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Kicking my estrogen habit

I had just unpacked my bag in a London hotel room when I felt a shiver of alarm. Where was the vial of little blue pills that allow me to sleep, think, avoid emotional meltdowns and generally feel like myself? I ransacked every corner of the bag – once, twice, 147 times. I emptied my purse and poked inside the toes of shoes until there was nowhere left to look. If I had to leave something behind in Toronto, why couldn’t it have been my toothbrush? Without my estrogen fix, our 10-day vacation would plunge me into hormone hell. I threw myself on the mercy of the closest chemist (as British pharmacists are called). But by law he could not fill a prescription from my doctor back home. Result: a whole day spent tracking down the clinic where, for a substantial fee that in my desperate state seemed like a bargain, a bored-looking doctor scribbled on her pad, saving me from night sweats and brain fog.

Along with the little blue estrogen pill, I take a big white one, progesterone. Both hormones work together to regulate the menstrual cycle, and they’re prescribed together for hot-flashing mid-lifers like me who still have a uterus (estrogen on its own can cause endometrial cancer). But I’ve always viewed progesterone as estrogen’s humble sidekick, and no wonder. It’s always estrogen that dominates discussions of so-called combined hormone therapy–confoundingly cast as both the key to women’s vitality and a serious threat to our health.

My heart sinks whenever I read that yet another study has raised a warning flag about estrogen. I keep promising myself that one day soon I’m going to kick my estrogen habit. I don’t like feeling so dependent on the stuff that I’d pay any price to replace it. But I want to be me, not a sleep-deprived wraith. I’ve made two attempts to quit the pills by gradually tapering the dose; both times I gave up within weeks. I never planned on becoming an estrogen lifer, but I seem to be headed that way. What am I doing to myself? In an effort to reassure hormone-phobic women, the Society of Obstetricians and Gynecologists of Canada (SOGC) has declared combined therapy “safe and effective” for relieving symptoms like mine – but only for short-term use, five years at most.

It’s been 15 for me.

At 45, I was the first in my circle to jump on the hormone bandwagon. The results seemed nothing short of miraculous. A few months into the job of a lifetime, editor-in-chief of Chatelaine, I’d been arriving bleary-eyed at the office and barking at my staff. How could I keep this up? My doctor told me I had the most treatable of problems: estrogen deficiency. Just to be sure, he gave me an estrogen injection that restored my spirits overnight, proving to his satisfaction and mine the time had come for the little blue pill, synthetic estrogen – supposedly a veritable wonder drug. It would protect my heart, strengthen my bones and ward off dementia while keeping my skin and vagina youthful. I started singing its praises to strung-out, middle-aged friends.

Then one fateful summer morning in 2002, news broke that a major hormone trial, part of the 15-year Women’s Health Initiative study (WHI) had been abruptly terminated for ethical reasons. Researchers had detected an increased risk of breast cancer, heart disease and stroke among women on combined hormones. Dismayingly, women and their doctors had been counting on this trial for proof that estrogen lived up to its billing. Now it seemed to have proven just the opposite. I’d no sooner sat down at my desk than a friend called in a panic. No more hormones for her! And just when did I plan to pitch my “cancer pills”? She didn’t think much of my answer: Risk is part of life and I intend to enjoy mine while I can.

That’s basically been my position ever since, despite the recent news about hormone takers in the WHI study who are still being followed. They’re more likely to be diagnosed with breast cancer and to die of the disease, warns a new report in the Journal of the American Medical Association. But the increased risk translates to one more death per year per 10,000 women. I can live with that. I think.

You don’t hear much about long-time users like me. It’s hormone refuseniks who get the attention. They’re the reason why breast cancer rates have been dropping since the WHI bombshell, according to a Harvard study that made headlines last spring. Predictably, the study has critics who cite other possible reasons why breast cancer rates have plummeted, but there’s just no denying one troublesome fact: The drop was most pronounced among affluent white women over 50. The very women most likely to be taking combined hormone therapy–until they began to reject it. In September a Canadian study made the same connection between the flight from hormones and a marked drop in breast cancer incidence (almost 10 percent),

I like to think the benefits of feeling like myself more than justify whatever risks I’m taking. After all, I lead a healthy life. I’ve never smoked, I work out faithfully, I eat my quinoa and leafy greens. I’ve been slim ever since I lost my pregnancy weight at 22. All of these things help prevent any number of diseases, including the one that women fear most – breast cancer. And when it comes to that particular scourge, an early pregnancy like mine is known to have protective effects. I’ve just about convinced myself that if medical science could put my entire health history in a test tube, shake it up and give me a score, I’d get at least an A minus for cancer prevention, never mind the hormone pills. Even so, I can’t suppress occasional flickers of unease.

