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The Honolulu Advertiser
Posted on: Sunday, July 28, 2002

Doctors share their answers to common questions

 •  Trying to ease the anxiety over hormone drugs
 •  Alternative hormone therapies abound
 •  Pseudo-estrogens may cut cancer risk

By Beverly Creamer and Tanya Bricking
Advertiser Staff Writers

We asked doctors and practitioners what kind of questions they were getting from Hawai'i women, and what they were advising. While they said nothing substitutes for talking to your own doctor, they passed on these responses.

Q. I'm already taking the hormone replacement therapy drug Prempro, and I'm worried about the risks. Should I stop taking my medicine?

A. "The first thing to do is to go talk to the doctor who gave you the medication and ask him or her, first of all, 'Why am I on this medication?'" said Dr. Laura Weldon Hoque, medical director of Kapi'olani Breast Center. "And ask the doctor if he or she thinks that maybe it's not appropriate anymore, given the new study. I think for some women, they're going to continue to stay on it because they have very strong reasons to be on it. And for some women, they really don't have a lot of good reasons, and then it's probably appropriate to go off."

Q. How great is the risk that the drug could harm me?

A. Women need to know the study found that hormone replacement therapy, specifically the drug marketed under the brand name Prempro, does not prevent heart disease and does cause breast cancer, Hoque said. The average person's risk of cancer is low, but it's enough for concern. "The main message," Hoque said, "is to talk to your doctor."

Q. If I stop taking my hormone medicine, do I face other risks if I stop cold turkey?

A. "No, you can just stop cold turkey," Hoque said. "Most women will get some hot flashes. I've been recommending to women to air condition their bedroom, which helps. But that is the normal part of menopause — hot flashes. Estrogen therapy does protect one against osteoporosis, so that is something that would have to be checked regularly by one's doctor."

Q. Is hormone therapy still considered the best way to relieve the symptoms of menopause?

A. "Yes, it's definitely the best way to relieve the symptoms of menopause," Hoque said. "And for someone who is going through a terrible menopause, it is reasonable to put someone on hormone replacement therapy for a couple of years. That's still safe to do."

Q. What should I do if I have heart disease, have had a heart attack and a bypass and have been using hormone replacement therapy?

A. Continue with the therapy, but make an appointment to discuss your medical situation with your doctor, said Dr. Frederic Pashkow, medical director of the Heart Institute at The Queen's Medical Center. According to the HERS trial (Heart and Estrogen-Progestin Replacement Study) the therapy is protective by the third year for women who have had heart attacks. However, there is increased risk in the first year, so it's not advisable for such women to begin HRT. There are other medications to reduce recurrent risk, including statin drugs and ACE inhibitors.

Q. What should I do if I was using HRT to prevent heart disease?

A. Based on the risks, Pashkow said, HRT should be stopped. Have your heart risk reappraised to see if medications are necessary. If they aren't, consider taking one 80-mg aspirin a day as a preventive measure, and reduce animal fats in your diet by choosing a Mediterranean-style diet and adding exercise.

Q. What should I do for high cholesterol?

A. Have your cholesterol risk evaluated, and use a cholesterol-reducing drug if it can't be brought down naturally by diet and exercise.

Q. What if I have both heart disease and risk for breast cancer?

A. The answers for this scenario are still unclear, Pashkow said. Make an appointment soon with your doctor to discuss options. Pashkow said he probably would take a woman in this situation off hormones. And many doctors would never put a woman with a high risk for breast cancer on hormones to begin with.

Q. What should I do if I have osteoporosis or a family history of bone loss?

A. First, have your bone density evaluated, said Dr. Richard Wasnich, Hawai'i's foremost osteoporosis expert. If you don't need medication, exercise and eat well to guard against developing brittle bones. (Free screening is available through Wasnich's research clinic, Radiant Research, by calling 441-6327. Free seminars on osteoporosis also are offered.) If medication is needed, biphosphonates are available to prevent bone loss. Two are on the market, Fosamax and Actonel. A third choice is Evista (raloxifen), a "designer" estrogen that also prevents bone loss and is officially called a SERM — Selective Estrogen Receptor Modulator. This may well be the new and best future alternatives for HRT. (See accompanying story.)

Q. What if I have Alzheimer's disease in my family? Are hormones still suggested to help with this?

A. This question still hasn't been answered definitively, but Dr. Jennifer Frank said this wouldn't be a strong enough reason to take hormones because of the other risk factors. However, if you have no other risks, and this is a major concern to you because you've seen a parent go through it, hormones may be a choice, she said.

Q: Is there a certain number of years considered safe to be on hormone replacement therapy?

A. "There really isn't. Unfortunately, that was never defined when the therapy originally was licensed and approved by the FDA. It was not for any length of time," Hoque said. "The way we used to think of it was lifelong." However, physicians are interpreting the study as indicating safety in the short term. Risk factors increased after long-term use.

Q. What if I've had a hysterectomy and I'm taking estrogen? Do I need to worry?

A. The study doesn't apply to you because women without uteruses are given only estrogen, not progesterone. "We have not seen a lot of evidence that estrogen-only increases one's risk of breast cancer," Hoque said. "It's probably the progesterone that's causing that increased risk of breast cancer." An arm of the Women's Health Initiative study looking at risks of estrogen-only among participants who have had hysterectomies has not been stopped because risk factors have not increased in this group.

Q. What if I'm a woman who has been on birth control pills for years? Should I worry?

A. "This study does not address that particular question," Hoque said. "There have been many studies on birth control pills and the risk of breast cancer. None of them have shown that today's birth control pills, which are lower dosage than the original ones in the 1960s, have any increased risk of breast cancer. So I would say to the woman who's on birth control pills, there's no need to go off of them. Generally, we don't give women hormones in the form of birth control pills over the age of 40 because of the increased risk of blood clots, so that advice would still hold true."

Q. What if I'm on hormones to improve my sexual function?

A: "Women generally have a much stronger sex drive and feel better sexually on hormones, and that is another reason people go on it, although not discussed a lot," Hoque said. "There are other options for that, as well, including vaginal estrogen creams, suppositories; things like that could also help."

Q. What are my alternatives if I don't want to take hormone therapy?

A: "I would say the No. 1 alternative is really natural remedies," Hoque said. "They fall into two large categories. One is estrogen-based natural remedies and the other is nonestrogen-based. The estrogen-type products, soy products, so-called natural estrogens, which are generally plant-derived, all are types of estrogen. If one's worried about estrogen, those are still estrogen, even though they're natural. There are some other alternatives. There are actually some antidepressants that are available, in very low dosages, for hot flashes, and have helped women. And that's something that should be discussed, again, with one's doctor."

Q. Do you think this study and the news about it is scaring women?

A: "I think it's creating a lot of uncertainty in women's minds — and the public in general," Hoque said. "I think we need to learn a lesson from this study. ... There was not a lot of hard medical evidence to support the use of hormone replacement therapy. But we just felt that it would probably be good. It made sense logically. It sounded good. And (now) we have to take this advice to other studies and other areas of medicine, and say we really need to study everything before we recommend it."