American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, November 12, 2013

Hormone replacement at menopause and the profound importance of 'maybe'

Colleagues and I published what I consider a very important paper in the American Journal of Public Health, indicating that tens of thousands of relatively young women who have undergone hysterectomy are dying needlessly because of an over-generalized fear of hormone replacement. Publication in the current issue of The Journal of the American Medical Association (JAMA) of a rich compilation of findings from the Women’s Health Initiative (WHI) trial does nothing to change our conclusions.

Our paper explains itself in clear detail for those who read the scientific literature. For everyone else, I have detailed our mission and our methods in online columns more than once. So I won’t belabor those efforts now. But in a nutshell, published data from the WHI showed a decisive survival and health benefit for women who had undergone hysterectomy and took estrogen replacement in their 50s. There are roughly eight million women age 50 to 59 in the U.S. today who have undergone hysterectomy, so this is not a trivial matter.

The WHI data also showed harmful effects of estrogen replacement for older women. But there are two key considerations here. First, we have long known that treating with hormones soon after menopause has dramatically different effects than doing so a decade or two later. If this seems at all counterintuitive, consider an illustration: regular exercise can markedly reduce heart attack risk when administered “early,” but exercise could well precipitate a heart attack when administered “late” to someone who already has advanced coronary disease. The analogy isn’t perfect, but it’s perfectly good enough.

The second consideration is that death is not the enemy; premature death is the enemy. Dying within a decade of age 50 is a very different matter than dying within a decade of 70. The former is dying too young. The latter could well mean dying at the standard U.S. life expectancy. The potential survival advantage of estrogen replacement in younger women does not become less important just because of potential harmful effects in women a decade or two older.

An editorial accompanying the new paper in JAMA seems to reach the conclusion that the WHI is a decisive argument against hormone replacement for all women. The editorialist, however, while pointing out the importance of the WHI in helping overcome the “dogma” that hormone replacement was always good, seems to be replacing it with the countervailing dogma that hormone replacement is always bad. This just isn’t so.

For starters, the WHI only studied one kind of hormone replacement, and not a preferred choice among my expert colleagues. The trial used CEE, or conjugated equine estrogens (Yes, that is estrogen from horses) for their estrogen, and MPA (medroxyprogesterone acetate) for their progesterone. No other preparations were studied. This was justified because these were the most commonly used hormones years ago when the study began. Equine estrogen may differ enough from human estrogen to have at least some importantly different effects, however. MPA is a fairly high-potency synthetic progesterone, apt to induce more side effects than the variety truly native to us.

Then there’s the fact, reaffirmed by the new JAMA paper, that the effects of hormone replacement vary considerably with the age of the women, along with the inclusion or exclusion of progesterone. Women who have had a hysterectomy—and as noted, for better or worse millions of women in the U.S. have—can take estrogen alone without progesterone.

My colleagues and I published our paper, and I have published my related columns, because we believe a small percentage, but still a very large number, of women are being harmed, even killed, due to an inappropriate aversion to the very concept of hormone replacement. We never said, and I am not saying now, that hormone replacement is good for all. Clearly, it isn’t. We are not refuting the potential for harm, especially when progesterone is in the mix, and in general for older women.

We are simply saying that one size does not fit all, and doctors and patients need to discuss the matter without bias to reach the most salutary conclusion for any given individual. The data in the newly published paper fully support this contention, even if the editorial attached to the study disputes it.

We have varied results by age and personal characteristics for one very well-studied form of hormone replacement. We actually know far less about many other forms of hormone replacement, some of them much preferred by those with careers devoted to the matter. An out-of-hand dismissal of hormone replacement for any woman is a misinterpretation of what we know, and a potentially grave mistake. No less so than the universal endorsement that once prevailed. We are making no progress if we replace one version of misguided dogma with another.

Please, my fellow clinicians and patients alike, be open-minded, be well-informed and make personalized decisions accordingly. The WHI never generated an all-encompassing “no,” and my colleagues and I are by no means defending a universal “yes.” We are merely pointing out the profound importance of “maybe.”

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

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One of the most popular anonymous blogs written by an emergency room physician.

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