"Give Me My Hormones!"
Inside the controversial demand
In 2002, San Diego was at the forefront of a groundbreaking study on hormone replacement that stunned the medical community, and prompted a generation of women to flush their hormones down the drain. A decade later, the controversy looms—but American women still want their hormones.
For Natalie Meyerson, menopause hardly passed as fast as a hot flash. After 30 years, it still hasn’t passed. The 77-year-old Oceanside resident wakes up in the middle of the night drenched, jostles on her fan, and falls back into the sheets weary and wide awake. Hot flashes used to come in the light of day too—sometimes hourly—while she played with her grandchildren or took strolls with her husband, Max.
This wasn’t always the case. In 1996, the determined Meyerson went to La Jolla to enroll in the Women’s Health Initiative, a landmark study of 160,000 women sponsored by the National Institutes of Health (NIH). Meyerson was happy to lend her body to science, fingers crossed that she’d get the real McCoy—a medication called Prempro with synthetic versions of the female sex hormones estrogen and progestin.
The effects were euphoric. “I got up every morning with vim and vigor,” Meyerson recounts. “My body reacted like a 21-year-old woman’s again. That was an awesome feeling after all these years of night sweats and hot flashes.”
Other women found their sex drives returned, arid vaginas flowered, moods improved, and at long last they could sleep through the night. It was an era when drug makers marketed hormones like candy and menopause as a medical problem, rather than a natural part of aging. Robert Wilson, a prominent gynecologist with ties to the pharmaceutical industry, jump-started the hormone craze in the ’60s with his blockbuster book Feminine Forever. Doctors even prescribed estrogen and progestin to women well past menopause, thinking it would actually prevent disease.
Then came the reports of cancer.
In July 2002, the Women’s Health Initiative brought rigorous science to the world of sex hormones—and the results weren’t exactly “feminine forever.” Some participants taking Prempro succumbed to invasive breast cancer, heart attacks, blood clots, and stroke. Women over 65 experienced more dementia. To Meyerson’s distress, the NIH abruptly halted the Prempro arm of its study. Mystified doctors and whipsawed women who’d previously been sold hormones as a virtual panacea slammed on the brakes.
“I read so much in all the newspapers about the WHI [study] and the women who got breast cancer, the women who got heart attacks,” Meyerson recalls. “I experienced none of that. My body did well with the Prempro.”
The startling news quickly became the hot topic on morning talk shows and evening newscasts. The largest clinical trial on hormone replacement therapy ever conducted was causing cancer. Cancer.
Meyerson received a letter from the NIH telling her to turn in any unused medication. Her trusted family doctor wouldn’t write her a prescription either. In fact, physicians around the country got gun-shy about prescribing hormones to menopausal women, no matter their age or family history. Prescriptions plunged more than 50 percent over the next 10 years. In all, 16,608 WHI participants were plucked off the estrogen and progestin therapy. San Diego was the third largest clinical center in the nationwide study, with clinics in La Jolla and Chula Vista. In San Diego, 774 women participating in the hormone study got the jarring news it was over.
A Decade of Slicing and Dicing the Data
Fast-forward 10 years: The screeching alarm from 2002 is now more of a cautionary hum, a dose of fear-fueled overreaction to the study’s results, according to Robert Langer, the former principal investigator for the WHI San Diego Clinical Center. After a decade of slicing and dicing the data, most doctors agree that short-term hormone therapy is a relatively safe choice for women up to age 59—if they’re suffering from menopausal symptoms and otherwise healthy. The WHI also showed that combination hormone therapy decreases the risk of colon cancer and improves bone health—a serious issue for aging women prone to hip fractures and osteoporosis.
“The pendulum is swinging back,” says Kathryn Macaulay, director of the UCSD Menopause Health Program. “There was a lot of fear about using hormones 10 years ago. There’s better understanding today, and there are safe ways to use hormones to help with menopause.”
It turns out older women are at much higher risk from hormone therapy than younger women, and personal health history matters. “There were a lot of women included in that study not necessarily representative of the women we’ll be treating with hormones,” Macaulay says.
