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The 'Pause
The menopause podcast with unfiltered conversations about the symptoms you hate, the changes you didn’t see coming, and the hilarious moments midlife can bring. You've got questions and we've got the experts to answer them.
The 'Pause
Estrogen Isn't the Enemy: Unpacking 20 Years of Menopause Misinformation
Hormone replacement therapy has been widely misunderstood since alarming headlines in 2002 claimed it caused increased risks of breast cancer, heart attacks and strokes based on the Women's Health Initiative study. We unpack what the study got wrong, how the data was misinterpreted, and what 20 years of reanalysis reveals about the actual safety profile of HRT.
• The WHI study results were released to media before peer review, creating widespread fear about hormone therapy
• Study participants averaged 62.5 years old, a decade past typical menopause onset
• The reported increased breast cancer risk wasn't statistically significant when properly analyzed
• Over 40% of study participants were current or former smokers, a factor not properly accounted for
• The study only tested specific synthetic hormones (Premarin and PremPro), yet warnings were applied to all hormone therapies
• Medical training on hormone therapy essentially stopped after the study, leaving providers unprepared
• Women have to advocate strongly for themselves to access appropriate hormone therapy today
• The WHI study did provide valuable research on women's health, especially regarding osteoporosis prevention
• Finding menopause-informed providers remains challenging but support groups can help
Join our Facebook group called The Pause Diaries where women actively discuss menopause experiences and share resources for finding knowledgeable providers.
Welcome to the Pause, the menopause podcast, with unfiltered conversations about the symptoms you hate, the changes you didn't see coming and the hilarious moments midlife can bring. I'm your host, val Leggo, and I've been a dedicated health reporter for 25 years and I wanted to normalize something that every woman goes through menopause. So together we're going to talk about it the Perry, the Menno and the Post. Welcome to the Pause. In this episode of the Pause, we're taking a look at one of the most misunderstood and, honestly, the most feared topics in women's health hormone replacement therapy.
Speaker 1:You may often hear it HRT, I'm taking HRT, I'm going on HRT. Now, if you were anywhere near a news headline back in 2002, you probably remember this. Hrt causes breast cancer, heart attacks and strokes, and I remember what this did to so many women. I remember women stopping their hormone therapy because they were afraid of it. Those headlines were based on the Women's Health Initiative, which was a massive government-funded study that tracked the health of more than 160 post-menopausal women starting in the 1990s. Now, the goal of the study was to figure out how to prevent things like heart disease and also track the rates of cancer and osteoporosis in aging women, which is great. I mean, that sounds really great, especially given the fact that very little research has ever been done around women's health, even to this day, unfortunately. But when the early results were released, especially around hormone therapy, it left millions of women and their doctors practically terrified of HRT. So, unfortunately, the story really didn't end in 2002 when they came out with this information.
Speaker 1:Over the past two decades, researchers have been reanalyzing that data and guess what? The risks were a lot lower than we were led to believe, especially for women in their 40s and 50s who are now just entering menopause. So we are going to unpack all of this what the Women's Health Initiative got wrong, what it got right and what the latest research is telling us. Now I'm joined once again by my trusted women's health advocate and certified menopause provider, nisha McKenzie. Nisha, you're well-educated and this passionate about it, if I dare say so. I mean, you're always talking about the Women's Health Initiative and what it did for that 20 years of women who were going through perimenopause and menopause. So let's set the record straight on the Women's Health Initiative study and I really want to ask you how do you think those 2002 headlines shaped those 20 years of women's health? Okay, buckle up, all right.
Speaker 2:You see smoke coming out of my ears.
Speaker 1:You are so on fire about this and you talk about it a lot, and I love your passion about it, but I also love the depth of knowledge that you have about it, because you really delve into all of the study of what's happening, what changed?
Speaker 2:the good, the bad, the ugly yeah, the details Single-handedly. We are where we are today because of the study. We have fear about estrogen. That is unfounded because of the study.
Speaker 2:The media coverage at that moment when in July 2002, when it was first released, it focused on the like you said, the increased risks of breast cancer and stroke and heart disease, but all without context. So context, as we know, is really incredibly important and it led to a massive fear and confusion about that. Most women still have about breast cancer, heart attacks and strokes. Most women still have about breast cancer, heart attacks and strokes, but mostly, honestly, breast cancer. And all of these women abruptly stopped their HRT and we also know that that led to further chronic health problems and diseases. Basically, what we thought we saw is an increased risk in breast cancer.
