The Dr Louise Newson Podcast - 039 - Oestrogen Matters - Dr Avrum Bluming & Dr Louise Newson

Episode Date: March 17, 2020

Avrum Bluming was a clinical professor of medical oncology at the University of Southern California and spent four years as a senior investigator for the National Cancer Institute. For more than two decades he has been studying the benefits and risks of hormone replacement therapy administered to women with a history of breast cancer. He is also the co-author of the book “Oestrogen Matters”.  In this podcast, Dr Newson talks to Avrum about the numerous health benefits of oestrogen in women, including reducing future risk of heart disease, osteoporosis and dementia. It is a very sobering thought that as many women die from osteoporosis as breast cancer, yet so many women are denied oestrogen in HRT for the wrong reasons. Avrum's wife was diagnosed with breast cancer many years ago and he talks about treatments for breast cancer which can lead to an early menopause.   https://estrogenmatters.com  Avrum Bluming's Three Take Home Tips About HRT: If every woman in the US started HRT, the median life expectancy of women would extend by 3.3 years If you ever hear "If you must take hormones, then take the smallest dose possible for the shortest period of time" - there is no scientific support for this! Women can take HRT for as long as they need. Some of the benefits of HRT, particularly for your bones, last as long as you continue to take it. If you stop taking the hormones, bone degeneration occurs at an accelerated pace.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So I'm very excited today to be recording with someone who isn't with me in my clinic for a change, someone who is many miles away, the other side of the pond, as they say, in America. In front of me, me today, Avram Blooming, who I first met over a year ago at a conference at the Royal Society. And his work has been amazing. His book that we will talk about is incredible. He used to be a professor of medicine in the University of Southern California, but he is tirelessly campaigning for, I would say, women's rights. I don't know how you feel, Avram, with saying that.

But firstly, just thank you ever so much for giving up your time to talk to me today. It's a pleasure and women's rights are in fact what is being discussed. Yes. And actually it's very pertinent because today is the International Women's Day, which we were talking about before we started recording, which is very key because it's about women having an equal voice and an equal right. And sadly, as some of you know who have listened to me before, I get incredibly frustrated that a lot of women are not being given an equal voice because they're not given the right care or treatment for their perimenopause and menopause. So when we first met Avron, we were both talking actually, weren't we, in this conference at the

Royal Society in London, and it was about patient choice. And you'd come over to the UK and your book had fairly recently been published, hadn't it, around that time? That week, yes. Yes. So tell us a bit about the book. And maybe before you talk about the book, tell us a bit about your background, your professional background, if you don't mind? I don't mind. I'm primarily a medical oncologist. I was in practice for about 45 years. About 60% of my patients were breast cancer patients. I live in Southern California. It is not an uncommon diagnosis here. And I watched breast cancer advances being made with great glee.

We not cure about 90% of newly diagnosed breast cancer patients. And I became aware that although we were curing these women, we were often putting women into premature menopause. And many of my patients came back with complaints, which in the grand scheme of things seemed like relatively small complaints. I had no way of evaluating them, although they were complaining that the quality of your life was really deteriorating.

And I say, but you're alive. And that continued for quite a while. And then my wife, who had breast cancer, was also put into premature menopause. So how old was she when she was diagnosed, if you don't want me asking? 45. Okay.

So she was young? Yes. And she's still young, but that was 32 years ago. And I became very well aware of what these symptoms were. And I also became aware that the message I was giving and the message that women were receiving were essentially suck it up. And it'll be over in about two years. And after all, it's just hot flashes and night sweats. And it turns out it's a great deal more than that.

