The Hot Topic

by Christa D'Souza

  She explains why, despite this very dark period, she steadfastly resisted taking hormones.

  ‘I’m not one who rushes to pills anyway. It is like when I gave birth to my son Louis. I did it without pain relief – not by choice; I was one of the .001 per cent of women for whom an epidural doesn’t take – but it was so amazing to have felt everything about it.

  ‘Plus, I worried about what would happen once I came off the HRT. Didn’t the symptoms simply return? A lot of my friends had gone on it, but I just kept thinking, I’ll tough it out. If it gets too bad, I can try them. I felt that whatever I was going through was completely natural for my body and that it was important that the entire process be allowed, not suppressed.

  ‘Of course, I had no idea that it would be another six years before the fog lifted. But I absolutely felt I did the right thing for me. I went through it fully aware of my body’s changes and I can tell you, I knew when my menopause was over – I literally woke up one day and felt like my old self. No kidding. I felt centred and calm and – bloody hell, what was that? – happy!’

  The idea of taking hormones? To be honest, I didn’t consider it either at first. But there were a few reasons for this. The first was that in September 2007 I was diagnosed with breast cancer after finding a lump the size of a grape pip in my right breast while on holiday that summer in Greece. Only grade I, treated with radiotherapy (my oncologist said I didn’t need to bother with tamoxifen if I didn’t want to) and a mere verruca compared to the experiences so many of my poor friends have had with the disease. But it was cancer nonetheless and oestrogen-positive to boot, meaning that I simply wasn’t eligible for HRT. HRT included oestrogen and the last thing my body needed, quite obviously, was more of it. The second is that I have always had a slight fear of hormones – it’s why I never took the birth control pill for any length of time. The third was the ‘embarrassment’ factor. There’s a rumour going round west London, of a woman, newly divorced, in the throes of passion with a new lover, and telling him the oestrogen patch on her arm was actually Nicotinell.

  Also, there were alternatives. There always have been. Belladonna. Opium. Rattlesnake poison. Star anise. Lead injections. All sorts of non-hormonal substances and methods have been used to treat menopausal symptoms over the years. In 1849, one William Tyler Smith recommended a course of ice water injections into the rectum and the vagina for hot flushes, followed by the application of leeches to the labia and cervix (as reported in Louise Foxcroft’s wonderful book Hot Flushes, Cold Science: ‘His colleagues were advised to count the leeches when they removed them to make sure none was lost and left there.’) The still common practice of prescribing antidepressants the moment the word menopause is mentioned in the GP’s surgery is surely a legacy of the Victorian response to menopausal women, which consisted of either treating them for hysteria or chucking them in an asylum.

  Black cohosh (originally used by Native Americans), Pueraria mirifica (extracted from a plant found in Myanmar); Relizen (whose active ingredient is harvested from Swedish flower pollen) – these are just some of the non-hormonal plant-based formulas out there which claim to relieve menopausal symptoms, many of them to be found on the shelves of Holland & Barrett. Kinesiology acupuncture and traditional Chinese medicine have been known to make a significant difference to some women. (Watch out for a new treatment from the US called Menerba which consists of 22 herbs used in Chinese medicine and is currently awaiting FDA approval). Then there is something called ‘maca’, a turnip-like root found on the Andean plateaus which Peruvians have been taking for centuries. As well as balancing hormones, protecting against brain damage and relieving hot flushes, maca is supposed to increase libido and aid vaginal lubrication. Does it get you high, too, you may ask? Well, it is taken by athletes to improve performance and old people to increase vigour, so there’s obviously something in it.

  There are wackier solutions… knicker magnets for example, which clip onto your pants and supposedly emit magnetic forces that soothe the nervous system and boost oestrogen and progesterone levels while they are at it, or what about cooling jewellery, as publicised by Oprah Winfrey, literally a necklace of beads filled with cooling gel that you keep in the freezer so they are nice and cold when you put them on.

