The legacy of WHI? Confusion and apprehension, possibly

Dr. Mitwally blames two entities for this state of affairs. “The credit goes to the WHI,” he says. “They did a wonderful job of screwing people up” with a “very poorly designed study.” There is also “a lot of misinformation,” thanks to the media. “They just want to get any bad news and magnify it.”

In the wake of the WHI, Dr. Mitwally recalls, “it was like chaos” for 3 or 4 years—and there is still a lot of confusion.

Nevertheless, when a patient complains of moderate or severe vasomotor symptoms, Dr. Mitwally usually turns to HT as a first-line therapy. “It is excellent for these patients,” he says, although he emphasizes that “every patient should be managed separately.”

“I think the most important thing in the whole issue of HT is that physicians should leave these patients to subspecialists,” he says, by which he means reproductive endocrinologists and ObGyns with expertise in menopause care.

Plethora of products

One of the more surprising impacts of the WHI is the array of estrogen products now available. Because the WHI was expected to confirm observational data that suggested that estrogen reduced the risk of cardiovascular disease, the number of products in development skyrocketed.

“I think something like 35 compounds got approved while the study was under way, so there is more stuff than ever,” says Dr. Santoro. “But that actually was attractive to some people in the survey and has been found to be attractive to patients because it does give more choices the way things are going, which is toward more of a customized approach to giving hormones.”

Raksha Joshi, MD, chief medical officer and medical director of Monmouth Family Health Center in Long Branch, New Jersey, a federally funded qualified health migrant center (FQHC), says the broader array of estrogen products adds to the time she spends educating patients.

“We do tell them about the other forms of estrogen and their bioeffectiveness and what they would achieve for this particular woman,” she says.

For patients who report moderate to severe menopausal symptoms, Dr. Joshi considers estrogen a first-line therapy, but recommends concurrent lifestyle changes.

“Of course, the WHI has not disappeared,” she says, so concerns about risks remain. “But in the transition, when the symptoms are paramount, I would tailor the treatment to what the woman wants to get out of it. But I think it is important for the woman to understand that this is not a panacea and that it will not cure all her symptoms. Therefore, lifestyle changes and getting hormone replacement therapy should go concurrently.”

As for alternative therapies, women are increasingly likely to ask for or about them.

“We talk about that,” says Dr. Shulman. “If they’re miserable and they don’t think they’re appropriate candidates for estrogen, we talk about other things. Or some people will come in and say, ‘I don’t want to take estrogen. Is there anything else?’”

In these cases, Dr. Shulman recommends a number of options. “Effexor has shown some benefit, apparently, in the literature,” she says. “And I mention black cohosh, which is in a lot of popular over-the-counter type remedies and which, apparently, recently was shown to have possibly some benefit.” Of course, “there’s a tremendous placebo effect with all of these,” she observes.

“And then I suggest things like getting plenty of exercise and eating sensibly, and I take my other patients’ recommendations. One patient told me that she takes a cool shower every night before going to bed and finds it beneficial, so I don’t know—it’s one of those ‘can’t hurt, might help’ things.”

Estrogen got a “bad name”

When she looks back over the past 5 years, Dr. Shulman thinks the WHI’s effects have been destructive in many ways.

“I think the most important thing is that [HT] got an undeservedly bad name when the Women’s Health Initiative was published,” she says. The WHI “really did a disservice for women who could benefit from [HT] enormously and weren’t really at risk—not just for vasomotor symptoms but also emotional lability, depression, increased anxiety, things like that.”

“I have many women for whom I did prescribe estrogen, and they’re still on it and will probably never get off because they think that I saved their lives. So for women to be scared unfairly by the Women’s Health Initiative and to have to suffer with vasomotor and emotional problems is really a disservice.”

Dr. Wineman agrees, and points out that even some professional organizations are beginning to reconsider the initial WHI findings. “They’re beginning to say, ‘I really believe that there are certain women who would probably benefit a great deal more than we once thought, and perhaps we jumped to some wrong conclusions.’”