Speaker 2:We immediately, without doing a peer review, without first publishing the data, all things that had never happened before in medical research we went to the press and we published Sorry, we didn't publish. We went to the press and said hormones cause cancer, hormones cause cancer and we, in that statement, took away women's opportunity to choose, to choose to you know the informed consent we all hear about. We took away the opportunity for women to give informed consent. We took away their opportunity to say okay. I know that there might be a slight increased risk of this, but the data also shows us that it can help solve this. Prevent this, help my hot flashes, help my night sweats, help osteoporosis all those things right.
Speaker 1:So, being someone on the outside you know you're the provider who sees all this and is like, ah, being on the outside it was the fear was so much that if I took hormone replacement therapy I will get breast cancer. Yeah, I mean, that was the message that was being sent and you didn't have a choice anymore and you had providers who were flat out saying I'm not prescribing hormone replacement therapy for you, even if you want it. Sorry.
Speaker 2:We not only took away women's choice, we also took away education for these medical providers in medical schools, NP schools, PA schools. We just stopped teaching them about hormones. We're like, oh, they're probably going to cause breast cancer, we're not going to use them. We're not going to teach you how to tell people what are the risks and benefits, because we have this emotional reaction to this. So I have I want to kind of break it down to five what I think are major flaws to the Women's Health Initiative. Okay, but I want to. I want to make sure I let you ask the questions you would like to ask as well.
Speaker 1:I really find this to be such a fascinating topic and something that so few women know about, because now everybody's talking about hormone replacement therapy again, because they've gone back and they've reviewed it and they found different evidence, right.
Speaker 2:I think that partially women are asking for it again because they are reading some of this evidence. A lot of times they're hearing things on social media from their friends. I want to make sure that we're clear that hormone replacement therapy is very likely appropriate for more people than what are using it right now, but probably not still for everybody. So I want to make sure that we're clear on that. We're not saying hormone replacement therapy is absolutely safe for everybody in every situation or cure-all for everything.
Speaker 2:Right, right, not that. So number one one of the major flaws was there were limited hormonal variations or formulations within this. It was Premarin and PremPro, if I remember those names. They are synthetic estrogen and a synthetic progestin taken orally. So very specific ways to increase your hormone levels and cannot be extrapolated to some of the types of hormones we use today. We actually don't use that really anymore. It's available still but nobody uses it. We have different methods now that do have different safety profiles, so we can't.
Speaker 2:The FDA still has, you know, these boxed warnings on estrogen, all estrogens. So this conjugated equine synthetic estrogen that's in the Women's Health Initiative has the same black box warning on it as a vaginal estradiol. That is bioidentical and it's just not accurate. So that's one of the things limited hormonal formulations. We can't take that data and extrapolate it. The second was it was released by the press and a journal publication prior to peer review. Even the authors of the study didn't get an opportunity to give feedback on how it was going to be published before it got published, so it just went out and it just created opinion.
Speaker 1:Which we have to establish, I think for our audience, who don't know a lot about studies, is that peer review is critical in a step before a study is released In order for it to be a credible study in the eyes of a medical community. There is peer review.
Speaker 2:And to my knowledge that has never happened before this study, that it was put out to the media without this peer review and it was put out saying major hormone studies stopped for breast cancer risk. That's it, one blanket statement. Women's health changed from these statements For 20 years, yeah, yeah. So it was really a gross misrepresentation, and again without context, which makes a big difference. Third, the average age of the women in the study was 62 and a half. The average age of the woman starting menopause is or going through that one moment in time that is menopause is or going through that one moment in time that is menopause is 51 and a half. By the time we get to 10 plus years later, especially if we get to that without hormones on board, we have higher rates of chronic disease. We have higher rates of heart disease already, higher rates of osteoporosis or the pre-osteoporosis osteopenia, and the things that weren't factored out were initial health when they got into the study. So about a little over 40% of the people who entered the study were either current or previous smokers.
Speaker 1:So now we know that they already would have had higher rates of heart disease Right, because we know what that does to health and how that is a huge impact on so many chronic diseases.
Speaker 2:Exactly, and that wasn't factored out. It was. Whatever happened to them was blamed on the hormones. Fourth, the reported risk. This is mind-blowing to me.
Speaker 1:I wish you could see the look on Nisha's face right now, because she's bursting the furrows, the smoke.