Hot flashes, night sweats. difficulty concentrating palpitations, symptoms that many people don't talk about. Numnness of the hands and feet. My wife, who is a voracious reader, found that she would read a book and realized that she wasn't remembering what she had been reading, and for her, that was devastated. Of course. And so I began looking into the symptoms associated with menopause and was,

appalled at how little we really knew. And that was 30 years ago. And that's really how I started getting involved in this. In 1991, Lee Goldman, who is a cardiologist and currently the dean of Columbia University's Vagelos College of Physicians and Surgeons, published an editorial in the New England Journal of Medicine, 1991, 29 years ago. And the editorial was entitled, uncertainty about postmenopausal estrogen, time for action, not debate. 91. Well, we still have not taken the actions that he recommended. In December of this year, Natasha Loder, who's the health policy editor for the economist, published an article in the economist entitled, Millions of Women are Missing Out on Hormonal Therapy. It may cost

them their lives. Well, you know this very well. And the question is, where are we now? I know you've been working very hard for quite a while on this issue. And I am as well, as are many people around the world when we are asked, well, why are you alone publicizing this message? The answer is we're not alone. We're holding with people all over the world. We're holding with people all over the the world. And they're just not given the voice that they should have. When we look at where we are now, there are several things that stand out starkly. And please stop me if I'm just going on too long. No, not at all. Carry on. It's brilliant. One is that menopause is not taught in medical school. It's just not taught. Now, I'm sure we can find some medical schools where it is, but I don't know of any.

Second, less than 25% of OBGYNF fellowship programs, certainly in the United States, talk it all about menopause management. And if we look at what is not contested, there are things in the issue dealing with menopause that are contested. But if we look at issues that are not contested, if we look at the heart, for example, a woman is times more likely to die of heart disease than to die of breast cancer. And what people tell me when I say that is, sure, but old women die of heart disease and young women die of breast cancer. And that's just not true. In every decade of a woman's life, starting at age 40, her risk of dying from heart disease is greater than her risk of dying from breast cancer. And the difference grows with each decade. even among women with diagnosed breast cancer, the leading cause of death is heart disease,

not breast cancer. And repeated studies, and there's no argument about this, you've found that estrogen decreases the risk of heart disease by 40 to 50% more reliably than statins. I'm going to stop you there because that's so important for people to listen to, isn't it, and hear because there has been a confusion about heart disease, menopause, HRT, if you Google it, you'll get different answers. But we know very clearly from, like you say, very well-established studies that women who have an early menopause and women who have their ovaries removed when they're young have a far higher risk of heart disease. And we know that's because estrogen is

protective on the lining of our blood vessels, which is so important, isn't it, for people to realise that the menopause, we've mentioned, the symptoms that it can occur and they can be very disabling for a lot of women. But actually, it's the longer term health risks, which us as physicians are really worried about. And I know as a GP, GPs over in the UK are actually paid for lowering cholesterol, for lowering blood pressure to reduce the risk of cardiovascular disease. Yet as a GP, most GPs, like you say, have no training in the menopause, but they don't even think the menopause is a risk factor for cardiovascular disease. So it's so important that we consider the menopause as a long-term female hormone deficiency rather than something that just causes a bit

of hot flushes that will go after a few years because we'll always have low levels of hormones once we've gone through the menopause unless we take HRT. And it's very important, I think, that people, physicians, nurses and women and also men realize that. Don't you agree? Absolutely. If you move to a different organ, we look at bone. Yes. The number of women die each year following an osteoporotic hip fracture approximates the number who die from breast cancer. Calcium and vitamin D, which is widely prescribed to postmenopausal women without HRT does not decrease the risk of these fractures. You need HRT to decrease the risk of fractures. Long-term HRT is. more effective than any other medicine we know, including the bisphosphonates like

Arridia and Zometa for people who know those snakes, or even prolia, in preventing femoral fractures. Post-metapausal estrogen reduces the risk of osteoporotic hip fracture by 30 to 50 percent. That's incredible. It is so important. Osteoporosis is not a very sexy condition for the media to talk about. It's never going to get frontline headlines. But even in the the UK, about two billion pounds a year is spent on osteoprotic hip fractures. And we know if someone has a hip fracture, they're more likely to be dependent on others, more likely to end in a nursing home, also more likely to have a chest infection. And the morbidity, as well as the mortality from osteoporosis is huge. Yet most women don't realize they have it until they have a fracture.

