HRT:
Question Doctors Before You Pop More Pills

FRANCES CERRA WHITTELSEY / Newsday 2dec03

It's not easy to look your doctor in the eye and ask tough questions about a drug that's just been recommended. We live in an era of "medicalization," a time when we have been taught - by drug company advertising and some of our doctors - that there is a pill for almost everything.

It's harder still to be skeptical when the medication in question is being used by many of your friends. If the doctor also argues that not using the drug may raise your risk of serious illness, then questioning may seem to border on the irrational.

But if more Long Island women had resisted taking hormones for menopause symptoms, oral contraceptives for birth control and hormones to prevent miscarriage, it is possible, and perhaps likely, that fewer of us would have developed breast cancer.

That is because, for decades, the medical profession minimized the risks of hormone treatments. Thanks to concerted campaigns by drug manufacturers, they maintained the benefits of treatment outweighed the undeniable fact that most breast cancer is estrogen-dependent. This is why, of course, any woman diagnosed with the disease must immediately stop taking hormones and also take drugs like tamoxifen that block the action of estrogen.

For years, Long Island breast-cancer activists have been searching for an explanation for the high rate of breast cancer on Long Island. They had hoped that the Long Island Breast Cancer Study, which they instigated, would provide one. But the study did not find a strong link between the disease and exposure to two large groups of chemicals. It did, however, connect higher risk with higher income, a connection that has both puzzled and angered some survivors, who see in it the suggestion that they have somehow helped cause their disease.

The book "The Greatest Experiment Ever Performed on Women" offers a disturbing explanation for the connection. Author Barbara Seaman asserts that higher-income Long Island women have suffered more breast cancer because they tried their best to take care of themselves. Simply put, they had the money to visit their doctors regularly and pay for synthetic estrogen in the form of diethylstilbestrol - which caused horrible birth defects and did not prevent miscarriages - as well as birth-control pills and hormone-replacement therapy.

Certainly, there is an element of sexism in this sorry story, but the larger lesson lies in understanding how doctors were persuaded that the benefits of hormones outweighed their undeniable risks. One of the most telling episodes related by Seaman deals with their purported benefit to the heart.

In June 1990, the drug manufacturer Wyeth-Ayerst asked the U.S. Food and Drug Administration (FDA) to add prevention of heart disease to the list of approved uses for Premarin, its brand of estrogen. The company's claim for effectiveness was based on a study of the health of women who were users of Premarin versus a group of non-users. The Premarin users had fewer heart problems than the non-users so, the drug company argued, Premarin prevented heart disease.

The staff of the FDA, to its credit, refused to approve the drug for heart-disease prevention, deciding to wait for the result of a double-blind study, the gold standard of medical trials. Such a study involves setting up two matched groups; one is given the drug and the other, a placebo. But, while the FDA waited, the drug companies and the leading doctors who are their paid consultants did not. They touted the heart benefits of hormone-replacement therapy, and many doctors, trusting their learned colleagues, pressed the drugs on women.

Then, last year, researchers halted the double-blind study early when it became clear that Premarin actually raised the incidence of heart attacks, while also raising the risks of hormone-dependent cancers. As for the earlier study, the healthier hearts of the Premarin users, it turned out, were due to the fact that they exercised more. Oh.

It's a hard lesson. We all want to trust our doctors. But we must ask tough questions before we pop more pills. What kind of study showed the benefits of the drug? Were the subjects of the study like you - your age, your gender, your test results? What are the risks, the side effects? How long has the drug been in use? Are the long-term effects known?

Women have paid a high price for their trust in doctors who, as Seaman puts it, allowed "some drug manufacturers to pull the wool over their eyes." Let's at least learn from the experience. Let's make the slogan, "Ask your doctor," really mean something.

Frances Cerra Whittelsey, a journalist and author, is a former features editor at MAMM, a women's cancer magazine.