

The conjugated estrogen group had bad results. The estradiol group had good results.

Now, I'm not saying that the difference in formula is the reason for the difference in results. It may indeed have more to do with timing, or with some other element in the study. I'm just saying that I can't imagine how responsible scientists and journalists could ignore the fact that these studies were looking at different medications. All estrogens are not alike.

What happens to younger women who take Prempro? Or to women who wait until they're 60 and then start taking estradiol? We don't know, because those questions haven't been addressed.

And why haven't they been addressed? I'm not into conspiracy theories, but I do think that "follow the money" can be good advice. Prempro and its sister medication, Premarin (conjugated estrogens without a progestin), are among the top selling medications in the United States. Estradiol, by contrast, is available in a generic version.

I checked prices at my online pharmacy, Prime Mail, and here's what I found.
  • A 30-day supply of Prempro (0.625mg conjugated estrogens plus 2.5mg medroxyprogesterone acetate) costs $94.34.
  • By contrast, a 30-day supply of estradiol (1.0mg) plus generic micronized progesterone (100mg a day for 10 days) costs $23.91.
  • For women who have had hysterectomies, the progestin/progesterone is unnecessary. A 30-day supply of Premarin (0.625 conjugated estrogens) costs $74.74.
  • By contrast, a 30-day supply of estradiol (1.0mg) costs $4.96.
For some reason American doctors don't prescribe estradiol nearly as often as they prescribe Prempro and Premarin. For some reason American researchers pay little attention to estradiol and none, as far as I can tell, to micronized progesterone. For some reason American journalists write as if all estrogens were alike.

And yet the difference between a healthy old age and years of debilitating illness could lie in the difference between an expensive patented medication and its inexpensive generic counterpart. We simply won't know until extensive studies have been completed and analyzed. And since that's not likely to happen during my lifetime, I plan to stick with the medication that costs less and yet appears to give far better results.

4 comments:

Amy T. said...

Having just read in the scholarly journal "Women's World" a mention of estradiol as being the estrogen that is the most irritating to breast tissue, I did a quick Google on estradiol and breast cancer and it appears that it is implicated in some way with causing/exacerbating breast cancer (the drug tamoxifen seems to work at least in part by shutting down an enzyme that converts regular estrogen into estradiol.) Whether or not it is inadvisable for healthy, low-risk women to use it I can't tell, but it is possible that US doctors are reluctant to prescribe it for that reason, whether that is due to the risks being significant or just being overly cautious to avoid potential lawsuits. Did the European study have anything to say about breast cancer risk?

LaVonne Neff said...

Yes, Amy T. - you can see the study itself by clicking on "European" in the first paragraph, or you can Google "Danish study hormone replacement" for a number of news articles on the study. From U.S. News, for example: "A Danish study of 1,000 women published earlier this month in BMJ suggested that women who began taking hormone replacement therapy early in menopause and who continued taking it for an average of 10 years cut their risk of having a heart attack, heart failure or dying without raising their risk for breast cancer or blood clots."

Most reports credit the difference in risk to the difference in timing, and that may turn out to be the case. I'm just pointing out that there was also a difference in the kind of estrogen used, and that difference should not be ignored.

Right now we simply don't know if cheap generic estradiol is less risky than Premarin and Prempro. The Danish study could indicate that it might be. Somebody needs to follow up on that.

Amy T. said...

Yes, I agree with you, it should be followed up on. Comparing the results of the studies without taking the differences into consideration is not very useful for making conclusions.

Anonymous said...

Thanks for this article. Have taken Estrace for over 15 years, reducing the prescribed dosage out of concerns that it isn't safe for such long term use, and/or has never been studied for scores of years. It is estradiol, so this piece makes me feel better. I knew it was not the combo hormone (Premarin), but it's difficult to estimate the risk/benefit possibilities of any of these meds. I appreciate this info.