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Interview with Dr. Bernadine Healy, Physician, Cardiologist, Professor, former Director of the National Institutes of Health and former President of the American Red Cross
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CBS CARES: Or, it could be the hormones?
DR. HEALY: Or, it could be there's a benefit to the hormones because those women are estrogen deprived or they are more estrogen deprived than other women who were indifferent about the hormones.
CBS CARES: What can we learn from the study?
DR. HEALY: What it showed was that hormone therapy is not for everyone. There was a presumed benefit on the heart, because in observational data, where you compared groups of women who were on hormone therapy to women who were not, the women who were on it had a much better outcome. All of the prevailing information at that time pointed in the direction of a very strong benefit to the heart as well as symptomatic relief. And, there was also a benefit to the bones, and the F.D.A. approved estrogen for the prevention of osteoporosis.
So, for the first time it was tested as it was being used, and it failed. But where it failed is that it was not a medicine for all. There's no universal magic bullet. Every drug comes with side effects. Skill and wisdom of benefit is required to decide what medicine is right for which patient.
But that was tossed out the window when people began to overreact and say, "Gee, hormone therapy is bad for every woman." In fact, estrogen is appropriate for some women. But now we're in a position, which is more difficult, because unfortunately the interpretation by some physicians and some people in the media has been that estrogen is for no women, and is somehow this horrible, dangerous medicine. So you go from one inappropriate extreme to the other.
CBS CARES: What is your opinion of recent studies suggesting that progesterone may be a catalyst to breast cancer?
DR. HEALY: There are some studies that used a particular formulation of progesterone, given in a continuous low dose characteristic of Prempro. These formulations have specifically been the agent that accelerated the development of breast cancer. This is the biggest concern. The reason the WHI study was stopped prematurely in 2002 was because, there was a difference in breast cancer-not quite significant-but a difference in cancer risk between the women who had hysterectomies and received only estrogen verses the women who still had their uteruses and received both estrogen and progesterone in the widely used drug, Prempro. The latter women, who received Prempro, had a slightly increased risk of breast cancer.
CBS CARES: Is there a safe window within which to use synthetic hormone therapy?
DR. HEALY: Oh, you know, everybody says to take it for the short term. Take it for the two years-period-when you're having symptoms. But the highest risk for heart attack and stroke is in that two year window, although it's one per thousand. So I've never quite understood that philosophy.
We need to get back to the question of the individual woman. I think that she has to look into her own health and symptoms. If she's having terrible menopausal symptoms and she wants to go on hormones and her doctor will work with her, she can do it, but she does have to realize that during the first two years she is on hormone therapy, there is a very slight increased risk of having a heart attack or stroke. We're talking about around one per thousand, but that is something she has to recognize.
CBS CARES: But, if a woman takes steps to reduce the heart attack risk in this two year window, couldn't that further increase the stroke risk? For example, a lot of people take high doses of fish oil and/or low doses of aspirin to reduce their risk of a heart attack, but don't these thin the blood and increase the risk of a brain hemorrhage or stroke?
DR. HEALY: You just pointed out something that's really, really important. There's a tendency to look at any of these drugs all by themselves. But you have to look at them interacting with other things. In fact, if you're taking low dose aspirin, and then you're also taking fish oil, and Vitamin E, because you're interested in the cardiovascular benefits of fish oil and Vitamin E, you have definitely increased the chance of having a hemorrhagic stroke. That is why I say it all has to be individualized.
CBS CARES: How have the findings of the Women's Health Initiative changed the way women and physicians think about hormone therapy?
DR. HEALY: Well, first of all, we were in this sort of very simple rosy world in which hormone therapy was perfect for everyone. It had been felt that there were almost no risks except if you had breast cancer. If you were going to get mammograms every year, there was a low risk. It was a very simplistic approach.
I think that we tend to suffer from trying to oversimplify both our bodies' chemistry, of which hormones are one part, as well as what we put in our mouths or on our skin. You know, hormones are powerful agents that affect various parts of our bodies. There are hormone receptors for estrogen on your brain, on your heart, in your knuckles, skin, your uterus, and ovaries. To think that hormone therapy is all good or all bad is a wrong perception that I think is, unfortunately, continuing.
CBS CARES: Have the drugs themselves changed or evolved in say the past decade?
What's happening now is that there's variability among hormone therapy preparations. It's not just a question of formulations, but whether it's natural progesterone or a natural estrogen. Also as important is whether you take it orally or transdermally. If you take hormones orally, you tend to get a very, very high level initially. There's a lot of processing that goes on in the liver. If you take hormones transdermally, you tend to get a continuous, more physiologically normal level of hormones without stressing the liver.
CBS CARES: So when hormones are absorbed transdermally, such as through a skin patch or cream applied to the skin, they are closer to what the body would have naturally produced?
DR. HEALY: Yes, it's a more natural preparation and you don't get the stress on the liver. And so, I think that those need to be studied more.
CBS CARES: What about bio-identicals? Are you a proponent of them?
DR. HEALY: I think that the more you can take something, which is bio-identical, the better. It makes a lot of sense. Now, what is the negative side? There has not been a controlled study of the different hormone preparations-both the bio-identical versus something like Premarin, which is the old mainstay, or transdermal versus oral preparations. We just don't have that kind of information. And quite honestly, they should be done very soon.
CBS CARES: Who should be doing these tests?
DR. HEALY: I think it should be the NIH
CBS CARES: Why have controlled studies of natural hormones not been done when there seems to be much at stake for women's health?
DR. HEALY: It's simple. They're hard to do. They're expensive. And it's a question of priorities. The Women's Health Initiative was never done before 1991 because some people thought it was too expensive. It was almost a billion dollars over 15 years. I don't happen to think that's expensive. When you look at it over 15 years, the NIH has a 30 billion dollar budget. But it has to be a high priority. You have to have an agency like NIH involved and at least partly supporting it to get it going. Comparing synthetics vs. bio-identicals is not a high priority. I think it is part of a neglect of women's health research.
And by the way, this is not just a woman's issue. We're seeing a really big increase of men taking testosterone. I think that as men live longer, the number of men taking hormones is going to continue to grow. Testosterone is thought to produce benefits in men, like cognitive benefits, mood benefits including less depression as men get older, and musculoskeletal benefits. So before we get carried away with testosterone patches for men, we ought to be doing that study as well.
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