All Things Considered
As the safety of hormone drug Prempro sits in question, women re-evaluate hormone replacement therapy choices

By Heather Stringer
November 5, 2002

Mary Koithan never expected her trek through the maze of midlife hormones to be humiliating, or for that matter, public.

The assistant professor of nursing at the University of Arizona found herself standing in front of dozens of students when she started to forget the names of authors she was quoting. As if her brain had mysteriously shorted out, she struggled for minutes on end to grasp questions the students asked in class.

The symptoms also plagued the professor outside of work. The grocery store was like a foreign country filled with foods she couldn't identify. There were severe panic attacks, then hot flashes. Koithan, Ph.D., RN, felt as though she was on the edge of Alzheimer's disease at age 45.

"I felt like I would have to retire because I couldn't think, couldn't make words come out of my mouth," she said. "My job depends on my ability to think and speak clearly. It was horrible."

Koithan soon discovered that her crippling mental and emotional crises were linked to two simple-yet amazingly complex-hormones: estrogen and progesterone. It wasn't until she started hormone replacement therapy that she began to recover her sanity.

Like many middle-aged women, Koithan relies on HRT to pump her body with hormones that stave off everything from hot flashes to poor concentration to panic attacks. But this summer, the safety of these hormone drugs was called into question when the National Institutes of Health abruptly halted the use of Prempro in the Women's Health Initiative (WHI), a study that set out to determine whether the combination of estrogen plus progestin-a synthetic form of progesterone-did prevent heart disease and hip fractures.

When the WHI data and safety monitoring board discovered that women using Prempro in the study had a higher risk of heart attack, stroke, blood clots and breast cancer, the board recommended stopping the trial.

The news left as many as 6 million American women in a wake of fear and confusion as they were compelled to re-evaluate their decisions about using HRT. Although the study's results give menopausal women ammunition to make more informed decisions, nurse practitioners and doctors interviewed by NURSEWEEK agreed that women should avoid the temptation to overlook the advantages of taking hormones. These health professionals are adamant that each woman needs to consider both quality-of-life benefits from HRT and the potential risks-and her personal values will greatly influence that final decision.

Informed decisions

Before people can make these choices, though, nurses such as Martha Drohobyczer, MSN, RN, believe that women need to take the time to understand the study's results.

"The statistics were not that alarming, but there's enough that we need to do further research," said Drohobyczer, a certified nurse-midwife at Alternatives for Women in Las Vegas.

In the WHI study, more than 16,000 women aged 50 to 79 with intact uteruses were taking estrogen plus progestin. The results revealed that during one year, among 10,000 postmenopausal women who are taking both of these hormones, eight more will have invasive breast cancer than women who are not taking the hormones. Seven more will have heart attacks, eight more will have strokes and 18 more will have blood clots.

"We already knew that there was a slight increase in breast cancer and had been counseling our patients accordingly," said Pennie Bosarge, MSN, CRNP, RN, a teaching faculty member at the University of Alabama School of Nursing. "We also knew there was an increased risk of blood clots."

Also, the average age of the participants in the study was about 63, and women in this age group would have entered the study with more pre-existing health problems than if the average age had been in the 50s, said Anita Nelson, MD, professor of obstetrics and gynecology at the UCLA School of Medicine.

Nelson also pointed out that the WHI study didn't examine the benefits of hormones in relieving vaginal dryness, hot flashes, mood swings or other menopausal symptoms. The WHI study also confirmed that hormones decrease the risks of colorectal cancer and osteoporosis.

"For the vast majority of women, it's perfectly safe for them to stay on HRT," Nelson said. "For most of them, the benefits outweigh the risks, or they don't have risks."

At-risk groups

But the decision is more complicated for women who do have risks of breast cancer or heart attack, Nelson conceded. If a patient has conditions such as hypertension, diabetes and obesity, for example, Nelson said, she might try anti-depressants rather than hormone replacement therapy. But if the patient continued to struggle with hot flashes, then Nelson said she'd consider prescribing a low-dose estrogen.