— Elizabeth Barrett-Connor, epidemiology professor at UCSD
Elizabeth Barrett-Connor, an epidemiology professor at UCSD, says some experts think the hormone trial was done incorrectly. The doses were too high. Today, doctors prescribe half the dose that was typical a decade ago.
“The WHI caused many people to put their pills right in their toilet without even talking to their doctor, because the newspaper headlines were quite alarming and surprising,” Barrett-Connor says. “That risk is not so huge, but it is real. So women themselves will decide based on their own history and personal anxieties what they want to take.”
From the Pill to the Patch
Many people shy away from discussing vaginal atrophy, and the aching dryness, that can happen when hormones drop, according to Andrea LaCroix, principal investigator for the WHI San Diego Clinical Center. But pain during intercourse can make sex anathema to women. A low-dose vaginal estrogen cream is often preferable for that, rather than pills, which have more side effects, she says. Smaller studies suggest that applying hormones through the skin, rather than taking them orally, may carry a lower risk of blood clots, though doctors say more research is needed on patches, creams, and gels.
Linda Kruger-Carter had had it with hot flashes at inopportune times, when she was toting high-end fashions to her customers at Neiman Marcus, for instance. It was the strangest sensation, like sitting on a heating pad, a red-hot wave rising up her body. “You want to put your head in the freezer,” she says. The 56-year-old Ocean Beach resident also wanted to maintain a thriving sex life with her husband, despite some vaginal dryness creeping in with “the change.”
Kruger-Carter met her husband at age 21 while cocktail-waitressing at the Bahia Hotel. He was there playing the sax. After 36 years, they still have date night every week, hitting dance clubs in the Gaslamp or sneaking off to a bed and breakfast in Laguna Beach.
“We’ve always been very spontaneous, taking honeymoon weekends,” Kruger-Carter says. “I still wanted to have that in our relationship, just to feel sexy. He’d been taking testosterone, and I wanted to be right up there with him.”
She planted an estrogen patch on her belly and the hot flashes subsided.
But LaCroix says there’s still a lot of controversy in the field, and some clinicians underemphasize the downsides of hormone therapy. “I’ve seen way too many young women who started hormone therapy and had a stroke,” LaCroix says. “Sure the absolute risk may sound small, but over the many women using hormone therapy, it’s not a small number of affected women.”
LaCroix agrees with the FDA guidelines on hormone therapy, which suggest women use the lowest dose for the shortest amount of time they need to relieve symptoms. But those guidelines are wildly open to interpretation.
“They leave it up to us,” says Sieu Truong, an obstetrician and gynecologist in Encinitas. “What’s the shortest amount of time? Who knows? Some people think maybe that’s five years. Maybe that’s three years. Maybe that’s 10 years.”
Truong adds that she’s more likely to keep healthy, active women on hormones longer—especially if insomnia returns in their golden years and they can’t get restorative sleep. UCSD’s Macaulay says several respected medical groups advocate a five-year cap, but she treats women on a case-by-case basis.
Part of it boils down to psychology. If you ask women their greatest fears, getting old and being alone top the list, according to psychologist and San Diego State University gerontology professor Mario Garrett. That drives the forever-young obsession, sometimes at the expense of biology, he says.
“At a certain stage you are not meant to feel like 30 or 40,” he explains via phone, while hiking Cowles Mountain one morning before class. “If the body is not producing hormones, think about what it’s doing. It may be protecting you from cancer.”
Garrett says studies of centenarians show they don’t tinker much with medical interventions, instead respecting the body’s internal rhythms and shifts. Women trying everything from hormone replacement to face-lifts may actually be compromising longevity.
“I drive a 25-year old diesel Mercedes. It’s a very sluggish car. If I put in certain additives it will make the car go faster, but it’s to the detriment of the engine,” he says.
New Choices, New Controversy
In her late 30s, Christine Knutson became exhausted and moody, with little interest in sex. Doctors said she was too young for menopause. Turns out the Vista resident was suffering from perimenopause, when the ovaries slow their flow of hormones before they stop ovulating for good in full-blown menopause. Perimenopause usually starts at 40-something, but can sometimes hit in the 30s.