Right. About 21% of people who have osteoporotic hip fractures die within the first year after the fracture. If women are afraid of one condition more than breast cancer, it's cognitive decline. Alzheimer's disease is a more frightening word for women than any malignancy I know. In 1900, only 5% of American women lived beyond their 50th birthday. Today, their life in efficiency is close to 80 years. A woman in her 60s is twice. is likely to develop Alzheimer's disease as she is to develop breast cancer. And as I mentioned, while 90% of newly diagnosed patients with breast cancer will be cured, there is no current effective treatment for Alzheimer's.

I don't know if you have the ads in England that we have. Yeah, we do. But these over-the-counter remedies don't do anything. The only known effect is estrogen. Estrogen starting within 10 years of menopause has been found to reduce the risk of dementia by between 24 and 65 percent depending upon the study that you look at. And I think this is really important because I'm, as I'm sure you know, I'm not a gynecologist. I've never specialized in gynecology, but I've done a lot of hospital medicine.

And my passion for the menopause is thinking it as a marker for future disease, as opposed to a gynecological condition because most women who are menopausal don't need to see a gynaecologist because they don't have bleeding, they don't have any gynaecological problems. You know, we're living longer, which is fantastic, but it's not just the quantity of our lives, it's the quality of our lives. And every day we read, certainly in the UK, something about Alzheimer's, about how common it is, how there's no cure, how nursing homes are full, how it's a massive drain on the NHS. We're desperate for a cure.

but we have a prevention that no one's talking about. And we're not guaranteed to prevent ourselves from having osteoporosis or heart disease or Alzheimer's by taking HRT, but we know the risk really reduces. And it's the best prevention for all these conditions. There's no other treatment that is going to prevent so many conditions in women that are so significant in women as well. And I think it's really important. I mean, I certainly only had symptoms for a few months, but I had such bad brain fog.

It was like thinking through treacle. I couldn't concentrate, even some of drug names that I've used for years, antibiotics, different drugs that I've prescribed over and over again. I couldn't remember the names of. And it's very scary. And a lot of women who come to my clinic are really worried that they have early Alzheimer's, many of them because they've seen a family member with Alzheimer's. But it's crippling when you can't think.

And very scary as well. So it's very important that we realize the important of estrogen in our brains because it has so, it's so important this hormone that gets all over our body, doesn't it? So tell us a bit more about your book then, because you've got this book, which we recommend, we've got copies in my clinic that we sell, we recommend it to lots of women and men, and it's called estrogen matters, isn't it? Yes. And just to start, my co-author, Carol, Taveris, who's a social psychologist and wonderful. I would sit down with Carol and give her a great deal of data and write a chapter that is very

informative, absolutely brilliant and boring as hell. And Carol would take those data and make it into a fun, readable book. She writes things that I can't write in a medical article. For example, the first article we wrote together, which was published in 2009, was called hormone replacement therapy, real concerns and false alarms. And I gave it to her and she tweaked it so that she would put something in like when we were arguing against the position held by other published doctors. she would write, what were they thinking after decimating their arguments? And I told her, I can't put that in a medical paper. And we submitted the paper to a friend of mine,

who was the former director of the National Cancer Institute here in the States, just for his comments. And he not only loved it, but said he's also the editor of a journal called the Cancer Journal. And with our permission, he'd like to publish it as is. And so we just, you ought to write together. And that's what we did with the book. And neither of us get any money from any drug company, from anybody who has a vested in pushing hormones.

But we do it once it's time other people spoke up and said, we have to recognize this. And when you talk to people about the benefits of estrogen, what you hear is, well, but it, causes breast cancer. And I don't want breast cancer. And so we devote a great deal of the to, well, does estrogen cause breast cancer? And the short answer, Louise, is no.

