Menopause Study And Lack Of Education
HELP CAN BE HARD TO FIND: A LACK OF EDUCATION AND SIGNIFICANT MISINFORMATION ABOUT HORMONE REPLACEMENT THERAPY LEAVES WOMEN WOEFULLY UNDERTREATED
If you have struggled to find the help you need to address menopausal symptoms, you are not alone. Despite the discomfort women experience during menopause, and treatment options that can improve one’s quality of life and perhaps prevent several chronic diseases, a minority of women are offered appropriate therapies. Today, American women can spend a third or more of their lives struggling with menopausal symptoms and related conditions, many without a clear understanding of what to expect, how to respond, and what treatment is possible.
According to Yale University, research shows that few menopausal women are receiving the medical care they deserve. The Yale study reviewed insurance claims from over 500,000 women in various stages of menopause and found that 60 percent of women with significant menopausal symptoms seek medical attention, however almost 75% are left untreated.
MANY MEDICAL RESEARCH PROFESSIONALS ARE ILL-EQUIPPED TO ADDRESS MENOPAUSE
Unfortunately, most medical schools and residency programs don’t provide education about menopause. As noted in an AARP article titled, “What Doctors Don’t Know About Menopause”, a survey revealed that “Just 20 percent of ob-gyn residency programs provide any kind of menopause training. Mostly, the courses are elective. And nearly 80 percent of medical residents admit that they feel ‘barely comfortable’ discussing or treating menopause.”
According to a North American Menopause Society (NAMS) survey of over 1,000 medical professionals (including doctors, physician assistants, and nurse practitioners) only 57% reported being up to date on Hormone Replacement Therapy (HRT) for treating menopause.
As quoted in the AARP article mentioned above, Philip M. Sarrel, professor emeritus of obstetrics, gynecology, and reproductive services and psychiatry at the Yale School of Medicine stated “Doctors are not helpful. They haven’t had training, and they’re not up to date,”
Gynecologist Wen Shen, an assistant professor in the Johns Hopkins School of Medicine Department of Gynecology and Obstetrics added “Nearly one-third of this country’s women are postmenopausal. Many of them are needlessly suffering.”
HORMONE REPLACEMENT THERAPY: MISUNDERSTANDING AND MISINFORMATION LEAD TO A LACK OF EFFECTIVE MENOPAUSE TREATMENTS
Beyond the fact that so many physicians are generally ill-prepared to address menopausal symptoms, as well as their belief that menopause should just be tolerated, a significant contributor to the lack of safe and effective treatment is the prevailing belief about hormone replacement therapy (HRT). Many of these erroneous beliefs - and the fear and confusion about HRT - stem from the Women’s Health Initiative study. The Women's Health Initiative (WHI) was a national health study that focused on strategies for preventing heart disease, breast and colorectal cancer, and osteoporosis in postmenopausal women.
DRUGS AND THEIR IMPACT ON THE FEMALE BODY
The WHI study utilized two drugs - Premarin (an equine estrogen) and Provera (a synthetic progestin) neither of which are bioidentical. While similar to a woman’s endogenous hormones, Premarin and Provera’s chemical makeup diverges from our natural hormones and the literature suggests these slight chemical differences have subtle but meaningful physiological impacts on the body. These two drugs are more estrogenic and progestogenic - and studies indicate that they confer different risks compared to medications like estradiol and progesterone that are chemically identical to our own, natural hormones. The WHI study, utilizing these two drugs, brought about the now widely-held - and erroneous - belief that any hormone replacement therapy equals an increased risk of cardiovascular events and breast cancer. Both doctors and patients became terrified of hormone replacement.
The Media And Incorrect Information
While the study’s objectives were laudable, the resulting media coverage, misrepresentation in the news and the medical community’s poor understanding of the data seeded the doubts and fear around hormone replacement that persist to this day. were two major problems with the WHI study and the subsequent media attention that are worth discussing. Firstly, the complex nature of this study, and the ensuing confusion about the results, was compounded by the inaccurate reporting and media coverage. Secondarily, the risk profiles of Premarin and Provera were not considered separately from the risk profiles of bioidentical estradiol and progesterone and the varying delivery methods.
Regarding the first problem concerning media inaccuracies, the initial results that linked hormone replacement therapy (HRT) to breast cancer and heart attacks were, according to those associated with the study, misleading. According to a lead investigator for the WHI study, “Good science became distorted and ultimately caused substantial and ongoing harm to women for whom appropriate and beneficial treatment was either stopped or never started.” Fear and sensationalism won out over science.
What is commonly omitted in the discussion of the WHI is that there were two arms of the trial with meaningful differences in outcomes. One arm of the trial placed women on Premarin (equine estrogen) and Provera (synthetic progestin) while the other arm of the trial used only Premarin (equine estrogen) in women who had a hysterectomy. Interestingly, the estrogen-only arm of the trial saw no statistically significant increased risk of breast cancer. Even with the stronger, much more estrogenic drug, breast cancer incidence did not change. Alternatively, the arm of the trial that utilized both Premarin (equine estrogen) and Provera (synthetic progestin) did find a small increased risk of breast cancer for longer-term use. These are just a few examples of how the data was misinterpreted. For instance, others have to do how long a woman was postmenopausal before being initiated on hormones.
The second problem with the study concerns the fact that Premarin and Provera were not assessed separately from bioidentical estradiol and progesterone, leading many to believe that all estrogen and progesterone, regardless of its type or delivery method, lead to an increased risk of breast cancer and cardiac events. The evidence suggests that there seems to be a difference in risk - particularly for breast cancer - between progesterone and progestin. For instance, according to this study, a meta-analysis showed that “in menopausal women, estrogen and progesterone use may be associated with lower breast cancer risk compared to synthetic progestin.” According to an article in Breast Cancer Research & Treatment, “Estradiol and progesterone demonstrated no increased risk of breast cancer. Synthetic estrogen (Premarin ®) and synthetic progestins all dramatically increase the risk of breast cancer. This was a ten-year study to date comparing natural hormones to synthetic hormones.” (Breast Cancer Res Treat 2007;101:125-134). There are other nuances surrounding differences between equine estrogens (Premarin) and estradiol, transdermal deliveries versus oral delivery, and the timing of initiation of hormone replacement post-menopause that add to this already complex story that most medical providers don’t grasp.
Because of the complex nature of the scientific literature on hormone replacement, many physicians - especially those who haven’t received training in research or taken a dive into the menopause studies and literature - propagate the idea that HRT is not a safe or necessary treatment for menopause. With so few physicians understanding the intricacies of HRT literature and research, women are often offered only woefully inadequate and inferior treatments such as antidepressants.
Effective treatment can not only resolve symptoms - including hot flashes, mood changes, sleep disturbances, and sexual dysfunction - it also plays an important, or arguably essential, role in preventing chronic diseases that plague the aging female. As noted on our Women’s Health and Aging page, many options can address menopausal symptoms. And you can learn more in Part 3 of this series on Menopause.
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