Speaker 2:I mean just really all in on Having a moment, yes, having a moment the reported increased risk of breast cancer was not actually statistically significant. It wasn't then and it never has been. We determine statistical significance based on a baseline or what we call a placebo rate. So we say here's the placebo, here's what general population would experience if no intervention happened. And then here's what happened with the intervention. What happened in this study is they did not preclude, they did not take out women who had previously been on hormones. So what happened was they thought they saw an increased risk of breast cancer in one of the arms of the study, but what they actually saw was a decrease in the placebo rate which made it look like an increase in the rate of breast cancer. And the decrease in the placebo rate went back to an actual placebo when they took out the women who had previously been on hormones. Because even in this study it showed that women who were on the Premarin alone so the estrogen alone had a decreased rate of breast cancer. That did not make media headlines.
Speaker 1:No, and completely opposite from what the headline of the study said, yeah yeah.
Speaker 2:So when we took that out, that was a statistical mistake or a statistical anomaly. When we took out the when they took out the women who had been on hormones previously, which we knew decreases rates of breast cancer that placebo came back to normal placebo rate and then there was no statistically significant increased risk of breast cancer. That there, that's it. Wow, that totally negates everything that people have believed. When people come in and say I'm curious about hormones but I'm really great, you know, hopefully we can turn the ship around a little bit for women, give them at the very least a curiosity to explore Absolutely, because, as we say, it's hormone replacement therapy isn't for everyone.
Speaker 1:It's for a lot of women, but it's not for everyone. But you should also still have that choice. You should, you have one more point you want to make.
Speaker 1:I do the want to make I do. Oh, I lied, I combined the last two. Okay, that's fine. I just feel like this is such an important issue and such an important topic to talk about, and I feel like we're finally starting to get women to understand exactly what this study was about. And what's sad to me is when I think about those 20 years where women didn't take hormone replacement therapy if they wanted to and what that did to their overall health.
Speaker 2:It did a lot to their overall health. And we have all this longitudinal data since then 20 plus years of data from the ongoing Women's Health Initiative that have shown us the increased rates of cardiovascular disease. Heart disease is the number one thing that kills women. It isn't breast cancer I don't want anyone to get breast cancer and we are worried about that. But we don't know what causes it exactly yet. We don't know that estrogen causes it, and most of the data tells us that estrogen is likely either neutral or protective for breast cancer. It doesn't. It doesn't. The preponderance of data doesn't tell us that estrogen causes breast cancer, but it does also protect against so many other things.
Speaker 1:Right right Protection that these women were not getting for those 20 years.
Speaker 2:And I think, because I got all fired up, I think I forgot, I think we should give a little bit of a context on what the WHI is and was right. I just I double right into the things that irk me.
Speaker 1:Yeah, I mean they were. They were designed to really study women's health, right they? They put together this huge study back in the nineties of 160,000 post-menopausal women and really wanted to take a look at many aspects of health, right, they wanted to look at things like whether or not they can prevent heart disease. They wanted to look at things like what are the rates of osteoporosis and aging in women, and did they get any of that right in the study? They?
Speaker 2:did what they powered the study for, how they developed the study was to look at prevention of heart disease alone. So the breast cancer wasn't even the primary reason that they did the study. It was kind of a secondary outcome. They monitor it and they look and they said, hey, these people are either getting more or less breast cancer. But they got plenty right.
Speaker 1:So much of what we know about medical nutrition, so much of what we know about medical nutrition, sleep, stress, hormones, brain health, heart health, bone health, metabolic health is all from the Women's Health Initiative. Even their ongoing research and that's the point I wanted to make is that this was not a one and done study once it came out in 2002. Once it came out in 2002, the research has been ongoing and gotten a little bit better at being peer-reviewed and being something that you can really trust when they come out with findings. Right, and I want to make clear too, it's not everything that we feel.
Speaker 2:That's bad about this whole scenario is not all in the study design. The study itself was not a terrible study and it still isn't. It was in how it was reported, how the media took it, what was perceived by the public as it was reported, and then what's happened with medical training since then. It got all blown out of proportion. But the study itself is not necessarily a fully bad study. There's more good than bad in this study. Can you name some of the good things? Cardiovascular health, bone health.