"We want our medicine to be risk-free, but this isn't the reality," Nelson said. "But women need to know the risks they are taking."

She also advises patients to reassess their status each year because priorities can change over time. For some women, menopausal symptoms drag on for years, influencing the need for HRT. For others, the symptoms fade quickly and hormones may not be necessary a year later.

Although the WHI findings complicate the decision for some women, for others the discoveries have made the choice easier.

For those who were taking HRT mainly for heart attack prevention, for example, Drohobyczer said it might be wise to find other tactics to prevent heart disease. She advises these women to tackle the problem with exercise and changes in diet. Patients who were taking hormones strictly for osteoporosis prevention should consider other strategies to increase bone density, such as increased calcium intake and exercise.

Drohobyczer started noticing the symptoms of menopause when she was 47, and seized the chance to experiment with different forms of HRT. For her, the signs of menopause began with hair loss and a new habit of misplacing things.

"I also had no motivation, and I'd wake up from 1 to 3 a.m.," she said. "You can tell you are just not as quick mentally. Going through it myself was really helpful for talking to women because they felt I could understand what they were going through."

Alternative remedies

Drohobyczer experimented with Triest, a compounded drug that includes three different forms of estrogen: estrone, estradiol and esriol. Although this form of hormone replacement therapy hasn't been tested for long-term effects or approved by the FDA, Drohobyczer said the combination of Triest plus progesterone worked well in relieving her symptoms. This compound drug can bypass the FDA approval process because it's made from naturally occurring, non-narcotic compounds, but women who want to use Triest still need a prescription.

Drohobyczer also tried an estrogen patch that was 100 percent estradiol, and this had positive results as well. She then used homeopathic remedies, and felt best using this treatment.

Bosarge took a different tack. She warded off the symptoms before they ever struck. She took low-dose oral contraceptives for three years, and then, at age 54, went straight to traditional HRT. Bosarge said this method facilitates a smoother transition by preventing vaginal dryness, hot flashes and heavy bleeding.

"I never had symptoms," she said. "The quality-of-life issue for most people my age is very important. Many are working professionals, and we don't have time for hot flashes and vaginal dryness."

Koithan, however, never had the chance to strategize before the onslaught began. Her battle started after she'd had a hysterectomy and oopherectomy (removal of the ovaries). Doctors prescribed the traditional treatments of Premarin and then the estrogen patch, but these drugs did little to improve her concentration or sudden panic attacks.

The desperate but determined nurse went online to find other solutions, and stumbled onto Triest. Her doctor was opposed to trying an untested drug, but Koithan was frantic for help and called a nurse practitioner who would prescribe the treatment. Once she started taking Triest, Koithan's mental clarity returned almost instantly, although she was still plagued by panic attacks and sleeplessness. Her nurse practitioner suggested she try taking small doses of progesterone for these symptoms, and this proved to be the solution.

Just when Koithan began feeling functional again, she received the shocking news that she had breast cancer.

"I wasn't afraid of the breast cancer, but I was afraid they would take away the hormones I was taking," she said. "I was terrified."

Koithan's cancer was the type that could be stimulated by estrogen and progesterone, a condition that usually prompts patients to stop HRT. But Koithan continued her dogged research and discovered that only one of the three estrogens in Triest was associated with breast tissue and tumor growth: estrone. She and her oncologist decided she could continue HRT as long as she eliminated estrone and gradually reduced her levels of estradiol and estriol.

The nursing professor continues to live relatively symptom-free, and she welcomes the chance to share her experience with friends, co-workers or relatives. She's one woman who has learned just how important it is to make informed personal decisions.

"Women need to think about HRT cautiously," she said. "For some women, going off hormones is devastating. You have to weigh the options. When people ask my opinion about the risk of breast cancer, I tell them I want to live, but not without being able to think."

Contact Heather Stringer at heathers@nurseweek.com