No? How could I responsibly say that? Doesn't everybody agree that estrogen causes breast cancer? Well, no longer. We used to say because estrogen causes breast cancer, a woman who had breast cancer, she had her ovaries taken out if she is premenopausal, and that will improve her prognosis. And there are at least seven studies in the medical literature looking to see if that works. And the short summary is it doesn't work.

And as you pointed out in the beginning, it precipitates many women into premature menopause. And if we just turn this around a little and say prostate cancer kills just about as many men each year as breast cancer kills women. And testosterone is much more associated with prostate cancer than estrogen is with breast cancer. How many studies have been done doing prophylactic castration on men to prevent prostate cancer from coming back? And the answer is it will never happen because men won't let it happen. And if you turn it around and say to men, what if you had these symptoms, hot flashes, night sweats, difficulty concentrating, palpitations, painful urination, and it'll go on, by the way, not for two years, but for over seven years on average.

and in some people longer than that, would the men put up with that as women are advised to? And the answer is, of course, they wouldn't. And just getting back to, well, does estrogen cause breast cancer? A full-term pregnancy before age 20, which floods the body with estrogen, will reduce the subsequent breast cancer risk by 70%. And I don't advise all women to get pregnant before they're 20,

but it points out that flooding the body with estrogen doesn't predispose to breast cancer. We used to tell women who were pregnant at the time they were diagnosed, they should have an abortion. And in fact, I recommended abortion to many of these women. Well, abortion does not improve the prognosis, and it may even worsen the prognosis. Pregnancy during or after treatment for breast cancer has no negative effect on prognosis. and the women's health initiative, which is the largest double-blind prospective, randomized trial of hormone replacement therapy ever done that was published first in 2002 and follow-up studies were republished frequently since then has just come out after 19 years

of follow-up saying not only does estrogen not increase the risk of breast cancer, it appears to consistently decrease the risk of eventual breast cancer. Which is so interesting because we, I don't know if you know, I did a survey a couple of years ago now of healthcare professionals. I did it on GPs, but then I also did it on doctors who have a special interest in women's health. And the majority thought it was the estrogen part of HRT that was causing breast cancer, which absolutely is not true. So it's really important that women know this because there's so many women who are denied Easterden either from their doctor or just they don't even go and ask for it because they're so worried. And so we've got really robust data, like you say, that's been around for many, many

years. So it's not going to change. So it's very important that women know that they're not putting themselves at risks. And like you say, even women who have had breast, breast cancer. Now, which is obviously more controversial, we know that those women don't always have a worse prognosis for being exposed to estrogen, which is quite unusual because a lot of people are told, well, I'm having treatment to block the estrogen. So therefore, estrogen is the bad bit. So as an oncologist, can you explain simply to people who are listening when they're given these anti-estrogen jugs, how that works? Well, there are several explanations. First, I think it's fair to say that anybody dealing in this field must not speak in absolutes.

The truth is, I'm an oncologist, I've been practicing for many, many years, and I don't yet know what cancer is. And I say that, not just that of humility, but in fact, nobody knows what cancer is, and it's probably a combination of many different diseases. I don't know what contribution estrogen plays in the development of breast cancer, but I know it's been greatly exaggerated, and anything we do in medicine must be a balance of benefit versus risk, and as best I can tell, the benefit far outweighs the risk. Having said that, the first anti-estrogen, which was introduced in early 1970s, was tomoxifine.

And tamoxifen was sold as a drug that blocks the binding of estrogen to a breast cancer cell. And because that binding of tamoxifen to a breast cancer cell is relatively weak, we were told that tamoxifen should be used only in postmenopausal women who have very low estrogen levels, and therefore the tomoxifen would effectively compete with estrogen for that binding site and could be effective. And it shouldn't work on premenopausal women who, when they receive tamoxifen, have a five-fold increased level of estrogen. And what we subsequently found is that tamoxifen works even better in premenopausal women than it does in post-menopausal women, that

Tamoxifen has at least 10 actions in addition to the binding on the estrogen receptor, and tamoxifen is no longer called an anti-estrogen. It's called a CERM, which is a selective estrogen receptor modulator. And if you don't understand what that acronym means, you're in very good company. Nobody understands what it means, but it means that calling it an anti-estrogen is simply simplistic and wrong. Yeah. There are the drugs that inhibit estrogen production that do have efficacy, and I'm not really sure exactly how they work.