  The use of actual mammalian hormones to treat symptoms of the menopause may be charted back to the 1890s when a US pharmaceutical company brought out a powder called Ovariin, made by grinding up dried cows’ ovaries. By 1933, the first HRT product, Emminen, was on the shelves. It contained the urine of pregnant women (the very first form of bio-identical hormone therapy, therefore). But it was very costly to manufacture and in 1941 it was replaced by the much cheaper Premarin.

  Manufactured by Wyeth Pharmaceuticals, Premarin was harvested from pregnant mares’ urine and by 1992 became the most widely prescribed drug in the US. ‘Keep her on Premarin’ as the jaunty, hugely successful campaign, aimed at both American men and women, went. And so the popularity of HRT in general kept growing. Until, that is, the findings of the now famous Women’s Health Initiative (WHI) study were published in the US in 2002.

  Initiated in 1991, the WHI study was intended to examine the effects of HRT on 161,000 menopausal and post-menopausal women for a period of 15 years. The point was to prove that drugs such as Premarin and Prempro (conjugated horse oestrogens plus progesterone, introduced in the 70s when it was found that unopposed oestrogen was linked to a higher incidence of uterine cancer) helped prevent heart disease in menopausal women. But the study had to be prematurely stopped when it was found that the risks of breast cancer and heart disease were far outweighing the drugs’ benefits. Suddenly, from being the course of action that every menopausal woman should take, as celebrity gynaecologist Dr Robert Wilson famously advocated in his 60s bestseller Feminine Forever, HRT users and prescribers were made to feel they were playing Russian roulette. The year before these injurious findings were made public, 33 per cent of women over the age of 50 were taking HRT (1.7 million women in Britain and 22 million women in the US). By the following year, that percentage had more than halved, with doctors only prescribing it in extreme cases.

  As critics, and there are many of them, have since pointed out, there were flaws in the study. For one, the average age of the women in the study was 63, 12 years older than the average age for menopause. (It had already been proved that administering HRT to women in their fifties protected against heart disease.) For another, they were all given the same oral dose of Prempro (0.625mg conjugated equine oestrogens and 2.5mg medroxyprogesterone acetate versus placebo, to be precise).

  But there were other studies to compound the turnaround; the Million Women Study, for example, which was set up to investigate links between HRT and breast cancer and conducted in the UK between 1996 and 2001. The findings revealed that 20,000 of the 950,000 women who took part developed breast cancer. In a joint statement, Professor Valerie Beral and Professor Richard Peto from Oxford University said: ‘HRT is one of the most important causes of breast cancer in the world and women can easily change their risk by stopping.’

  Again, critics pointed to flaws, including the fact that women may already have had breast cancer when they embarked on the study. The lobby to rehabilitate HRT grows. Take the study conducted in Denmark, published in the British Medical Journal in 2012, which suggested that there was no increased risk of heart disease from taking HRT and that it may even protect against it. A study published in the Journal of Clinical Oncology in 2015 led by researchers at the Institute of Cancer Research in London found that women with the commonest type of ovarian cancer could not only safely take HRT during or after treatment, but could actually survive longer by taking it.

  Meanwhile, the latest guidelines from the National Institute for Health and Care Excellence (NICE), published in 2015 in the UK, sought to reassure doctors and their female patients about the safety of HRT, and highlighted the importance of educating women about its benefits as well as its risks, to make it less of
the bad guy, and to give those of us who suffer debilitating symptoms, such as having to change the sheets every day and so on (and, indeed, the one in a hundred women who become menopausal before the age of 40) more options. But the debate continues to rage, and the reputation of HRT is still very much in recovery.

  Not helped, it would seem, by the rising trend for bio-identicals, an alternative to HRT about which, as I discovered, much confusion reigns…

  If you are a baby boomer, like me, and have a vested interest in such things, chances are you think you know the difference between bio-identical hormones and conventional HRT. The former are the modern organic ones that are made of plant sources like wild yams or soybeans, have an identical structure to the hormones our bodies produce, and are only available through private doctors. The latter consists of the hormones they’ve been using since the 60s, harvested out of the groins of mares who are never allowed to lie down, are reinseminated immediately after they give birth and not given enough to drink in order to make their pee more concentrated – the one-dose-fits-all chap that your harassed NHS GP prescribes just to get you off his back. Good guy, bad guy, right?

