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| THE ESTROGEN QUESTION
June 19, 1997TRANSCRIPT |
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More and more older women are taking estrogen replacements to ease the symptoms of menopause and stem the effects of aging. Margaret Warner looks into new research that suggests long-term hormone replacement therapy reduces a woman's risk of death from heart disease, but increases her chance of developing breast cancer.
MARGARET WARNER: Many women take estrogen for two or three years at the onset of menopause to ease its more uncomfortable symptoms. And there's little dispute in the medical community about the safety of that. But the long-term use of hormone replacement therapy, which is growing rapidly among older women, is far more controversial.
NewsHour Links:
A RealAudio version of this NewsHour segment is available.
March 27, 1997:
Reversing a recent panel of medical experts, The American Cancer Society advises women in their 40's to receive annual mammograms.
January 24, 1997:
National medical experts meeting in Washington, D.C. say women in their 40's should decide for themselves whether to have annual mammograms.
OUTSIDE LINKS
On The New England Journal of Medicine's Web site an abstract and an editorial article on estrogen replacement therapy.
A position paper on the pro's and con's of taking estrogen at the onset of menopause.
Today, the New England Journal of Medicine released the most extensive study yet on the relationship between estrogen replacement therapy and mortality rate. The study compared nearly 700 post menopausal nurses who died over an 18-year period with a roughly equal number of nurses of similar age who lived. Here to explain the results is the study's chief author, Dr. Francine Grodstein, an epidemiologist at Brigham & Women's Hospital in Boston. She's joined by Dr. Nananda Col, a practicing physician an epidemiologist also at the New England Medical Center in Boston. Dr. Grodstein, first, what is estrogen? What does it do?
DR. FRANCINE GRODSTEIN, Brigham and Women's Hospital: Estrogen is a hormone which women produce naturally, primarily through their ovaries, during their reproductive years. At the menopause, which comes at an average age of 51 in the United States, women's ovaries stop producing estrogen.
MARGARET WARNER: And so what did your study find about the impact of taking estrogen after that period on the rates of death among women?
DR. FRANCINE GRODSTEIN: On the average we did find that the benefits of estrogen therapy appear to outweigh the risks. There was about a one third decrease in mortality rates for women who are taking estrogen.
MARGARET WARNER: But you did find also some significant differences, correct, in sort of length of time, for instance?
DR. FRANCINE GRODSTEIN: Right. More specifically, we looked at the duration of time that the women were using menopause [estrogen] and what the relation of estrogen duration to the balance of risk and benefits were. And we did find that while during the initial years of use, up to 10 years, the benefits outweighed the risks that--
MARGARET WARNER: That is fewer women died during that period if they were on estrogen than not?
DR. FRANCINE GRODSTEIN: Right. Now, after 10 years of continuous years, there still overall were benefits, but not the same extent as we had seen during the initial use--initial years.
MARGARET WARNER: And can you explain why?
DR. FRANCINE GRODSTEIN: The diminished benefits over time were primarily due to an increased risk of breast cancer mortality for women who were using hormones for ten or more years.
MARGARET WARNER: I see. Dr. Col, what's the meaning of this study, as you see it, for women, your patients, perhaps, who are trying to decide whether to go on estrogen therapy or stay on it?
DR. NANANDA COL, New England Medical Center: I think that this study again highlights the difference between short-term therapy and long-term hormone therapy. It confirms that short-term therapy, that is, therapy that's on the order of several years but say less than five years, appears to be a benefit without risk, if you're looking at life--at survival. However, when you are considering long-term hormone use, that is on the order of five to ten years, or longer, then you have to seriously weigh the risks and benefits. This study found that, on average, there was a 20 percent reduction in mortality for long-term hormone users, but that tells us again about an average woman, and we still need to be able to individualize this decision from an average to the woman who comes into your office.
MARGARET WARNER: Explain to me, Dr. Col, the science behind the fact that estrogen therapy is useful to someone who's at a high risk of heart disease but actually potentially dangerous for someone who's at a high risk of breast cancer.
