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Doctor discusses risks, benefits of controversial treatment

Andrew Thagard | Wednesday, March 31, 2004

Dr. Marguerite Shepard, professor emerita of obstetrics and gynecology at Indiana University School of Medicine and a nationally renowned expert in reproductive endocrinology, lectured Tuesday on the risks and benefits of hormone replacement therapy. The talk marked the second in the 10th annual “Mini Medical School Lecture Series” presented by the South Bend Center for Medical Education and sponsored by the Medical Education Foundation.Shepard, who received her medical degree from Johns Hopkins University, said that hormone replacement therapy has the ability to relieve many of the symptoms that menopausal women experience but may also have some deleterious effects.Hormone replacement therapy involves administering estrogen or a combination of estrogen and progesterone to ease symptoms of Menopausal Syndrome including hot flashes, night sweats, weakness, memory loss, anxiety, depression, joint pain and decreased sexual desire. The menopausal transition age range is 35 to 60 and the severity of the symptoms varies between individuals.”This [menopause] is not a sudden thing,” Shepard said. “It is a gradual process and it is more prominent in some than [in] others.”Although about 20 percent of women will have only mild symptoms, others will experience more extreme hot flashes, which hormone replacement therapy can help alleviate, Shepard said. She emphasized the importance of communicating with health care providers and seeking early treatment.”Early treatment is important,” Shepard said. “One shouldn’t wait until things get beyond the point of no return.”The options of managing menopausal symptoms, Shepard said, include ‘toughing it out,’ estrogen or estrogen and progesterone therapy, alternative medicine and lifestyle modifications.While ‘toughing it out’ may only be an option for those who have mild symptoms, Shepard said, making minor adjustments to a person’s lifestyle, including eating a healthy diet, exercising moderately and taking calcium and vitamin D supplements to combat osteoporosis, is something that everyone should consider.”The choice that you’re going to make may be situational,” she said. “The woman who is working might have a shorter fuse than someone who is retired. It’s a choice that has to be made by you.”Estrogen therapy has the potential to alleviate vasomotor symptoms, reduce vaginal atrophy and urogenital symptoms and prevent osteoporosis. Some studies, Shepard said, also show a reduction in the risk of primary coronary artery disease, colorectral cancer and overall mortality.At the same time, however, hormone replacement therapy can also increase the risk of developing endometrial cancer if estrogen is administered in the absence of progesterone and strokes and, to a lesser extent, breast cancer.”The increased risk of breast cancer is there regardless of whether you take hormones, though there may be a slight increase [with hormones],” Shepard said.She criticized the media’s coverage of a World Health Initiative study which led many women to abruptly discontinue their therapies without consulting a physician – a potentially dangerous decision, she said.”There was just this panic,” Shepard said. “This is an example of how data can be manipulated in the popular press.”The WHI discontinued a study involving conjugated equine estrogen in 2002 because of fears that it causes adverse cardiovascular effects, particularly strokes.”The stroke risk was not one such that people should stop immediately,” Shepard said. “Much of the results were not statistically significant.”She criticized the studies for only using one form of estrogen and progesterone to be cost effective and the use of women with a median age of 63 – none of whom had menopausal symptoms. The study was conducted in this manner to prevent certain groups from realizing they received the placebo after their hot flashes remained.”The criticism is if you’re trying to prevent something you need to start [prior to when] all the damage occurs,” Shepard said.The current recommendations for hormone replacement therapy are that it should be used for the relief of moderate to severe vasomotor symptoms, including hot flashes and night sweats, and not as a first choice to treat vaginal atrophy and osteoporosis.Treating the symptoms individually, as they occur may be a viable option for some. Alternative medicine, including acupuncture, muscle relaxation techniques and relaxation responses, may also prove effective, Shepard said. She warned, however, against the use of over-the-counter, non-FDA approved products which may lack appropriate concentrations, be inappropriately prepared or not achieve what they promise.”Your skin cannot extract progesterone from wild yam cream,” Shepard said, adding that it must be altered in a laboratory first.The “Mini Medical School Lecture Series” will continue next Tuesday with a presentation by Psychologist Dominic Vachon titled “Transcending Suffering: Spirituality and Maintaining Compassion in the Encounter with Human Pain.”