MEDICINE Valley doctor will continue to prescribe therapy despite findings

The results of the study caused many women to call doctors' offices around the Valley.
By WILLIAM K. ALCORN
VINDICATOR HEALTH WRITER
A Mahoning Valley gynecologist says going off hormone replacement therapy may pose greater health risks than those cited in a new study that says hormones place women at greater risk for breast cancer, heart attacks, stroke and blood clots.
The results of the study, published this week, caused many concerned women to call doctors' offices around the Valley.
However, Dr. Anthony R. DeSalvo, whose practice is in Howland, said he "absolutely" will continue to prescribe hormone replacement therapy for menopausal women when appropriate.
As part of the study, conducted by the Women's Health Initiative and supported by the National Institutes of Health, 16,000 women took either hormone replacement therapy drugs or a placebo. That portion of the study was stopped when it was discovered that the use of estrogen and progestin caused slight increases in breast cancer, heart attacks, strokes and blood clots.
Another Valley gynecologist, Dr. Douglas E. Van Rees of Canfield said the new study will make it more "difficult" to prescribe the hormone therapy.
He said doctors must look closely at a patient's personal and family history to evaluate the risk vs. how the patient feels before recommending it, he said.
Life expectancy
Dr. Van Rees said the main reason to prescribe hormone replacement therapy is to extend life expectancy. But he said that for the last two years, he has not recommended hormone therapy to prevent heart disease.
However, Dr. Van Rees said, there are many aspects to consider when a woman goes off hormones, such as quality-of-life issues. Every part of the body, including the brain, has estrogen receptors, and when they are deprived, hot flashes, night sweats, short-term memory loss, sleep deprivation and vaginal dryness can occur.
When asked how much stock he puts in the new study's results, Dr. DeSalvo said: "None at all."
First, he said, the study is backed by Wyeth Pharmaceuticals and tested only Wyeth's brands -- Prempro, a medroxy progesterone acetate, and Premarin, an estrogen.
"The study's results were for Premarin and Prempro and cannot be generalized to other brands because they are all different in some respect," Dr. DeSalvo said.
There is not just one hormone replacement therapy any more than there is just one blood pressure medicine, he said.
Finally, Dr. DeSalvo said, most of the information was already known. He said earlier studies indicated there was a relative risk factor of 1.4, with 1.0 representing no effect, for women on hormone therapy to develop breast cancer, and it was not considered clinically significant.
The relative risk factor for Prempro for developing breast cancer is lower, at 1.26, which he said translates to an increase for breast cancer of eight cases per 10,000 women using the medication.
Dr. DeSalvo said doctors also already knew that there was a relative risk factor for blood clots with hormone replacement therapy.
"That's why we don't give Prempro to people with blood clot problems," he said.
New evidence
However, he said there was one piece of new evidence resulting from the study -- that the risk factor for colorectal cancer is 0.6, which means using Prempro is a benefit in that area.
Colorectal cancer is the third leading cause of cancer deaths among women, behind lung and breast cancer, he said.
He also backed the importance of hormone replacement therapy to maintain bone strength and for osteoporosis, which he said is "no disease to discount." He said 20 percent of postmenopausal women who suffer hip fractures die, and another 20 percent end up in a nursing home and never leave.
What's getting glossed over, Dr. DeSalvo said, is that the part of the study in which women are taking Premarin only is continuing because no increased risk for breast cancer was found.
Dr. Van Rees said he has recommended that women, if they are concerned, stop taking hormones for a month and see what happens. There is no medical danger involved, he said.
But, he said, when women come off estrogen therapy, they may have a menstrual period. He predicted 30 percent to 40 percent would experience mild symptoms; 30 percent to 40 percent, no symptoms; and the rest, intense symptoms. They should wait for a month to see how they are feeling and then consult their doctors, he said.
There are quality-of-life issues vs. quantity-of-life issues, Dr. Van Rees said.
For instance, "You still have to consider osteoporosis, but there are other medications available for that," he said.
Researchers are getting closer to developing hormones that control menopause symptoms while not increasing the risk for disease. But the perfect hormone has not yet been developed.
Dr. Van Rees said it is guaranteed that another study will come out that will further confuse the issue.
In the meantime, he noted that the American College of Obstetrics and Gynecology has said estrogen replacement should be individualized.
The bottom line, said Dr. DeSalvo, is that there isn't anything in the study that wasn't previously known except about colorectal cancer.
"If it [the study] is an eye-opener ... if there is a bad apple, we can't generalize this to all estrogen and progesterone use," he said.