Knutson first tried Premarin, the estrogen drug used in the WHI and once the most commonly prescribed medicine in the world.
“I felt terrible,” Knutson says. “I felt a million times worse than I ever felt before.”
— Mario Garrett, gerontology professor
at San Diego State University
Plus, Knutson didn’t like that Premarin (short for PRegnant MARe’s urINe) is made from estrogens derived from horse urine. So the hospice nurse researched another class of hormones called bioidentical, or biologically identical. They’re derived from plants to mimic the same chemical structure as a woman’s natural hormones. She sought out Dr. Truong and started a cocktail of estradiol, estriol, and progesterone, custom-made from a compounding pharmacy. Knutson says her brain worked better, her body filled with energy, and her weight dropped away.
In some cases, Truong favors bioidentical hormones—made both by pharmaceutical companies and smaller compounding pharmacies—over synthetic ones. But she says there’s no bioidentical study on par with the WHI. Truong says the risks of bioidentical hormones are assumed to be the same. Many mainstream doctors are wary of the compounded versions, since they’re regulated by state boards and not the FDA.
There’s another camp, a smaller one, almost evangelical about bioidentical hormones. Popular books like Suzanne Somers’ Ageless have become a go-to source on them. Experts point to European studies showing bioidenticals are safer than synthetic hormones —although they admit those aren’t long-term, double-blind clinical trials.
This is worth noting because the placebo effect is so profound. Cynthia Stuenkel, a professor of medicine at UCSD and past president of the North American Menopause Society, says women on fake medicine typically report a 40- to 60-percent reduction in symptoms.
Advocates of bioidenticals say compounding pharmacies tailor-make each woman’s dose to fit her needs. “This is not cookie-cutter medicine,” says Melinda Silva, a bioidentical hormone specialist. The directory in her Chula Vista office reads “MD Anti-Aging Clinic.” Canisters of protein powder and pamphlets on penile injection dot her South Bay office.
Indeed, some of her patients say they feel younger than ever. Silva claims she’s cured fibromyalgia, migraine headaches, and depression with bioidentical hormones.
“If they get better from the treatment, guess what? I’m going to continue with that treatment because it works,” she says. “As long as it’s not hurting somebody, I don’t see the issue with that.”
Silva says she’s her own guinea pig. After her fourth child, she was snappy, headachy, and out of sorts. Reluctant to take conventional hormones, she discovered bioidenticals.
Flexing her bicep like Popeye, the physician adds, “I’m stronger, sexier, and more fit now at 49 than when I was perimenopausal and practicing mainstream medicine.”
Science vs. Female Intuition
So how’s a woman to navigate the chasm between anti-aging doctors and epidemiologists, as well as a torrent of books and talk-show tidbits?
Melanie Fiorella, a family medicine physician at the UCSD Center for Integrative Medicine, suggests women at least try the alternatives.
“The first thing I’d like her to consider is the body is beautifully designed to find its own state of balance,” Fiorella says. “There are many things women can do for themselves without hormone therapy.”
But back in 2002, after she was forced to quit the hormones, Natalie Meyerson’s night sweats came back with a vengeance. She flung open her windows and began carting her miniature desktop fan from room to room. Today that fan remains a constant companion.
For those women—the “Give me my hormones, now!” generation—the options are out there, thanks in part to San Diego women like Meyerson who participated in the initial hormone study. Today scientists have a far greater understanding of women’s health at mid-life.
“There are other people, and I’m one of them, who believe that a woman should get estrogen if she’s miserable because of menopause,” says UCSD professor Elizabeth Barrett-Connor. “You can’t argue with that. It’s like my gynecologist told me when I delivered a baby that it didn’t hurt that much, but he hadn’t ever had a baby himself. It would be inappropriate for me to say to women with hot flashes that you’re not as miserable as you think you are. She needs to know there are increased risks with the drug and there may be benefits. Previously we couldn’t tell women what the risks and benefits were, and now we do a much better job.”