Archive for April, 2011

The researchers with the Women’s Health Initiative (WHI) released more findings last week. The study began in 1999 as a joint venture between the National Institute of Health (NIH) and Wyeth pharmaceuticals and enrolled tens of thousands of women. The study was supposed to run for ten years but was stopped in the summer of 2002 because the risks of hormone therapy (in this case Prempro™ for women who had a uterus and Premarin™ for women who did not) outweighed the benefits. The risks included an increased risk of heart disease, blood clots and breast cancer in the women on the hormones. The benefits included a decreased risk of colon cancer and hip fracture.

My ob-gyn office phone rang and rang and rang when these initial findings came out. Prior to the WHI, the use of “hormone replacement therapy” was almost automatic for a peri-menopausal or menopausal woman. After the initial reports, many of my patients chose to discontinue their hormones. Some immediately restarted the hormones because of hot flashes and then gradually weaned off the hormones. Some stayed on the hormones because they felt the quality of their life was better on hormones than off of them.

As a nation, the incidence of hormone use decreased and the incidence of breast cancer has also decreased since the 2002 report came out. (See the graph at the beginning of the post) The latest report from the WHI suggests that breast cancer rates are LOWER on Premarin™ alone versus placebo in the women who had had a hysterectomy. I doubt this report will change hormone use a great deal.

As I said before in my book, the WHI left us with more questions than answers. What if different hormone preparations had been used? (Wyeth co-sponsored the WHI – the reason for the hormone choice) What if rather than a broad-based population we had targeted younger sympotamatic women (the average age of WHI participants was sixty – well after the onset of menopause). What if we screened the population and only treated nonsmokers?

I’m amazed that there were no extensive data gathered on nutrition (other than “low-fat”), life-pacing or stress management as part of the WHI. What’s more, as in most clinical trials that involve taking chemicals into our body, there was no discussion or measurement of our individual differences in metabolizing the same chemicals out of our body. Our genetic uniquenesses are likely to drive this discussion in ten to fifteen years; for now we are all lumped together as if we were identical metabolically. It’s unlikely that we’ll ever had this large a study population to explore these questions.

Here’s my short summary of recommendations regarding hormone: 1) Do you need them? If the perimenopausal years are wreaking havoc on your sleep patterns or your vaginal lubrication, start first with nutritional choices rich in fruits, veggies and whole grains. Ease off of the animal protein, sugar and caffeine. Learn some breath exercises and/or biofeedback techniques and practice them twice a day. Exercise three or four times a week. 2) If these lifestyle changes don’t lighten the severity of your symptoms, use low dose hormones topically (gels, creams, patches, intravaginal rings, etc) that are chemically identical to the hormones you make yourself. These “bio-identical” hormones are on your formulary and purchased through your insurance plans or compounded to a specific prescription by a specialty pharmacy. 3) If you stay on hormones longer than three months, measure your estrogen metabolites and make sure you are removing the hormones safely from your body. You’ll probably need to find functional medicine practitioners to do this.( 4) Reassess your hormone needs yearly and decide if you need to stay on them or if you can wean off of them. Wean slowly. Ask for assistance from your practitioner.

No doubt about it, some women need hormones for the perimenopausal transition. As a culture, however, we don’t always grasp that our nutrition and lifestyle choices affect our hormone levels. The WHI didn’t answer that question!

This blog is about that phone call and the follow-up testing. You know the phone call I mean. The one where the chipper woman calls and tells you there’s something wrong with the testing you did last week. It could be a doctor’s assistant calling about lab results or a hospital (in my case) staff member calling to let me know that there was “this new area” on my mammogram that needs further testing. And don’t get me wrong. I appreciate that she called on Monday morning and not Friday afternoon giving me the weekend to sit and stew!  But here’s the thing. She hadn’t really looked at the computer and/or wasn’t empowered to answer questions. For instance: why? what was seen or not seen on the original test? What was the concern? Was there a comparison to the testing done last year in Cincinnati? (Did they have the old information?)  Were there calcium deposits?  (Did the radiologist use the term “calcifications”?) You get the idea. No dice. Her job was to call and get me scheduled, not provide clinical information. Now forget for a moment that I’m a board certified ob-gyn physician. Even if I weren’t I’d still want some basic knowledge up front prior to the testing!

So then I make my appointment and check in. The receptionist doesn’t make eye contact or welcome me.  The intake clerk confirms my insurance information and collects my co-pay but never asks me how I would prefer to be addressed. I am Mrs. Harsh to everyone there. I correct the first three people who call me and ask to be called by my first name. (Yes I’m a doctor, but comfortable using my first name in just about every circumstance.) What’s your preference? Would it make you more comfortable if your preference is noted and used? Of course it would!

The waiting area is playing a brisk military march and there is a coffee pot and water dispenser. There are the usual magazines to read. And then there’s the mammogram tech. Pleasant, skilled and thorough. I ask to see the digital results from the previous test – there they are with the radiologist’s “circle” of concern. And then there’s the ultrasound tech. Pleasant, skilled and thorough. And then there’s the radiologist. Very nice and chipper because the spot compression films and the sonogram confirm the new area is a dilated duct and not pathological. Great news. No discussion about ways to reduce my risk of breast cancer. Just a “see you next year for your mammogram”.

So if I ran the hospital, I’d coach everyone in the front to introduce themselves and make eye contact and greet everyone who walked in. I’d capture the usual data for the purposes of the insurance billing and then double check if there were issues or concerns for this visit. I’d check on the clients preferences for how they were addressed. Then I’d listen to my staff and see if they had ideas for efficiency.

That’s how I’d run the (hospital) world. Focused on the patients. Allowing the professionals and their support staff to do the work they have trained their life to do. <sigh>