  Well, kind of, but not quite.

  The word bio-identical is slightly tricky. Yes, it refers to hormones that are biochemically similar to the ones the body produces. But, although they derive from wild yams or soy, they have to be chemically synthesised in a laboratory. True, the idea of having reconstituted sweet potato in one’s body is a hell of a lot more appealing than having reconsitituted horse urine (well it is for me, anyway), but the idea that bio-identicals are all-natural – as you, like me, may have been led to believe – is simply not true. Remember, too, a lot more trials have been performed on synthetic hormones (such as Premarin) than on bio-identicals. To further confound the issue, a lot of commercially available HRT preparations, the ones your GP might prescribe, contain oestradiol 17-beta, the natural human oestrogen, or micronised progesterone which is the same thing as natural human progesterone.

  But then, if you hear a friend raving about the bio-identicals she has been prescribed, what she probably means is that they have been compounded for her in a specific strength (in a cream or lozenge, for example, rather than a pill) – that is, titrated, by a specialist pharmacist as opposed to being dispensed in a one-size-fits-all dose. Same medicine, different strengths.

  Now, there are thousands of these compounding pharmacies in the US, many of which sprung up in the wake of those worrying WHI findings back in 2002. (And as US critics argue, since their production or titration is not monitored by the FDA, there is reason to believe they are actually less safe than synthetic HRT such as Premarin, Prempro et al. In the UK, we have just one compounding pharmacy – though of course that’s bound to change.)

  ‘If you treat the menopause as a lack of hormones then you miss the point totally.’ So declares Dr Mikael Rabaeus, head of cardiology and internal medicine at the Clinique La Prairie medical spa in Montreux, Switzerland. Founded in 1931 and made famous by clients such as Marlene Dietrich, Winston Churchill and David Bowie, it is the first medical spa in Europe to boast a clinical centre entirely dedicated to the menopause. This, by the way, was the first port of call in writing this book. ‘I find when I talk to my female patients,’ continues Dr Rabaeus, ‘most do not qualify for taking hormones; they qualify for taking care of themselves. But then lifestyle is my main concern as a cardiologist. It accounts for 80 per cent of your risk of early death. Ceasing smoking and doing physical exercise has an excellent effect on menopausal symptoms and life expectancy in general. I also belong to the school of thought which is little convinced by a treatment you have to take for an indefinite amount of time.’

  ‘To treat menopause, it is very important to tailor the needs to the patient,’ says his colleague, Dr Thierry Pache, an endocrinologist by training, who founded the menopause centre at Montreux in the late 90s. ‘I felt such shame for my gynaecologists when I discovered the average length of a gynaecological appointment was 12.5 minutes – and that included taking your clothes off and putting them back on again. Seeing a patient about menopause requires a minimum of half an hour, and that’s just the talking. There was a lot of criticism when I first started,’ he adds. ‘The least nasty comment I got was: “Pache, what’re you doing with all these old ladies?” But this had been happening all through my training in ob/gyn back in the day. When I told my former mentors that I was interested in gynaecological endocrinology and how hormones could be regulated, they just said to me, “Listen, you are here to remove uteruses and deliver babies. Just work and shut up.”’

  It is a shame that Dr Pache, who speaks five languages fluently and has won several awards for his vineyard in Argentina, only practises in Montreux. He is so full of bonhomie and so lacking in the patriarchal smugness that has always permeated the world of ob/gyn. Unlike his colleague Dr Rabaeus, he thinks hormones can be ‘fantastic, if you are administering the appropriate dose to the appropriate patient. I have patients who are 75, 76, who are still using HRT. We try stopping, and back come the hot flushes.’ He cites publications that reveal that having two glasses of wine a day are more of a breast cancer risk than taking full-dosage conventional HRT and says he is ‘still waiting for the paper to show me that oestrogen causes cancer. Because it doesn’t exist’.

