Thirty-nine million baby-boomer women have begun, or are entering, menopause. Most will experience one or more menopausal symptoms including hot flashes, insomnia and vaginal dryness. And a large number will be faced with the decision of whether to take hormones such as estrogen, progestin and progesterone. Currently, as many as 32 percent of women in the United States are receiving hormone treatment of some kind.
It's not an easy decision to make: The slim body of information available on hormone therapy is often incomplete, contradictory and downright confusing. Hormones have been shown to alleviate unpleasant menopausal symptoms, and many studies show they reduce a woman's risk of death and suffering from heart disease and osteoporosis. At the same time, so-called hormone replacement therapy is linked to breast and endometrial cancers. And a recent slew of inconclusive studies indicates that taking hormones may reduce a woman's risk of getting ailments such as Alzheimer's disease and strokes, but increase the risks for gall-bladder and thromboembolic diseases.
Dr. Susan Love attempts to dispel the confusion around hormone treatment with her latest offering, "The Hormone Book." Love is best known for "Dr. Susan Love's Breast Book," a women's guide to the prevention and treatment of breast cancer, based on more than 20 years of her work as a breast surgeon. In 1991, she co-founded the National Breast Cancer Coalition, which has drawn national attention to the issue and raised research funding by millions of dollars. She is now a professor of surgery at the University of California at Los Angeles.
Love's career has not been without controversy. A champion of breast-conserving surgery -- a lumpectomy followed by radiation, instead of a radical mastectomy -- she's been accused of risking women's lives for cosmetic reasons. Now critics claim her stance on hormone therapy -- in most cases she thinks it should be used only as a last resort -- is skewed in favor of preventing breast cancer over preventing heart disease, which kills an estimated 485,000 American women a year, nearly 10 times the number who die of breast cancer.
Love's endorsement of herbal and other
alternative treatments has also drawn criticism from some members of
the medical community. In Sunday's special Women's Health section of the
New York Times, Dr. Richard Friedman, director of psychopharmacology at New York Hospital-Cornell Medical Center, dismissed the notion of herbal remedies as "romantic."
"Like all ideology, it's dangerous," Friedman was quoted as saying. "The bottom line should be, if it works and it's safe and effective, what does it matter where it came from?"
Love's personal life has raised eyebrows in the traditional, conservative medical establishment as well. An open lesbian, she has lived with her companion, Helen Cooksey, since 1982. In 1988, using sperm donated by Cooksey's cousin, Love gave birth to their daughter, Kate Cooksey Love.
Salon spoke with Love by phone at her office in Los Angeles about the pros and cons of hormone therapy, the misconception of menopause as a "disease" and the possibility of eradicating breast cancer in the next five years.
Hormones and menopause are a change of topic for you after dealing with breasts and cancer for so many years. What made you decide to switch gears?
It's not really that much of a change in topic. The question I was asked most commonly by my patients and by women when I gave talks about breast cancer was: "Are menopausal hormones safe?" I also became very concerned at what I saw as this growing, almost universal use of hormones, and people ignoring the breast cancer risks associated with them. So it's really part of the same breast cancer story, but just a little broader. The other part of the story is that I'm 50 and was flashing myself so I decided to figure it out.
What was it like to be going through something and writing about it at the same time?
It was good. Granted, I don't think every doctor has to get the disease they specialize in, but I do think it gives you much more insight into what you're talking about.
Part of what you do in the "Hormone Book" is clear up confusion about exactly what menopause is. What are some common misconceptions?
The notion of menopause has been that your ovaries just shrivel up, dry up and become useless. That's been the image of postmenopausal women to boot. In fact, that's not the case. Women who go through natural menopause continue to make hormones well into their 80s, albeit at a lower level. We need high levels of hormones to reproduce, but we don't need to have them as high throughout our lives.
You are fairly critical of pharmaceutical companies and, sometimes, of other doctors.
Pharmaceutical companies have marketed hormones to us and to physicians pretty strongly, and the message has not always been totally accurate. At this point in time, we actually have not proven that hormones prevent heart disease, and yet that's the message that's out there. [Proponents of hormone therapy] believe all the observational data that says taking hormones may prevent heart disease, yet they pooh-pooh the observational data that shows it may lead to breast cancer. You can't have it both ways.
Also, the reframing of menopause as a disease or at least as a deficiency needs to change. Calling hormone therapy "replacement therapy" implies that you're replacing something that's missing rather than adding something that's not routinely there.
So calling menopause a disease or a deficiency isn't accurate?
Those words imply that the premenopausal woman is normal and the postmenopausal woman is diseased and needs to be fixed or replaced or put back into a premenopausal woman. That's crazy. Menopause is programmed in and it's programmed in most likely because it's not good for us to have high levels of hormones at all times.
What do you think this misconception stems from?
