By Roy Benaroch, M.D., Emory University
Hormone replacement therapy (HRT) was wildly popular in the second half of the 20th century. It promised to treat menopausal symptoms and prevent osteoporosis and cardiovascular disease. But all this changed in 2002 when The Guardian declared, “HRT study canceled over cancer and stroke fears.”
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Here’s the irony: Physicians and the popular media both misunderstood the conclusions of this landmark study. It was designed to look at the risks and benefits of using HRT to prevent long-term health issues.
Most of the almost 30,000 women enrolled in the Women’s Health Initiative (WHI) study were already well over 60 years of age, at least a decade past menopause. Subsequent analyses of the huge data sets from the WHI study have shown that the health risks associated with HRT are only really seen in older women.
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So-called “post-hoc” analyses occurred in published papers in later years following the original WHI study. The analyses scoured large data sets in an attempt to find new insights by asking different questions.
For instance, one post-hoc analysis of the WHI data showed that among women who started hormones within 10 years of menopause, there was no increased cardiovascular risk.
A separate Danish study published in 2012 that only looked at women taking hormones right around menopause showed a significant reduction in both cardiovascular disease and breast cancer. And, for women less than 60 years old, hormone replacement therapy reduced the overall mortality by 30 percent.
The bottom line, which is reflected in current guidelines, is that most women in their 40s and 50s struggling with menopausal symptoms should use HRT therapy. These medicines can safely relieve symptoms, improve the quality of life, and even reduce short-term mortality; however, it doesn’t mean women should keep using it forever.
Looking back at the HRT story in hindsight, there are some lessons to be learned. HRT was never as great as our enthusiasm led us to believe when the popular thinking dictated that all women ought to use it. By the same token, it was never as bad as it seemed to be when the headlines shouted it was killing women.
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The Male Version of Menopause Drugs
There’s another ironic side to this story concerning men. Though men don’t experience something akin to menopause—where in women, the ovaries completely stop producing hormones over just a few years—men do experience a gradual drop in their sex hormone, testosterone, over decades as they age.
Sure enough, a huge industry has developed in response to treating men for what has become known as “low T.” Testosterone therapy is being pushed to treat a variety of ailments, including fatigue, sexual dysfunction, and declining muscle mass.
The purported benefits of testosterone for men reads like a Christmas gift list: build lean muscles; cut fat; improve your mood; recharge your energy and libido; and turn you back into a youthful, sexual dynamo.
Marketing materials from drug companies, and numerous articles in men’s magazines, have encouraged men to “talk with their doctors” about low T based on vague symptoms and promises of feeling more youthful.
One low-T marketing tool involved a questionnaire that started with “Do you have these symptoms?” and ended with “If you said yes, talk to your doctor.” This was called the Androgen Deficiency in the Aging Male, or ADAM test.
It was originally developed by Dr. John Morley of St. Louis University. He told The New York Times that he wrote it on toilet paper in the bathroom in about 20 minutes.
That quiz was reproduced dozens, maybe hundreds of times, and helped drive U.S. sales of testosterone replacement products to over $2 billion a year.
The boom in testosterone wasn’t limited to the United States. One study showed a remarkable jump in testosterone sales in 37 of 41 countries reporting data from 2000 to 2011.
Genuine low testosterone is referred to in the medical literature as “hypogonadism,” and it is a valid indication for testosterone therapy. Men with genuinely low testosterone levels do experience genuine symptoms that can be serious and at times debilitating, including especially low energy.
Just how many men have genuinely low testosterone is a matter of some debate—there are reasonable questions about just what cutoffs should be used. But many men who’ve been prescribed testosterone haven’t even had their testosterone levels measured, and aren’t being monitored to see if replacement normalizes blood levels or consistently improves symptoms.
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Does Testosterone Therapy Live Up to the Hype?
What do the studies show about routine testosterone use in otherwise-healthy men? A 2016 systematic review of the literature summarized that testosterone supplementation overall did not show consistent benefits for sexual function, mood, or behavior—it doesn’t work, at least for some of the most important reasons men give for taking it.
Additionally, testosterone supplementation can increase the risk of cardiovascular events like heart attacks. Within 90 days of beginning testosterone, the risk of a heart attack doubles. That risk is even higher among men with previous heart trouble.
But, research also shows that men with genuinely low testosterone levels are themselves at a higher risk of heart attacks. It seems to come down to some essential questions: Are we prescribing testosterone for the right patients, for the right reasons?
Men with genuinely low testosterone can benefit from supplementation, and for them, the benefits may well exceed the risks. But the concern is that all of the hype about testosterone has driven prescriptions and sales to too many men, and especially too many men who probably won’t have much benefit.
In 2014, the FDA clamped down on testosterone advertising, declaring that product labels need to explicitly say that testosterone is only to be used for men with objectively low testosterone levels and that testosterone therapy may raise the risk of cardiovascular problems.
Manufacturers said they would voluntarily curtail their advertising. You don’t see quite so many mentions of low T in men’s magazines anymore. Sales of testosterone products, predictably, have begun to drop.
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Hormone Replacement Therapy: A Balanced Perspective
But as with hormone replacement for menopausal women, we need to be careful that we don’t push the pendulum too far. The bottom line with hormone replacement for men and women is that it’s not a magic elixir that everyone should take, but neither are these therapies automatically bad.
These nuanced decisions need to be made based on the best medical evidence, considering each patient’s medical history and individual needs.
Unfortunately, the media doesn’t give “maybe” declarations to the public in its headlines. Advertising and popular media tend to oversimplify, presenting things in black and white, when in truth, scientific knowledge is often filled with gaps or grey areas.
Sometimes, we’re too eager to accept advertising claims for the next super pill, especially one that will return our bodies to their youth.
We need to spend less time looking at the headlines and more time looking at what the actual studies say. That means asking the right questions and digging into details.
Only then can we cut through the hype and arrive at an informed decision.
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Common Questions About Hormone Replacement Therapy and Cancer
Hormone Replacement Therapy is a time-sensitive treatment. It must be done at just the right time for menopausal women, usually at the beginning, in order to reduce the risk of breast cancer.
When menopausal symptoms become a problem for women, this is a good time to consider Hormone Replacement Therapy. Symptoms can include vaginal dryness, insomnia, hot flashes, and mood swings.
Women typically report benefits from Hormone Replacement Therapy as soon as two weeks after the treatment begins or as long as three months.
There are no reported withdrawals from Hormone Replacement Therapy, and it is generally not a problem to stop suddenly. It should be noted that women who have had HRT are more likely to develop breast cancer than those who have not.