Estrogen may be Enron of menopause

Writing about estrogen is risky business for a male, but I come from a house full of women. I am so steeped in estrogen that I occasionally find myself wondering if I would look good in heels and a sundress. The wife is a female (a darn good arrangement), the kids, dog and gerbil are all females, and I am suspicious about the turtle but do not know how to check. The only other male in the house is the hamster, and the two of us guys have, of necessity, developed a finely tuned sense of what is important to women.

Estrogen is, and last week estrogen as a medication for women took a big hit. A pair of studies published in the prestigious Journal of the American Medical Association suggested that hormone replacement therapy (HRT), the combination of estrogen and progesterone taken daily by millions of American women to beat back the effects of menopause, may be doing those women more harm than good. (A woman’s natural estrogen is lost after menopause.) The studies showed that prolonged use of HRT (at least six years) increases the risk of heart attack, stroke, blood clots in the legs, and worst of all, the risk of breast cancer. The estrogen in HRT is the likely culprit.

The news hit many American women like a bad hot flash. Estrogen is the most commonly prescribed medication in America. Fully 40 percent of American women have taken some form of HRT in their menopausal years because of its effectiveness in treating the aggravating and often very unpleasant symptoms of menopause, such as hot flashes, difficulty concentrating and even depression. Many were then kept on HRT in the hopes that its estrogen component would help combat the effects of menopause on the heart, the bones, the brain and the estrogen-sensitive tissues of the breast and vagina.

Rarely has so much hope for so many ridden on a single pill. Behind the benefits sought for the heart, bones and brain were the hidden hopes of some that HRT, if not a full fountain of youth, was at least a daily sip from it, and would help prolong youth and sexuality in a society that worships both in its women. HRT seemed to stand between aging and the disproportionate burden aging puts on women as a kind of hormonal field-leveler. The bad news reminded us that we cannot dig graves with our lifestyles and hope some pill will dig us back out. It amounted to the prescription version of the Enron implosion, and was a big enough story that it made the cover of Time magazine.

HRT despair, however, should not be complete. Despite the bad news there is reason for optimism about aging and even about estrogen. First and foremost, healthy aging can be achieved by exercise, good diet, weight control, etc.; it does not require estrogen pills. Second, estrogen is not the only pill in the medicine cabinet. It may be the best one for symptoms of menopause, but for everything else that estrogen was supposedly good for there are better remedies. Beta blockers and cholesterol medicines are better at preventing heart attacks than estrogen ever was thought to be. Plain, old aspirin has a long track record of lowering the risk of repeated heart attacks and of strokes. Exercise, vitamin D and calcium, weight training, and other medications, all can reduce the risk of osteoporosis. Besides, estrogen never prevented osteoporosis in a woman who sat on her cushions all day.

For those women desperate to stay on HRT regardless of the risk there is also good news. At this point it still appears to be safe for limited use. Furthermore, in almost seven years of use in the study subjects, HRT only increased the risk of an individual woman between the age of 50 and 79 of having either a heart attack, stroke, blood clot in the leg, or getting breast cancer, each year, from just under one chance in a hundred to about 1.3 chances in a hundred. While that is a risk increase of more than 30 percent, the overall risk of these complications still remains low. Some women may choose to stay on HRT, take that risk, and then do other things to reduce total risk of illness and disease. For example, if a woman started exercising daily, got her weight and cholesterol down to a healthy range, and wore her seat belt 100 percent of the time instead of 50 percent of the time, her overall risk of death from all causes would probably go down even if she chose to remain on HRT.

Finally, women can trust the macho forces of capitalism when it comes to HRT. The female baby boomers are hitting their menopausal years, and the size of that market for an alternative to estrogen-based HRT will drive America’s pharmaceutical companies to find one.

If you ask the hamster and me they had better get to it.

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.