DR. NANANDA COL: Yes. Estrogen has multiple effects on the body. Estrogen has been shown to decrease the risk of heart disease by nearly half, and it's also been shown to decrease the risk of osteoporosis. However, it has also been shown to increase the risk of breast cancer, so you basically have significant benefits, one significant risk. Now, how do you weigh those benefits with the risks? Well, it depends on what your risk of developing each of those diseases is to begin with. If you cut a very small risk in half, you don't gain much.
On the other hand, if you cut a very large risk in half, you gain a lot. So what you need to do is for an individual woman is to determine what her starting--her base line risk for heart disease, breast cancer, and hip fracture is, then factor in the impact of hormone therapy into that equation. And if you do so, then you can come up with some--with a way of estimating what the long-term impact of estrogen therapy is on her life expectancy. Now, again, this only applies for long-term therapy, as Dr. Grodstein's study showed. The attenuation, the risks--the negative side of hormone therapy become significant after--the mortality side becomes significant after 10 years of therapy. The increased incidence, the chance of developing breast cancer, have been shown by Dr. Grodstein's previous study to become apparent after only five years of therapy. So it needs to be reconsidered. Long-term therapy needs to be reconsidered after five years of therapy.
MARGARET WARNER: Dr. Grodstein, would you agree with that assessment of sort of the meaning for patients of your study?
DR. FRANCINE GRODSTEIN: Yes, I do agree, and in particular I think what is important, as Dr. Col pointed out, is for each woman to think about her individual risks. We--we were able to separate our women into those who are at high risk of heart disease, meaning women who have--
MARGARET WARNER: Yes. Please explain that.
DR. FRANCINE GRODSTEIN: --women who have risk factors for heart disease.
MARGARET WARNER: Right.
DR. FRANCINE GRODSTEIN: That is women who are overweight; women who smoke cigarettes, who have high cholesterol, or high blood pressure. Things like these are known to increase your risk of heart disease. So for those women we saw significant mortality benefits. In contrast, when we looked only at women who had low risk of heart disease, meaning they had none of these risk factors, there were not very significant benefits.
MARGARET WARNER: But now skeptics would say there are other ways to lower those risk factors--overweight and smoking and so on--other than taking a pill which might actually increase your risk of another disease, i.e., breast cancer.
DR. FRANCINE GRODSTEIN: Right. I think that's an extremely important point which is often looked over in the discussions of hormone use. I think one way to look at our finding that women who don't have risk factors for heart disease are not getting significant benefits is that if women can eliminate their risk factors, then they potentially don't need to be taking hormones to gain those mortality benefits. So we can tell women--and I think we should be telling women--that hormones are one option among many lifestyle options that are available to them to reduce their risk of heart disease, as well as osteoporosis. And if we can encourage women to exercise, to lose weight, to stop smoking, to maintain a healthy diet, those things will give them only benefits.
MARGARET WARNER: Now, Dr. Col, many women, though, take estrogen, I gather, for reasons other than having to do with mortality. I mean, there are quality of life issues.
DR. NANANDA COL: Exactly. There are as many different reasons for taking hormone therapy as there are different kinds of women. Estrogen therapy has so many different effects on your body, on the way that you feel, on the way that you look, on the way that you think that you look. Many women do take it for a variety of different reasons, and it's very important to let--to understand why the patient is interested in taking hormone therapy. Many women would like to take it because of the way it makes them feel. They perceive that their memory is improved. They perceive that their mood is improved on it. And such women are looking for reassurance that by taking hormone therapy that it won't be compromising their life expectancy to any significant extent. On the other hand, there are women who don't feel good taking estrogen, and those women would only be interested in taking it if they could--if they were expecting a significant mortality benefit from it, so it runs the full gamut.
MARGARET WARNER: And Dr. Grodstein, do you think that estrogen replacement therapy is being oversold at all to women?
DR. FRANCINE GRODSTEIN: It's actually a very difficult question to answer. I think it's important for women to keep in mind that this is a personal decision and the balance of risks and benefits are going to depend on the individual woman, not just--we've been talking about mortality benefits and how women can lower their risk of heart disease using estrogen, as well as other things, but there are many other considerations. And I think women should understand all of their options and should be able to make informed decisions, which are also just based on their personal preferences.
MARGARET WARNER: All right. Well, Dr. Grodstein and Dr. Col, thank you both very much.
DR. NANANDA COL: Thank you.
DR. FRANCINE GRODSTEIN: Thank you.
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