No surprise to Jennifer Blake, chief of obstetrics and gynecology at Sunnybrook Health Sciences Centre in Toronto. “Women are made to feel they’re doing themselves a disservice by taking hormones,” she says. As Blake explains it, the dangers of hormone therapy have been vastly overhyped and the nuances lost in the furor. Take the WHI findings. Still the biggest pool of data we have on hormone therapy, they’re the source of that five-year safety window, which I’ve already exceeded by a decade. The participants weren’t typical hormone users. They were older, 63 on average. Many were overweight or had high blood pressure. This might seem a peculiar way to study drugs prescribed mainly for healthy women in their fifties, but WHI’s vast scope went beyond hormones. The researchers were also looking at the role of diet and dietary supplements in keeping women well. They needed statistically significant data on heart attacks, which are more common in older women, and this skewed their results.

As for breast cancer, Blake wishes women would look at the big picture. Obesity and poor diet pose greater risks than hormone therapy, which is “equivalent to having a baby later, or starting your periods earlier and stopping them later.” What’s more, women now have alternatives to the combination of hormones – estrogen and synthetic progesterone, or progestin- that caused the elevated cancer risk. I take a plant-derived progesterone called Prometrium that precisely mirrors the chemical structure of what the female body produces. Two years ago, a French study found that estrogen plus bio-identical progesterone did not cause breast cancer. Why didn’t I hear about this sooner?

The hormone therapy decision has been widely reduced to a simple question: yes or no? Yet researchers have been shifting their sights to a more meaningful question: when? Earlier seems to be better. Remember those alarming reports about hormones as a risk factor for dementia? They were based on WHI subjects in their sixties. Newer studies suggest that women who start estrogen in their fifties, before age has begun to compromise their brains, will gain protection from dementia. Roberta Brinton, a pharmacologist at the University of Southern California, has shown that estrogen helps the female brain to fuel itself efficiently and respond to stimuli. Since Alzheimer’s has ravaged my family tree, I’d like to think the little blue pills could have bought me a few productive years. I’m not counting on it, though. The only thing I know for sure is that I feel better on hormones. According to Blake, that’s reason enough to stay the course.

I hear a radically different story from Jerilynn Prior, an endocrinologist at the University of British Columbia, the driving force behind the Centre for Menstrual Cycle and Ovulation Research (CeMCOR) and co-author of The Estrogen Errors. Prior denies that there’s any such thing as estrogen deficiency – or that estrogen levels wane in the run-up to menopause, the known as perimenopause, when up to 20 per cent of us feel nothing like ourselves. What really cause our symptoms are sudden estrogen spikes. And the safest treatment is not more estrogen but bio-identical progesterone – that big white Prometrium pill on its own and in a larger dose than I’m currently taking.

In a menstruating woman, monthly progesterone levels peak at more than a thousand times the peak estrogen level. Yet a woman on hormone therapy takes the same estrogen dose her body once produced naturally and only one-third the progesterone. Prior is asking what’s wrong with this picture.

Her stand hasn’t won her any friends in the medical establishment. She’s had to fund her own research with private donations. In a new study of 114 women, Prior found that Prometrium can relieve hot flashes within four weeks. In addition, it promotes sleep and strengthens bones. Not bad for a hormone that has no rap sheet. As for estrogen, Prior dismisses the hope that research now underway will uncover good reasons to take it at the right time. She accuses mainstream medicine of rigid loyalty to a groundless faith in estrogen’s importance. She writes in The Estrogen Errors: “Estrogen was not and is not useful in preventing disease and has, in fact, been shown to cause harm.”

If you Google “stopping estrogen therapy,” the first destination you’ll see is the CeMCOR site. “Women are just desperate,” says Prior, who personally fielded questions from visitors around the world until she found herself swamped by demand. Herself the veteran of a tough perimenopause, she has posted a bracing and helpful guide to kicking the estrogen habit. Step one: increase your progesterone to 300 milligrams (triple the standard dose, and the amount your body naturally produces before perimenopause). Step two: switch to the estrogen patch because you can cut it up for more gradual tapering. Step three: give yourself 15 weeks and be prepared to bump up the estrogen temporarily if the going gets rough.

Don’t be surprised if it does. Says Prior, “My latest wild idea is that withdrawal from estrogen is like withdrawal from opioids [such as heroin and morphine].” She points to studies showing that estrogen promotes addiction in female rats, which get hooked faster than males. Removing a female rat’s ovaries will protect it from addiction, but dependence returns if the rat is then given estrogen. (With women the picture is not so clear, but it looks as if progesterone helps female addicts recover by easing stress and counteracting the drug high.)

Okay, I admit it. My name is Rona and I am an estrogen addict. Now I know I have an alternative besides toughing out withdrawal. If I were just entering the hot-flash zone, I’d give progesterone a try. But for now, anyway, I’m sticking with the tried and true. I’ll never know the consequences of my choice, and I’ve decided that’s okay. Much as I hate to admit it, I’ll eventually die of something. Why not savour every minute of the time I’ve got?

Previously published in More (Canadian edition), Dec./Jan. 2011. Since this article first appeared, there’s been more bad news but my position hasn’t changed.


Posted by Rona

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