#42 - Avrum Bluming, M.D., and Carol Tavris, Ph.D.: Controversial topic affecting all women—the role of hormone replacement therapy through menopause and beyond—the compelling case for long-term HRT and dispelling the myth that it causes breast cancer
Drs. Avrum Bluming (hematologist/oncologist) and Carol Tavris (social psychologist) discuss 'Estrogen Matters,' challenging HRT misconceptions for menopausal women. They argue HRT's benefits often outweigh risks, debunking breast cancer fears and critiquing the Women's Health Initiative.
Deep Dive Analysis
19 Topic Outline
Introduction to Guests and 'Estrogen Matters' Book
Historical Context: Hormone Therapy for Men vs. Women
The Abrupt Drop of Estrogen in Menopause
Historical Mistreatment and Skepticism Towards Women's Health
Comparing Mortality: Breast Cancer vs. Heart Disease in Women
Personal Motivations and Experiences with HRT
The Women's Health Initiative (WHI): Background and Flaws
Conspiracy vs. Bias: Interpreting WHI Findings
Understanding Absolute vs. Relative Risk in WHI Breast Cancer Findings
The Role of Progesterone and Different Estrogen Types
WHI Follow-up Studies and Course Correction
HRT's Impact on Brain Health and Alzheimer's Disease
HRT's Impact on Heart Disease and Timing of Initiation
HRT's Benefits for Bone Health and Osteoporosis
HRT's Potential Impact on Colon Cancer and Diabetes
Downsides of HRT and Approaching Your Physician
Future Research and Evolving Understanding of Cancer
Reception of 'Estrogen Matters' and International Perspectives
HRT After Breast Cancer Diagnosis
5 Key Concepts
Estrogen Plummet in Menopause
Unlike the gradual decline of testosterone in men, estrogen levels in women plummet to about 1% of their pre-menopausal levels, a significant and often unrecognized drop that contributes to many menopausal symptoms.
Absolute vs. Relative Risk
Relative risk describes how much more or less likely an event is compared to a baseline (e.g., 26% increase), while absolute risk describes the actual number of additional cases (e.g., 9 cases per 10,000). Understanding both is crucial to assess the true impact of a risk factor.
Maturation Arrest (in Cancer)
This concept suggests that some cancers, like acute promyeloblastic leukemia, are not primarily caused by cells multiplying too quickly, but rather by cells failing to mature beyond an immature stage. Treatments that induce maturation can resolve the disease.
Bioidentical Hormones (Compounded)
While 'bioidentical' sounds appealing, it often refers to hormones prepared by compounding pharmacists, where quality control and dose equivalency can be lacking. Pharmaceutically prescribed estrogens like estradiol are also bioidentical and have established safety and efficacy data.
Healthy User Bias
This bias occurs in observational studies where people who choose to engage in a healthy behavior (like taking HRT in some studies) may already be healthier or more health-conscious, making it difficult to attribute positive outcomes solely to the intervention.
8 Questions Answered
The authors argue that estrogen does not cause breast cancer. The Women's Health Initiative (WHI) initially reported a 26% relative increase in breast cancer risk with combined estrogen and synthetic progestin (CEE+MPA), but this finding was not statistically significant, was largely due to issues with the control group, and disappeared in later follow-up analyses.
Menopausal symptoms extend beyond hot flashes and night sweats to include palpitations, cognitive decline, joint pains, and sleep disturbances. These symptoms typically last about 7.5 years on average, but can persist for decades in some women.
In every decade of a woman's life, the incidence of death from heart disease is greater than the incidence of death from breast cancer. Across a lifetime, women are approximately 7 times more likely to die from cardiovascular disease than breast cancer.
Estrogen has been shown to reduce the incidence of Alzheimer's disease by 20% to 50%. Women are twice as likely to die from Alzheimer's than men, and estrogen is considered the one potential preventive medication for this condition.
The ideal time to start HRT is around menopause, within the first 10 years of cessation of periods, for women without pre-existing cardiovascular disease. Starting later or with existing cardiovascular disease may carry a higher, though still small, initial risk of cardiovascular events.
Yes, estrogen can decrease the risk of osteoporotic hip fracture by up to 50%, making it more effective than other long-term treatments. Calcium and vitamin D alone have no protective effect against hip fracture in post-menopausal women not on estrogen.
The main downsides include a small increased risk of pulmonary embolism and venous thromboembolism, particularly during the first year of treatment and in women with pre-existing cardiovascular disease. There is also a statistically valid increase in the incidence of gallbladder disease (gallstones).
