Dr. Robert Langer at the Family Medicine Clinic of the University of Nevada, Las Vegas. (Credit: Brenton Ho)
About 20 per cent of women sail through menopause without any issues at all. But for the other 80 per cent, symptoms can range from mild to extremely severe. For those with the worst symptoms, any treatment that can provide relief is a life-changing opportunity. Fortunately, we’ve for decades had a very effective treatment in hormone therapy (HT), but it’s been hounded by controversy about the balance of risk and benefit during much of its history. Most recently, a landmark study conducted by the Women’s Health Initiative (WHI) caused a lot of fear and concern that HT was putting women at risk of other diseases. But, according to Dr. Robert Langer, one of the study’s principal investigators, that concern is rooted in a substantial misinterpretation of the results.
To properly understand the findings, some background is required. “In the latter part of the 1980s, there was finally enough long-term experience with HT that studies started to come out suggesting that, when started near menopause to relieve symptoms and continued beyond, it was also protective against major chronic illnesses like heart disease, bone fractures related to osteoporosis, and perhaps even dementia,” explains Dr. Langer. “Around this time, some people were starting to recommend that HT could be used even in women who were without symptoms and were well past menopause, with the idea that it might prevent these problematic diseases.”
That brings us to the WHI study, designed to test this idea of whether giving HT to women well past menopause would have the same benefits that it seemed to have in women who started it at the time of menopause. The study began in 1993 and continued into 2002 for the section involving women with a uterus, and 2004 for women who had already had a hysterectomy. The design of the study, to specifically study effects in older post-menopausal women, is of critical importance. “What we set out to do was to enroll women who were well past menopause,” says Dr. Langer. “The average age of women participating in the study was 63, and on average they were 12 years past menopause.”
The study was stopped early because it was not showing the benefit they had set out to find. Further, in the older cohort, who would not traditionally have received HT, there were small increases in the incidence of both breast cancer and heart disease that were not statistically significant. “In reality, the study was stopped for futility,” says Dr. Langer. “But all the headlines blared that HT caused breast cancer and heart attacks, despite the fact that, for the women who would typically be considered candidates for HT, the WHI results showed no harm. We have come to understand that the effects in women starting well past menopause are due to changes in a woman’s body that emerge over 10 years or so with little estrogen in circulation.”
In the years that followed, HT use among women in all age groups dropped dramatically. That’s an entire generation of women who have been harmed by the fallout from bad data interpretation and amplification of fear in the media. “While we now know that older women are not good candidates,” says Dr. Langer, “the women aged 50 to 59 who could really benefit are getting the short end of the stick due to fear and misinterpretation of the results.”
This message is just now starting to gain traction and a lot of misinformation remains prevalent both in public discourse and within the medical community. For these reasons, it’s important that women be prepared and well-informed when speaking to their doctors about menopause treatment. We mustn’t let poor data interpretation in the media keep a good therapy out of reach for those who need it.