A Healthier Life for the Elderly: HRT: The Controversy Continues After Decades of Debate
By Professor Vak Yeong Yoo
As a physician, with interest and experience in osteoporosis and the menopause, I cannot emphasize enough the importance of the prevention and treatment of osteoporosis. As is now appreciated, a vertebral fracture is associated with substantial morbidity and mortality including loss of functional ability and significant loss of days at work. Moreover, once a patient has suffered a fragility fracture, the risk of future fractures increases 2-5-fold. However, because spinal fractures are largely asymptomatic, these fractures can easily go unrecognized and undiagnosed by busy clinicians. The majority of fractures are due to low BMD. At menopause, estrogen deficiency is a major factor in accelerating bone loss. Therefore, not only do doctors need to be more observant, but also after mid-life, women themselves must become more knowledgeable about changes in their endocrine physiology, if their elder years are to be as healthy as possible.
Furthermore, the reasons that we must seriously consider the issue of healthy elderly life at this time, is that by the year 2020, women over the age of 65 will account for 21% of the total American female population, according to data from the US bureau of Census. Women born between 1946 and 1964, the so-called baby boom generation, are going to have a longer life expectancy.
However, the prospects of increased life expectancy are overshadowed by the prospect of a greater incidence of chronic diseases and functional disorders such as osteoporosis. This longer life expectancy is occurring worldwide, especially among countries that were involved in the 2nd World War. Further projections place the elderly at a constant but much higher level, after the baby boom generation ages.
As the female baby boom generation enters the menopausal stage, all body organs start to deteriorate. The reduction in hormone levels, especially estrogen, leads to various symptoms. The menopausal period generally spans 4 years to as many as 10 years when cessation of ovarian function is complete. During this time, estrogen output gradually decreases but is variable from woman to woman. Representative organs that can be affected by the depletion of estrogen include bone, heart, blood vessels, breasts, urogenital organs, brain, skin and colon.
The menopausal period is a time of sharply reduced bone density and can be associated with debilitating osteoporosis. Hyperlipidemia occurs gradually after the menopause and with aging, leading to elevations in blood concentrations of undesired fats, such as low-density cholesterol and triglyceride. An obvious consequence of hyperlipidemia is coronary artery disease. The coronary vasculature can also be adversely affected directly by estrogen deficiency. It is believed that the series of pathophysiological events related to the cardiovascular system is responsible for the sharply increased incidence of cardiac disease after the menopause. Therefore, it is absolutely critical that we recognize and effectively manage this most vulnerable time of change in a woman’s life. If appropriate measures are not taken, then the chronic disorders of aging will surface earlier and be much more difficult to control.
What we need to know about our mid-life body signals is well defined. Common early symptoms of the perimenpausal period include memory lapses, depression, irritability, anxiety, insomnia, severe sweating (especially at night), hot flashes, thin, dry, non-elastic and rough skin, dry and itch vagina, frequent urogenital infections, reduced intestinal functions, and collapsed or drooping breasts. Uterine prolapse and urogenital tract dysfunction lead to an increased incidence of incontinence, which may be marked by embarrassing involuntary urination while laughing or sneezing.
Men, on the other hand, do not experience an equivalent, rapid fall in androgens in their middle years. But men can and do feel tired for no apparent reason, have insomnia, lose motivation and confidence, and have digestive or sexual problems. Although not likely, these symptoms could indicate an abrupt andropause due to disease (hypogonadism).
The logical approach to estrogen loss is estrogen replacement. The controversy surrounding its use continues, even after decades of debate. Despite the controversy, demand for HRT continues to increase, because mid-aged women recognize estrogen as a preventative agent for osteoporosis. HRT also is recognized to counter some early menopausal symptoms and may help to prevent heart disease and Alzheimer’s disease. So much is this so, that some middle-aged women have opted to use HRT as a symbol, just like cigarettes or coffee, and are proud to say, “I take estrogens!”
Over its 60-year history, HRT at one time was shunned because of perceived risks to the uterus and breast, but because of the accumulating mass of data concerning its beneficial skeletal features, the FDA approved it as a preventative agent for osteoporosis in 1988. Since then, most doctors who prescribe HRT to prevent osteoporosis are more impressed by its benefits than by its risks. This opinion is supported by reports on other positive preventative benefits of HRT with regard to cardiac disease and to Alzheimer’s disease. In retrospect, when one looks at the overall clinical performance of HRT as a preventive measure for osteoporosis, over the last 15 years, it is evident that women have benefited in terms of their overall quality of life.
