Hormone Replacement Has Risks

Q:  I just don't know what to do about my hormone replacement therapy. I have been on Premarin since I was 48. I am now 62. I have no complaints with it, although you hear so many pros and cons about heart attacks, strokes and cancer. Recently when I went for my annual exam my doctor suggested I start weaning myself off of Premarin. I am hesitant about doing this because I am worried about osteoporosis.

The technician doing my osteoporosis test said she takes Premarin and she will continue to take it. She stated it has been around a very long time and the older doctors seem to want their patients on it, while the younger doctors feel they should be off it. The technician also does mammograms and over the years has not seen any more breast cancers for the patients on Premarin. At this point I am confused and would appreciate some advice.

A:  Although I have addressed the recent Premarin studies in this column before, I want to answer your question because I still get a lot of mail about estrogen. Let me first say what we know: In older women - or an average age of about 65 - many years of taking the combination of estrogen and progesterone (that is, Premarin and Provera) causes more heart attacks, strokes and breast cancers than it prevents broken bones from osteoporosis.

In other words, it does more harm than good. We are still studying the effect of estrogen alone in women who have had a hysterectomy. (Women with their uterus in place cannot take estrogen alone.) The effect of short-term use - about a year - of estrogen and progesterone in women at menopause (about age 50) is probably safe.

Doctors, just like patients, can get attached to a certain way of doing things. Estrogen happens to be a medication that has a lot of added meaning to a lot of people and so it is easy to get attached to.

Older doctors have seen many patients feel so much better during menopause because of estrogen. Gynecologists, in particular, have likely noticed the lack of osteoporosis in their patients on estrogen, but since they are not usually the doctors caring for heart problems, they probably didn't notice the negative effects of estrogen on the heart. Even internists (of which I am one), who often care for people with heart problems, didn't generally notice more heart problems with women on estrogen. That's why we needed a rigorous scientific study like the large Women's Health Initiative trial. (And why we cannot put all our faith in the observations of your technician.)

If you're a doctor who has seen a lot of good come from estrogen, it's hard to suddenly say it's bad. And yet, we do know now there are serious risks with estrogen in older women.

So, although you may get many opinions on this matter, I agree with your doctor. If you're worried about your bones, there are other medications specifically to treat osteoporosis.

"Dear Doctor" is a compilation of patient questions answered by doctors from the Medical College of Wisconsin.