The answers to the following FAQ’s are generalized for the population-at-large and meant to help educate readers. Please be aware, however, that individualized therapy may dictate different approaches for specific patients that can differ from what is written here. That is why it must be emphasized that consulting with Dr. Altman, or any other expert in the areas of menopause, hormonal therapy or sexual dysfunction, is the only way to receive the appropriate individualized care that each and every patient deserves.
Questions on the WHI Study
You say that the WHI was misrepresented to the American public. What do you mean by that?
Answer: When the WHI was first presented to the American public at a press conference in July of 2002, there were many misrepresentations:
1. They said ‘hormones were bad for women’. However, the study was not about hormones . The study was about the oral hormone products, Premarin and Prempro. One cannot extrapolate results from Premarin or Prempro to any other hormonal product, especially not to non-oral estrogen products, nor to natural progesterone products. If a study shows that a certain blood pressure pill causes a specific problem, that does not mean all blood pressure medications cause the same problem!
2. The study was not about women. It was about women who averaged 12 years beyond their final menstrual period. Estrogen is a preserver of good function, not a repairer of bad function fifteen to twenty years down the road when the damage has already been done. Estrogen should be started within 5 to 7 years since the final menstrual period (the menopause). The women in the WHI study who started hormones within ten years of their final period and less than the age of 60, showed excellent results as well as prevention of heart disease and no significant increased risk of breast cancer.
If the WHI researchers who presented at that first press conference 8 years ago had broken the results down into the appropriate age groups, good news would have been reported which agreed with numerous studies that came before, and now, since, WHI.
WHI said there was an increase in breast cancer. What is the truth about that?
The breast cancer information from WHI was startling. As it turns out, in the Prempro arm, the women who were using the combination oral product Prempro, there was no statistically significant increased risk of breast cancer! That means that any slight increase in the incidence of breast cancer in the women who took Prempro could have been from chance rather than from the Prempro!
Even more fascinating about the WHI study, was that in the Premarin-only arm of the study, which included only women who had had prior hysterectomy, there was a statistically significant DECREASED risk of breast cancer, regardless of age, in the women who actually took their medication greater than 80% of the time!!! Over the years, the data on hormone therapy and its impact on breast cancer have shown no consensus. There are papers that show a slight increased risk, those that show no change in risk at all, and those that show a slight decreased risk. This means that the worst case scenario is that there may be a slight increased risk in breast cancer on hormonal therapy, but the data supports other conclusions as well. This is extremely good news for women!
How come the WHI showed a decrease in the quality of life?
Answer: This is one of the most frustrating and angering parts of the WHI study. In 2003, a paper was published from the WHI saying, not only was there not an increase in the quality of life in women taking hormones, but there was, in fact, a decrease in their quality of life. Many, of my patients called and said “What, are they crazy? How could this possibly be? Of course you feel better when you’re taking hormones especially when you’re having symptoms.” I explained to them that this was precisely the problem. Ninety percent of the women who enrolled in the study had no hot flashes, night sweats, sleeplessness, palpitations, headaches. If they had these symptoms, they would not have been allowed to be in the study!!! You see, this was a “double blind” study. That means that the study subjects would not know whether they were taking drug or placebo, which gives us much better answers to the questions that the study is looking at. So, women with symptoms were not allowed in the study because the doctors in charge of the study knew that women with symptoms who received drug instead of placebo would know they were on hormones because they would feel better!!! Hence, they would un-blind, so the study would not be valid. After all, the researchers knew that hormones take away the symptoms mentioned above, as all the data prior to WHI demonstrated increased quality of life in women taking these hormones, so they couldn’t allow those women into the study. Do you understand the absurdity of saying “we don’t want you in the study because we know that hormones will make your symptoms will go away and you will feel better?” And then publishing a paper saying that the women in this study experienced a decrease in quality of life!
That to me is a fraudulent academic study, because when you put a 72 year old women on Prempro who stopped having symptoms long ago, she will frequently get headaches, breast tenderness, bloating, maybe her blood pressure will go up and she will stop taking that medication within a couple of months. By stopping the medication, she will then check off “decreased quality of life” in her study questionnaire. Hence, the absurdity of this part of the study.
Was there good news about heart attack prevention and death in the WHI study?
Answer: There was exceptionally good news. For the women who started their Premarin less than the age of 60 and within 10 years of their final menstrual period, there’s a strong decreased risk of about 35% of getting a heart attack later and, most importantly, there was a decrease of approximately 30% in dying from any cause at all.
Are there other studies aside from WHI that show these benefits?
Answer: There are two major studies from Standford University Medical Center in 2007 and 2008. These papers demonstrated that women who start their hormones less than the age of 60 and within 10 years of their final menstrual period, cut their future risk of heart attack by 35 plus percent. They also lowered their risk of dying from any cause at all by 40%! So it turns out that WHI confirmed the good news that prior studies had shown, and studies that came after WHI continue to agree on the benefits as well!
Doesn’t estrogen have an effect on breast cancer?
Answer: Yes, estrogen can promote an early breast cancer that is already present prior to starting estrogen therapy. There is no data demonstrating that estrogen causes (initiates or starts) a breast cancer. The difference between promotion and initiation is extremely important. Also, estrogen can only promote those breast cancers that are able to respond to estrogen…and these are usually the more “benign” cancers. This can also mean we are able to find these cancers sooner.