  But it remains his heartfelt conviction that in general, women in Western society are overloaded with hormones, and he would never treat me, a breast cancer survivor (how melodramatic that sounds!) with them. ‘I have four or five patients who have suffered from oestrogen-positive cancer like you but they are having six hot flushes an hour and they have begged me to do something about it. In these exceptional cases I have contacted their oncologists and so far they are doing perfectly well, but you, with your history, I would refuse to treat with hormones.’

  He recommends, instead, a formula called Climavita Forte, which contains black cohosh (also known as Cimicifuga racemosa) and, as I later read up, is fantastic at treating bed bug bites. ‘It can be used by women even when they are being treated for positive breast cancer,’ says Dr Pache, ‘and if you pair it with a good acupuncturist it has been shown to help a lot with symptoms.’ But no, it will not do a thing for an expanding middle. Only four hours of exercise a day and a change in diet, he says, will do that. ‘I think even Audrey Hepburn had trouble in this area,’ he says sympathetically, ‘but then the way a woman’s body changes around menopause, a lot of men, including myself, find that rather beautiful.’

  And so I flew back to London with my prohibitively expensive bundle of Climavita pills, feeling, it has to be said, rather dejected. The hot flushes were still coming thick and fast, I was imprisoned in leggings mode because none of my jeans fit, and the impotence and resentment I felt as a result were becoming increasingly hard to deal with. Why did I have to bloody go and get cancer? Why couldn’t I be one of those women who felt better than well after taking HRT?

  Like my friend Rosa, a successful documentarist in her early fifties, who herself had a terrible time of the menopause despite being super-prepared. After what she euphemistically calls a ‘treasure hunt’ of doctors, she was prescribed bio-identical HRT, and within a few days of taking it – a mixture of non-synthetic progesterone, oestrogen and testosterone – went through what she described as a kind of epiphany. ‘I have to say, I didn’t feel better, I felt incredible, with these real proper power surges of well-being. I mean, if hormones are bad for me, it’s hard to believe because it feels soo flipping good.’

  ‘Whatdoyoucallit? Cimicifuga? Honestly, sometimes I do despair.’ This is Professor John Studd, consultant gynaecologist at Chelsea and Westminster Hospital, Professor of Gynaecology at Imperial College and former chairman of the British Menopause Society. Striking slightly of Sir Lancelot Spratt (the character James Robertson Justice played in the Carry On Doctor films), with his quiff of silver hair and booming patriarchal tones, Professor Studd is a world expert on the links between menopause and loss of
libido, and was the founder of the very first menopause centre in this country in 1969. (The first in the world was set up two years earlier at the Groote Schuur Hospital in Cape Town, South Africa, where Christiaan Barnard performed his first heart transplant.)

  Studd is also an unashamed proponent of HRT, yes, even for women like me who have had breast cancer. While I tell him about my history, he gets up from his desk and pads over to a chaise longue with his shoes off, all the while peering at me from above his glasses. I have now gotten to the bit about being prescribed Prozac for depression back in 1988 and still being on it, a quarter of a century later, at double the dose (40mg) I had taken to start with. And my history of osteopenia (that is, low bone mineral density, thought to be the precursor of osteoporosis).

  ‘With your history of depression and low bone mineral density, of course you must take it,’ he says and, padding back to his desk, he briskly whips off a prescription for oestrogen gel, testosterone gel and progesterone in pill form, the latter being the only one he anticipates I might, even at this low dose, have trouble with – but necessary ‘because you still have a uterus’.

  Typically, he doesn’t hold back on the subject of bio-identicals. ‘Such bullshit. All I can say is that we in Europe have been using so-called “bio-identicals” for 20 years. It’s only the Americans who were using horse piss. Now, of course, they’re waking up to the fact that they’ve been wrong for 30 bloody years. I wouldn’t touch Premarin with a barge-pole.’