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THE
PILL AFTER 40 AND ERT...
TWO
TROUBLESOME CONTROVERSIES
One
of the not-so-positive consequences of having women's
health be such an open topic of discussion is that,
with a plethora of scientific research and data
available, there are bound to be conflicts of
information.
This,
unfortunately, is the situation with two important
choices for women who have entered what is
euphem-istically referred to as their middle years.
That is the time of "reproductive
limbo" before the "M" word takes place,
while some method of contraception may still be
necessary. When
menopause does occur, the question of whether or not
to begin estrogen replacement therapy (ERT) must often
be addressed.
For
many women, these issues represent true dilemmas -- a
choice between equally
unsatisfactory alternatives.
In the final analysis, the choice becomes a
process between a woman and her doctor.
Reaching the decision, however, should also
involve gathering
a good sampling of pertinent information helps
to make the
judgment as informed as possible.
THE
PILL...IS IT SAFE?
In 1989, when the Food and Drug Administration (FDA)
announced that oral contraceptives were safe for women
to use without interruption until menopause, the
announcement was met by overwhelming silence. What the FDA considered to be a major policy change was all
but ignored by women because "The Pill" had
developed a bad reputation over the years, primarily
due to reports that it caused -- or was linked to
--various kinds of cancer and serious cardiovascular
problems.
The
American College of Obstetricians and Gynecologists
became concerned because public opinion polls showed
that people thought that the pill was more dangerous
than pregnancy. The
medical organization's publications argued that women
were four times more likely to die from complications
related to pregnancy than from the pill, and pointed
out that the risk in either case is very small.
RISKS
AND REWARDS
There
have been a lot of changes in oral contraception since
it was first introduced in this country in the 1960's.
For starters, both the pill itself and
prescribing practices are safer.
The pills today, for example, contain about
half the estrogen as was in the original formulation,
so there are fewer side effects.
There is also less progestin (the pill's other
active ingredient) in the formula.
Research
has discovered that the earlier hazards of using the
pill were confined almost exclusively to two groups of
women who made up only a small segment of users:
women who smoke and hose
who were already at high risk for cardiovascular
disease.
Today,
before prescribing the pill, the potential users are
thoroughly screened for heart disease risk factors,
family history and -- perhaps most importantly -- they
are questioned about their smoking habits.
Research
has revealed a very strong synergy between
smoking and taking the pill that does significantly
increase the risk of heart disease.
For women who do not smoke, however, many
scientists believe that taking the pill may actually
work in their favor by protecting them against heart
disease.
There
is also updated information about the two biggest
fears related to the use of birth control pills:
blood clots and breast cancer.
Because of the estrogen in the pill, there is a
small increased risk of blood clots forming in the
veins, so women who have clotting disorders or
phlebitis should avoid taking them.
For those with no history of clotting
disorders, the risk of a blood clot forming is
virtually nil. Experts
argue that the natural rise of estrogen in the body
during pregnancy poses a higher risk of blood clots
than taking the pill does.
As
far as the link to breast cancer, current studies
suggest that there is a much stronger relationship or
link from a family history of the disease or delayed
childbearing.
If
you really want to start an intense debate in a room
full of women just ask, "When the body stops
making estrogen, should it be replaced?"
There are no easy answers because every woman's
circumstances are unique to her.
It
has been well documented in both science and fiction
that menopause (or more accurately the drop in
estrogen) can produce a wide range of side effects --
ranging from minor inconveniences to major,
life-threatening conditions.
As far back as the 1940s, doctors found that
ERT could ease the hot flashes and mood swing
problems.
Thirty
years ago, estrogen replacement somehow got the
reputation for being a "fountain of youth"
so women badgered their doctors for the promising
therapy. The
euphoria quickly evaporated when there was an epidemic
of uterine cancer in the 1970s.
Estrogen users discovered that their risk for
uterine cancer had increased about six fold.
Later
research added still more concern by suggesting a
possible link between estrogen therapy and breast
cancer. It
didn't take long before demand for the therapy
vanished.
Now
that additional research has resolved some of the
earlier fears, doctors are once again recommending ERT
for their patients. They found, for example, that giving estrogen in combination
with progestin would counteract the risk of uterine
cancer.
Research
over the past 15 years or so has overwhelmingly
demonstrated that estrogen therapy can help ward off
heart disease in post-menopausal women.
This, more than any other findings, has helped
swing the pendulum in favor of estrogen replacement.
Heart
disease is the number one killer of American women age
50 and older, and affects one-third of them between
age 50 and 75. Half of them die from heart disease. Out of 21 studies completed on the effect of estrogen on
heart disease, 17 of them found that ERT lowers the
risk.
The
most compelling of these studies is the Harvard
Univeristy Nurses' Health cohort study which kept
track of 48,000 nurses for at least 10 years.
The results reported in the New England Journal
of Medicine showed that the nurses who had used
estrogen experienced half the risk of heart
disease than non-users had. Researchers may not thoroughly understand exactly how
estrogen produces such favorable results, but the
benefits speak for themselves.
ESTROGEN
AND BREAST
CANCER
Even
though estrogen has certainly demonstrated some
impressive benefits in reducing the risk of heart
disease, there are still some concerns about the
relationship to increased risk for breast cancer.
More than 30 studies have been conducted since
1974 to resolve this issue, but the answer remains
elusive. The
general consensus is that ERT involves less risk of
developing breast cancer than having a mother or
sister with the disease.
Experts
now speculate that supplemental estrogen does not
initiate breast cancer, but it could promote the growth
of tumors already present.
Once the therapy is ceased, however, the risk
of tumor growth seems to diminish rapidly.
Estrogen
replacement therapy does play a favorable role in
preventing osteoporosis, a bone-thinning disorder that
affects four in 10 older women.
Many
doctors believe that the benefits of delaying
osteoporosis and heart disease by 10 years or more by
taking estrogen far outweighs the minimal risks for
developing breast cancer.
They point to some very impressive statistics:
each year about 251,000 women aged 50 or over
die from heart disease, versus some 39,000 who die
from breast cancer.
If you assume that estrogen could cut the
number of fatal heart attack victims in half,
widespread use of ERT could be responsible for saving
more than 100,000 lives each year.
There
is no magic formula. It all comes down to the
individual woman...how she looks at her own
priorities, and what risk factors she already faces
for heart disease and cancer -- and then how she
weighs the potential benefits against the possible
risks. Its
up to her --with the help of her doctor -- to make an
"educated" decision, then to follow up with
regular exams and careful monitoring.
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