January 24, 2011

Hormone Replacement Therapy

I’m 51 years old and have entered menopause. Hot flashes are making my life a misery. My older sister was on hormone replacement therapy, and her doctor stopped it. I had a hysterectomy 10 years ago, and I’ve heard that makes HRT easier. What do you advise?
Hormone replacement therapy (HRT) came into vogue when menopause was viewed as a state of hormonal deprivation. It seemed logical to replace the estrogen that had fallen so precipitously in the postmenopausal woman. Such replacement did make many women feel “normal” again, but the risk of endometrial cancer rose. Progesterone was added, and this latter risk disappeared. Many studies suggested that HRT was protective of the heart, but in the early 1990s a study was commenced that proved conclusively that in older women in their 60s with factors making them at risk for heart disease, HRT actually raised these risks.
So many studies had shown benefits of HRT that this study was viewed with skepticism. Its findings, however, were corroborated. Further studies showed that estrogen alone, without progesterone, was less likely to worsen the risk of heart disease, but it still had a negative effect. The original use of HRT had been for postmenopausal symptoms, not treatment of heart disease risk, but, of course, a suggestion that HRT could reduce heart disease risk greatly inflated its presumed benefit.
2011 1503 page28A fly in the ointment of the Heart and Estrogen/Progestin Replacement Study (HERS) has been that the group studied were in their mid-60s and had heart disease risk factors. Prior animal studies (in monkeys) had shown no benefit of estrogen in those who already had arteriosclerosis, but a protective effect in castrated monkeys with no arteriosclerosis.
The question was then raised: If estrogen doesn’t treat heart disease, does it prevent the development of arteriosclerosis in women who don’t already have it? That question is as yet not answerable.
Whatever the final word, we know there’s been a decrease in breast cancer of the estrogen-receptor-positive variety, coinciding with the reduction in use of HRT. The risks of stroke and blood clots are also shown to rise with HRT. These increases are not of a large order, however, and risks or benefits in women of your age are not clearly defined.
Currently the Food and Drug Administration does not approve of HRT (in your case, only estrogen, because you have no uterus) for prevention of heart disease or as a first-line treatment of osteoporosis, but practice guidelines still recommend its use in really bothersome postmenopausal symptoms.
Many reading this will have concerns about “natural” estrogens and promote their benefits. Others will talk about the transdermal delivery systems. The probability is that any kind of estrogen receptor stimulator is likely to trigger similar responses, regardless of its source. If you can manage well without HRT, that is what you should do; but if life becomes unbearable, you alone have to make choices and take on consequences.
What is the cause of so many cases of Alzheimer’s disease? Does a vegetarian diet protect against it?
Alzheimer’s disease affects millions of people, but its major risk factor is age. The older one gets, the greater the risk. In fact, the incidence has been found to double every five years once a person has reached the age of 65. It’s not aging itself that causes Alzheimer’s, because many old people never get it. Yet nearly one third of people living past 85 years will be diagnosed with it.
The Adventist lifestyle, with its longevity-promoting features, may expose more persons to this hidden predisposition, and yet not play a causative role.
The pathology of Alzheimer’s is accompanied by the accumulation of a substance called ß amyloid peptide in brain cells, with associated death and degenerative changes in these cells. It’s thought that an imbalance between production and removal of this amyloid may be a factor causing the disease. Biochemists are untangling the multiple and diverse reactions that play a role in the metabolism of amyloid and the cellular consequences of its presence.
It’s been postulated that “oxidative” stress may play a role in the abnormal process. Dietary antioxidants occur in fresh fruits and vegetables, but there is no evidence that ingesting more antioxidants is protective. The connection between nerve cells (synapses) are often broken down in Alzheimer’s, and impaired transmission of nerve impulses has been documented in such damaged brain tissues.
Besides accumulating amyloid, Alzheimer’s brain cells show disturbed mitochondrial function, as well as disturbed responses to insulin. Blood supply is also altered, and inflammation around brain cells takes place. Calcium regulation is disordered, too. One issue as yet unresearched is the relationship of high cholesterol levels to Alzheimer’s. High serum cholesterol levels in middle-aged individuals are associated with increased risk of Alzheimer’s, and statin drugs have been shown to reduce this risk. Statins have an antiinflammatory effect, which may also be a factor. Their use and the question of their benefit are controversial.
Researchers are exploring factors such as estrogen deficiency in postmenopausal women, chronic stress, genetic predisposition, and many other potential factors.
Alzheimer’s is not the only form of dementia, and may be bearing the blame for some other age-related dementias. Currently there are no defined and conclusive mechanisms that can be blamed for Alzheimer’s, so claims about our Adventist lifestyle preventing the disease are obviously unwarranted. It could be that by living longer, more Adventists would come down with the disorder.
Send your questions to Ask the Doctors, Adventist Review, 12501 Old Columbia Pike, Silver Spring, Maryland 20904. Or e-mail them to [email protected]. While this column is provided as a service to our readers, Drs. Landless and Handysides unfortunately cannot enter into personal and private communication with our readers. We recommend you consult with your personal physician on all matters of your health.
Allan R. Handysides, M.B., CH.B., FRCPB, FRCSC, FACOG,  is director of the general conference Health Ministries department. Peter N. Landless, M.B., B.CH., M.MED., F.C.P.(SA), F.A.C.C., is ICPA executive director and an associate director of the General Conference Health Ministries Department. This is article was published January 27, 2011.