Maybe part of the reason for this misconception is that the model for how we deal with menopause is having your ovaries out. The assumption is that women who go through natural menopause will experience exactly the same thing as women who have their ovaries out, which is not true. The fact is, since most women have some hormone production well into their 80s, the ovaries don't stop working, they just shift to a different level. Also, maybe that lower level is adequate for preventing things like osteoporosis, one of the main reasons women are prescribed hormone therapy. There's a new study showing that women who have at least 5 picograms of estrogen, which is a very small amount, actually have 50 percent less osteoporosis. So you don't have to be making hormones at the levels of a premenopausal woman in order to prevent osteoporosis.
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Last month, the New York Times ran a story about the drugs Tamoxifen and Raloxifene, and reported that they might not only delay breast cancer, but -- Tamoxifen particularly -- possibly prevent it. What is your take on these two drugs?
The effects of Tamoxifen were only studied over four and a half years. There's some evidence -- or concern -- from the literature that after five years the cells may become resistant to the drug and we may in fact see an increase in risk for breast cancer. There are also other downsides. It can cause endometrial cancer as well as phlebitis and pulmonary embolism. So if you look at the deaths in the study written about in the New York Times, in the placebo group there were five deaths from breast cancer. In the Tamoxifen group there were five deaths -- three from breast cancer and two from pulmonary emboli. So it's not actually decreasing death, it's just shifting one disease to another. I'm not sure that's the way we want to do prevention. On Tamoxifen, if you don't die from one thing, you'll die from another. It's not preventing, it's merely changing what you die from.
Isn't there any good news here?
It's interesting that we've shown that a drug can have some effect in terms of prevention. I think that part of it is good. I'm not sure this is the drug that we want to use. With Raloxifene, the data is only two-year data, so it's much too soon to know whether it really does prevent breast cancer. It's not as good a drug for osteoporosis as estrogen; it's not as good on cholesterol as estrogen and it causes hot flashes. As is often the case, the first drugs of a new genre are not always perfect. Maybe we'll do better. But I would like to see us not use drugs for prevention. I think there are safer ways to do prevention.
Exercise will decrease breast cancer, osteoporosis, heart disease, colon cancer and Alzheimer's -- and you feel morally superior. A diet that's low in fat and high in fruits and vegetables really makes a difference. Not smoking -- almost all premature heart disease is in smokers. We tend to go directly to drugs as a mode of prevention and don't emphasize that the foundation has got to be lifestyle changes. If you still need to add drugs on top of that -- for example, people who are very high risk for something -- then that's a different matter.
As I read through your book, I got a little frustrated, because it seems if a woman wants to eliminate some of the less pleasant aspects of menopause and prevent osteoporosis, then she risks breast and endometrial cancer. It seems there's no winning.
It's not like we're going to prevent death entirely last time I checked. So what people really want is to reduce and prevent suffering and disability. There was a very interesting study that came out in the last month or two in the Journal of the American Medical Association. They looked at three factors in people at middle age: weight, smoking and exercise. If you had maintained a healthy weight, didn't smoke and exercised, then you reduced the disability at the end of your life by six years. I don't think we care whether we live to 87 or 86. We don't want to suffer. We don't want to be disabled. I think that's what a lot of this is about: getting rid of premature, early death and getting rid of suffering and disability. The way to do that is first with lifestyle changes, and then, only in those people who really still need it, you consider whether you want to add drugs.
So when do you recommend hormone treatment?
It depends on the woman. When the symptoms are really interfering with the quality of women's lives and they don't feel like they can deal with it, then short-term use for three to five years is reasonable. For prevention, I don't think we have the data to recommend it universally, so women are going to have to look at their own situations -- what they're at risk for, what scares them, what their lifestyle issues are -- and make their decisions based on that.
The other issue that is important to remember is that this is not a one-time decision. You're making the best decision you can for the moment and this stuff is changing every two weeks. So all you can do is make the best decision you can make for right now and reevaluate as things change. I think sometimes women get this notion that this is a big life-and-death decision and if you choose wrong, you die, and if you choose right, you live. It's just not. This is prevention. You're talking about preventing something you may or may not get down the road. We make prevention decisions all the time. We decide whether to put our seat belts on or not. You decide whether to eat that extra piece of chocolate cake.
At the end of the "Breast Book," you talk about wanting to eradicate breast cancer so your daughter's generation won't have to worry about it. How will this happen?
I think what we really need is a pap smear kind of thing. With the pap smear you've got levels one, two, three, four, five. And five is cancer and four is precancer. Two and three are somewhere in the middle there. What we need to do is find breast cancer when it's at two or three, just like with pap smears. Then you go in and get fixed. We'll just fix it before you ever get the cancer. And I think that's going to happen in the next four or five years. That's what I'm working on now -- research that's going to lead to that approach. I don't think surgery and radiation and chemo are the answers. We just need to prevent it.
So perhaps it's premature to look at Tamoxifen and drugs like that as the hope, but there is hope. The optimism isn't unfounded?
Oh yeah. I think that even drugs like Tamoxifen or Raloxifene offer some hope. I don't think drugs are the answer to all life's problems, but for women who are very high risk or maybe have precancerous conditions, to take them for five years now may make sense for them. I'm not against any of these things. I'm just against this notion that everybody should be on drugs forever. But there certainly are people for whom that may be a choice. And I think we're going to have better and better choices, because breast cancer is a moving target.