Midlife part 4(a)
How women were misled, the ultimate clickbait, having discernment and how to have discussions with integrity.
Part 4 is separated into two parts purposely because I really want to emphasize this first piece of information. The topic of hormone replacement therapy (HRT) or menopausal hormone therapy (MHT) can be so polarizing (from all sides) that it can be difficult to have open conversations about it with others. Or we may find ourselves already so biased without truly understanding why. Both were the case for me.
What you will find in this newsletter
Why and how this topic interested me. (open to all)
Dr. Peter Attia on the Andrew Huberman podcast discussing the WHI study. (open to all)
A digestible bullet point of their discussion. (open to all)
Knowing relative risk vs absolute risk. (open to all)
Some words from OB/GYN and Author Dr. Jen Gunter. (open to all)
More thoughts from me and my POV on the topic now. (paid subscribers)
Questions to ask yourself and discuss with a trusted healthcare provider. (paid subscribers)
An informative and entertaining article on menopause that is a nice break from the scientific literature. (paid subscribers)
A 30min video with additional links to how you can become more informed on the art of reading scientific studies. (paid subscribers)
And I wrap this all up by sharing one of my biggest pet peeves and how we can all become pillars of integrity when it comes to defending our POVs. (paid subscribers)
And of course all of the sources, plus additional goodies and book recommendations under resources.
“It’s hands-down the biggest screw-up of the entire medical field in the last twenty-five years. I’m pretty confident that I won’t be able to think of a bigger act of incompetence than what happened with the Women’s Health Initiative in the late 1990s and early 2000s, which is effectively the study that turned the entire medical field off hormone replacement therapy for women”
- Peter Attia, MD, on the Andrew Huberman podcast ep. 85
I know I shared this quote by Dr. Peter Attia in another newsletter, but it’s worthy of a second and third share, maybe even more. I also shared that when I started researching hormones, I started at the bottom. In nursing school, there weren’t nearly enough opportunities to learn about hormones, and when we did cover the topic it was surface-level learning.
And up until 2020, I really didn’t need to think about hormones other than when I was suffering from PMS, and they were an easy target to blame. Not even when I was diagnosed with stage IV endometriosis that required two surgeries, one that took my right ovary and fallopian tube, did I think maybe I should learn more about this. Nope, I just continued on my way with my head in the sand.
It wasn’t until I was neck-deep in perimenopause and hormone hell that I came across the work of the World Health Initiative. Or should I say all of the work that the WHI got wrong? Really wrong. I was shocked and suddenly aware of my own bias when it came to three little words - hormone replacement therapy. And it dawned on me that this study was where my truly uneducated but passed down (not dissimilar to an old wives tale) bias had come from.
The reason I really want to dig into this is that I personally had no idea why I, like most women I’ve noticed, shudder when the topic of HRT is talked about. Not because I knew anything about it, but on some subconscious level, it had been ingrained in me that HRT unequivocally equals a future with cancer.
Sharing this clip again. Digestible bullet points are below the video.
Decades ago the medical world recognized the difficult symptoms a woman has going through perimenopause and post-menopause. Such as hot flashes, night sweats, trouble sleeping, brain fog, vaginal atrophy, vaginal dryness, osteopenia, osteoporosis, etc.
Recognized replacing estrogen can help alleviate these symptoms and this became standard. Until realizing that estrogen alone can increase the risk of uterine cancer.
Updated the practice of replacing estrogen alone to replacing both estrogen + progesterone in order to protect the uterus. Standard and accepted care for HRT in the 1970-90s.
1990s medical world states the epidemiology is showing that women on HRT are feeling better (symptoms lessen/go away), a lower risk of heart disease, bone fractures, and diabetes. NIH (National Institutes of Health) wants a proper study on the use of HRT.
WHI (World Health Initiative) becomes the entity that would do this study.
The women chosen in this study were all post-menopause and not at the age when you would normally start HRT. This was done because the study wanted to know death rates. Younger women wouldn’t die in the time frame they wanted this study to be completed.
The average age of women in this study was 63. In reality, the average age of a woman entering menopause is 51.
The comorbidities of the women in the study were also high. For example, 30% (ish) were smokers. The prevalence of obesity and diabetes was also high (as per Peter “enormous”).
None of the women in this study were symptomatic.
The actual hormone that was used in this study was a conjugated equine estrogen CEE (urine from pregnant mares). Also known as Premarin. The exact hormone my (now fired) PCP impulsively prescribed me when I asked about HRT. I spoke about this here. And MPA (medroxyprogesterone acetate, synthetic progesterone).
The HRT products used today are different. They are known as bioidentical estrogen (estradiol) and bioidentical progesterone (micronized progesterone).
When the preliminary results of this study were made available (not yet peer-reviewed or published) there was a press release. In this press release, the headline was along the lines of the Largest study on women’s use of hormone therapy has been stopped due to higher incidence of breast cancer.
Now granted that anything scary and polarizing is a catchy headline, we call that clickbait these days. But it turned out not to be true. Unfortunately, that big catchy headline lived on. IT STILL LIVES ON.
Relative risk reduction vs. Absolute risk reduction
Relative risk reductions give a percentage reduction in one group compared to another. These can be misleading and over-exaggerate how helpful something is. Absolute risk reductions give the actual difference in risk between one group and another.
Listed under resources, I have added a short and as non-dry as possible video on the concept of RRR vs ARR.
The well-orchestrated release of information to the media in the summer of 2002 was problematic on several fronts. Principal investigators of WHI did not have an opportunity to review the data, which was not completely adjudicated, and the results were rushed to publication and disseminated to the media. Here the statements were dogmatic, and there was no explanation of the differences between relative risk and absolute or attributable risk.
The relative risk in the WHI cohort that was published was 25%. The absolute risk reduction was an increase from 4 women in 1000 to 5 women in 1000. This means the ARR was 0.1%. An increase, yes. But a 0.1% increase.
CONTEXT: Going from 4 to 5 is in fact a 25% increase. However, it is taken out of context. This is why knowing how to read and interpret studies is so imperative. This is why when talking about any sort of risk percentage, the ARR must be known. Otherwise, RRR means nothing without ARR other than it can be used in any way the author wants the reader to lean towards.
Overall, the data suggests no increased risk of death with hormones for women younger than 60 years who are within 10 years of menopause and there may even be a net benefit. There is an increased, though still very rare, risk of stoke and blood clots. The increased risk of breast cancer is 1 woman out of 1,000 per year. For perspective this is also the risk of breast cancer from drinking one glass of wine a day. There is a definitive decrease in osteoporosis and possibly a reduction in heart attacks. One analysis suggests in the 10 years after hormone therapy became tainted with risk between 18,000-91,000 women may have died prematurely because either they or their doctors feared estrogen.
-Dr. Jen Gunter. Author of The Menopause Manifesto
“For perspective this is also the risk of breast cancer from drinking one glass of wine per day.”
Did you catch that line in there? Yes, the final piece to this whole midlife series (part 5) will be all about the alcohol consumption of the middle-aged woman.