Estrogen-like molecules have become available which show similar beneficial preventative and therapeutic effects on osteoporosis. These molecules, called SERMS (Selective Estrogen Receptor Modulators) have an advantage over estrogens in being anti-estrogens at the breast and the uterus. Their introduction was welcomed by clinicians, providing them with wider options for the prevention and therapy of osteoporosis. On the other hand, this good news is not without concerns, such as the association of SERMS, like estrogens, with thromboembolic disease, and, unlike estrogens, with a myalgic syndrome.
No matter how, estrogen-like treatments must be freed from their known adverse effects. On top of this list of negatives, recently an increasing number of reports have been published on the significant risks posed by, and the negative effects of some of the extra-skeletal effects of HRT, with are widely known and have been experimentally verified. It is likely that such reports may have placed clinicians in a serious dilemma and caused some confusion.
In 1998, the HERS study on the effect of HRT in the cardiac system, claimed negative effects of HRT on coronary artery disease, which was unexpected and frankly shocked the medical community. In addition, there have been reports claiming ovarian cancer as a side effect of HRT, as well as others indicating an elevated risk of breast cancer with HRT. Just recently, another report associated HRT with negative effects on Alzheimer’s disease.
Just several weeks ago, on July the 17th, JAMA published about the consequence of WHI trial which was “estrogen (0.625mg conjugated equine estrogen) plus Progestin (2.5 mg medroxyprogesterone acetate) component of Women’s Health Initiative (WHI), a randomize controlled primary trial where planned duration 8.5 years focuses non defining the risk and benefits of strategies that could potentially reduce the incidence of hearth disease, breast and colorectal cancer, and fractures in postmenopausal women. On May 31, 2002, the trial was stopped early based on health risk that exceeded health benefits over an average follow up 5.2 years .The trial concluded all-cause mortality was not affected during the trial. The result indicated that this regimen should not be continued for primary prevention of CHD.” This was no more shocked the medical community, but disappointed to HRT prescribing physicians and researchers who were expecting good news year since the HERS study, exclusively the media was interested, the news circulated throughout the world and HRT users may be confused.
These reports, which are by no means conclusive, must be weighed against much more robust positive clinical data on HRT. “A parallel trial of estrogen alone in women who have had a hysterectomy is being continued, and the planned end of this trial is March 2005, by which time the average follow-up will be about 8.5 years. And this trial was proved the benefits that decreased the rates of osteoporotic fracture and colon cancer.” Preemptive decisions to withdraw HRT for all women especially under five year users who have no coronary artery problems and hysterectomized women on the basis of reports that are still in the process of being analyzed are unwise. We must keep our eye on the goal, namely to improve the quality of life of the elderly. Withdrawal of HRT could well jeopardize our attempts to meet this goal.
In medical research, today’s “yeses” may become tomorrow’s “nos”. While we are trying to define tomorrow and to improve the quality of life, we know with certainty that amidst the present controversy concerning HRT, nothing has been resolved. Whether we use HRT at optimal doses; whether we use combinations of HRT and other agents to reduce osteoporosis, prevent cardiovascular disease, Alzheimer’s disease, and most of the signs and symptoms of the menopause, we need to be vigilant and diligent to the task.
Longevity is determined by how well our bodies compensate for the insults and injuries of life. If we detect disorders before they surface, then deficiencies can be addressed, with optimal treatments, and careful management. Life can be extended and aging can be effectively confronted. We should all then be able to look forward to a comfortable mid-life and a more serene elderly life, riddled less by pain and desolation by diseases such as osteoporosis and chronic cardiovascular disease.
Immortality is certainly elusive. This is not the point. The point is that
we should all be able to look forward to life that is not only long but also
Since 1981, Dr. Yoo has held the post of Head of the Medical Examination Center. From 1981 until 1992, Dr. Yoo was Director of Yoovakyeong Internal Medicine. She has also served as Head of the Menopause and Osteoporosis Unit since 1992. In addition, Dr. Yoo serves as Director of the Cheongvak PrimeBeyond Hospital and also as Leader of NOF YVY -QOL Osteoporosis. On October 24, 2000, Dr. Yoo was appointed as visiting Associate Professor in the Department of Medicine of The University of Nairobi. Dr. Yoo is editor and publisher of the Journal of Meno/Osteoporosis. She has been active with the Scientific Committee and the Editorial Committee of the Korean Society of Menopause. In 1998, Dr. Yoo was the founder of YVY-QOL Support Group for Menopause and Osteoporosis, and founded the YVY-QOL Medical Research Institute.
As a recognized professional in her field, Dr. Yoo has received several awards for her research conducted at YVY-QOL MRI. In addition to the BWW Society/IAPGS, she is also a member of various associations, including the North American Menopause Society, The Endocrine Society, the American Society of Bone and Mineral Research, and the NOF Professional Partner Network. To relax, Dr. Yoo enjoys singing, listening to music and spending time on the computer.
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