Speaker 2:We solidified what we thought we already knew that hormones prevent osteoporosis, and that is actually so. There are two FDA-approved reasons to use hormones. One is vasomotor symptoms, which is hot flashes and night sweats, and one is osteoporosis. A lot of people don't know that we can use it just for osteoporosis prevention and that is an FDA approved reason. I don't know that we're ever going to get an FDA approved reason for prevention of anything else After this study and the way it was handled and the lawsuits that this drug company had to endure afterward really just because of media not because of what the data showed, but because of the media. So so many dollars in lawsuits. I don't know that anybody's going to take the time or the money to do another study that opens themselves up to the emotion of what people have after they hear data like this right.
Speaker 1:And unfortunately, what it did was it sent women down this path where they have to now advocate for themselves to get hormone replacement therapy. And you mentioned earlier on in the podcast how you know, for those 20 years after the study came out, that providers weren't even being trained about hormone replacement therapy. And so now that that's changing, you know some women are still going to providers who were part of that 20 years who are saying no, or it's all in your head, or here's a birth control pill, or you know you'll get through it. It's just 10 years of your life, your grandma did it, you can do it. And so now there's so much advocating that we have to do to say I really want to try it. You know, finding the biggest thing I get on our um page, the Pause Diaries, which is a support group for this podcast, is how do I find a provider who's going to listen to me?
Speaker 2:Yeah, Well, we've talked in a previous podcast about that menopauseorg, that website where you can do a find a provider.
Speaker 1:Have you ever gone on it and tried to find it within the region that you live in. It is not easy.
Speaker 2:It's not. It is not easy. It takes the money it takes to fully and in-depth dive into the data. And so there are people who are still even in the menopause society, even who have gone through some advanced training, who are still doing some of those old, harmful things based on myths or what we've learned over time or what our mentors taught us and told us. And so what I just encourage people to do is talk to your friends, get in support groups like the Pause Diaries, like your group on Facebook, and find out.
Speaker 2:How did you navigate this person, I don't know, on social media. How did you? When you went in and asked for this and they told you, no, is that legit? What if it doesn't resonate with me? I always tell people if it doesn't resonate with you first. Please give your practitioner the opportunity to hear that and say, hey, but I heard this, can you comment on it? And if you feel like you continually get brushed off, that person may be phenomenal at delivering babies, at saving your life from a complex gynecologic surgery, and they may not have hormone training and it's okay to walk away from them for that and find someone who does it's hard to do.
Speaker 1:There's not many. Well, you know what? It's very similar to quitting your hairstylist. Oh yeah, Listen, we hold on to them like white knuckle, hold on and you don't want to cheat on them. It's a bad thing.
Speaker 2:And you don't want to reschedule because you can't get back in for months. Get back in and then they'll be like who did your hair?
Speaker 1:Right, you can't tell I'm going there Women's Health Initiative, how it has continued to go on since 2002 and made remarkable strides in research. Women's health was really never studied until the Women's Health Initiative came out. I mean, everything was based on white males in their 40s and that was the blanket that we used for every ethnicity and every gender, for whatever medical condition you had. So this I want to highlight the fact that it really did make a difference in women's lives and it was wonderful to be able to know that we had something that was specifically studying women's health studying women's health.
Speaker 2:Yeah, so when you ask what did the WHA get right so much, what did the world get wrong? What did the media get wrong so much? But the WHA provided an invaluable foundation for advancing women's health, health research, especially regarding menopause and postmenopausal care.
Speaker 1:This has been a heavy topic, but it was definitely one. I feel like we needed to just get out there and let women know the pros and the cons and the future yeah, Unfortunately of what's happening.
Speaker 2:Ask questions. Ask questions in the pause diaries, your Facebook, if you're in that Facebook group or you're in other support groups, ask questions. Why can't we do this? What does the data show here? What are the real risks? Ask all of those questions and get that conversation. Keep that conversation going.
Speaker 1:Because women are strong in numbers and we can make big change. Heck, yeah. Thanks so much for the conversation, nisha. As always, it has been informative and passionate, which is what I love about you so much so until next time, join our Facebook group that we've been talking about.
Speaker 1:It's called the Pause Diaries. It's a very active group talking about. It's called the Pause Diaries. It's a very active group, lots of women in there talking about many different things, and we just want to know what you think, what your thoughts are on this podcast or what your thoughts are on anything else that you need to know inside that group. I'm always checking it and I'm always posting for you, so remember this is not the end of anything. It is the beginning of the rest of your life and we are going to definitely talk about it.