Women should educate themselves with data-driven resources like 'Estrogen Matters' to become better consumers of healthcare. This allows them to engage in an informed discussion with their physician to collaboratively determine the best treatment program for their individual needs.
18 Actionable Insights
1. Consider HRT for Longevity & Quality of Life
The overall benefits of hormone replacement therapy (HRT) for most women, including reducing risks of heart disease, Alzheimer’s, and osteoporosis, generally outweigh the downsides. Women should at least be offered HRT for consideration to live longer and better.
2. Re-evaluate Midlife Symptoms
Many symptoms in midlife, such as depression, muscle pain, cognitive decline, sleep disturbances, joint pains, and palpitations, may stem from the dramatic drop in estrogen during menopause, rather than other causes like a ‘midlife crisis’.
3. Challenge Estrogen-Breast Cancer Link
The widespread belief that estrogen causes breast cancer is an embedded assumption not fully supported by evidence; in fact, women diagnosed with breast cancer while on HRT often have a better prognosis.
4. Prioritize Heart Disease Risk in Women
Heart disease is a greater killer of women than breast cancer in every decade of life, with a 7x lifetime difference in mortality. Be aware of atypical heart attack presentations in women, such as an upset stomach.
5. Understand HRT Timing for Cardiovascular Health
If you have pre-existing cardiovascular disease, do not initiate HRT. The ideal time to start HRT is around menopause, within the first 10 years of cessation of periods, as this window shows no increased cardiovascular risk for women without pre-existing disease.
6. Estrogen for Alzheimer’s Prevention
Estrogen is a potential preventive medication for Alzheimer’s disease, capable of reducing its incidence by 20-50%, while common interventions like diet and exercise have not been shown to prevent it.
7. Estrogen for Bone Health
Estrogen can decrease the risk of osteoporotic hip fracture by up to 50%, outperforming other long-term treatments. Calcium and Vitamin D alone offer no protective effect against hip fracture in post-menopausal women not on estrogen.
8. Informed HRT Discussion with Physician
Empower yourself by reading comprehensive resources like ‘Estrogen Matters’ to understand the data, allowing you and your physician to collaboratively determine the best HRT program for your individual needs.
9. Caution with Compounded ‘Bioidentical’ Hormones
Be wary of ‘bioidentical’ hormones prepared by compounding pharmacists due to potential lack of quality control and clear dose equivalency; pharmaceutically prescribed estrogens like Premarin have extensive supporting data.
10. Micronized Progesterone for HRT
If progesterone is required as part of HRT, micronized bioidentical progesterone appears to be the safest form of administration.
11. HRT for Breast Cancer Survivors
For women with a history of successfully treated breast cancer, HRT is an open question, not an automatic contraindication, with multiple studies showing no increased risk of recurrence. This decision requires careful discussion with a physician.
12. Challenge ‘Natural’ Arguments for Health
Question the notion that interventions like HRT are ‘unnatural,’ especially when considering living a longer, healthier life beyond reproductive years.
13. Avoid Extremes in Medicalizing Problems
While over-medicalizing problems should be avoided, equally important is not to under-medicalize legitimate health issues, finding a balanced approach to care.
14. Practice Critical Thinking
Be aware of cognitive biases like confirmation bias and negativity bias when evaluating health information. Do not accept claims of ‘almost statistical significance’ as valid findings.
15. Read ‘Estrogen Matters’ Book
Read the book ‘Estrogen Matters’ to gain a deep, data-driven understanding of hormone replacement therapy, and follow up on its references to verify information for yourself.
16. Read ‘Mistakes Were Made (But Not by Me)’
Read Carol Tavris’s book ‘Mistakes Were Made (But Not by Me)’ to understand why people resist new, beneficial information and the barriers to critical thinking.
17. Review Podcast Show Notes
Check the podcast show notes for visual aids, such as images illustrating the female hormone cycle and charts comparing cardiovascular disease and breast cancer mortality risks, to enhance understanding.
18. Support the Podcast
Consider becoming a subscriber to Peter Attia’s podcast to access exclusive content like detailed show notes, downloadable transcripts, AMA episodes, and discounts on products he endorses.
5 Key Quotes
The statistical police have to leave the room.
Rowan Shlebowski (one of the three writing authors of the WHI study)
What's not natural is for a woman to live to be 85 or 90 years old.
Barbara Sherwin
If all you care about is looking good, feeling good, and living a long time, then take estrogen.
Leading opponent of hormone replacement therapy (during a debate with Avrum Bluming)
We too often enjoy the comfort of opinion without the discomfort of thought.
Peter Attia (paraphrasing JFK)
The more, you know, the less you fear.
Avrum Bluming