But calling any of them anti-estrogens is simplistic. So when we look at HLT, there's still, in fact, there was something in the Sunday Times today written by a male doctor, actually. He's quite a celebrity doctor over here, but he doesn't practice medicine anymore. And he talks about the menopause and he also talks about HRT causing cancer should only be taken for five years, preferably only one year to get through the symptoms. So yet again, I'm banging my head against the wall thinking this isn't right. But for some women, there does seem to be a small increased risk of breast cancer, which is talked over and over again in the media.

But this, like you quite rightly say, is not related to the estrogen. it seems to be associated with the synthetic progestrogens, which I don't actually prescribe any more in my practice. But the risk, even if you look at the worst studies, if you like, the ones that show the highest risk, the risk is still small, isn't it? Yes, but it's a bigger problem than even that. And this is clearly a set up question because you know my answer, which is that the women's health initiative, which said there is up to a 30% decreased risk of breast cancer among women who take estrogen, said, but at 19 years, we are still seeing an increase in risk associated with women who took the

combination of estrogen and progesterone. And for those people who don't know, progesterone is only used in women who still have a uterus because estrogen alone does increase the risk of uterine cancer, and giving progesterone with that eliminates that risk. And the progesterone that was used in the Women's Health Initiative was Megase, which, as you point out, is a semi-synthetic progesterone. There is a progesterone that sold under the name Prometrium, which hasn't been associated with an increased risk of breast cancer. But if we look at the studies of estrogen and progesterone, if we look at just progesterone,

what we find is that women who are deficient in progesterone have a dramatic increase risk in the development of breast cancer. When progesterone was compared to tamoxifen among women who have measurable breast cancer, progesterone was as effective as tamoxifen. And progesterone alone contraceptives do not increase the risk of breast cancer among women who get it. So why was this combination found to increase the risk? And the answer, and this was published in 2018 by a doctorate Yale named Phil Sorrell and a doctorate at University of Southern California named Howard Hodas,

the answer is that it has nothing to do with the risks of progesterone. when you do a trial, you compare your study group with a control group. And what is found is that the control group, when compared to women who got the combination, the control group had a lower than expected risk of breast cancer. Why? The lowered risk appears to result from including women who had been taking estrogen before entering the study and were then randomized to placebo. And they, the control group, because of this population, had a lower risk of breast cancer than expected. And I think this is so important because people

don't always understand risk. I don't always understand it. And it can be very misinterpreted by the media as well. So then it's a double misinterpretation. And, you know, I think also when you put even a risk that is misinterpreted out there, we need to look at other risk factors for breast cancer. And it's the modifiable lifestyle risks for me as a physician are really important that women understand. So things like being overweight or obese, drinking alcohol, not exercising, all these increase the risk of developing breast cancer far more than whether or whether not HRT increases the risk. And so many women I see and speak to who are perimenopausal and menopausal find that it's really hard to exercise because they're tired, their joints are stiff, their muscles are sore, their motivation's gone.

And then they often comfort eat because they're feeling so bad about themselves, and they have a lot more desire to have sugary foods. A lot of them tell me they drink more alcohol just to numb their symptoms, but they wouldn't want HRT because they're worried about the breast cancer risk. yet their lifestyle is increasing their risk of developing breast cancer, but also heart disease and osteoporosis, because these are risk factors for those conditions as well. And once I sit down and talk about that, they go, oh my gosh, I wish I'd take an HRT five years ago when my symptoms started.

Over in the States, obviously there's a higher incidence of obesity. We're catching up over there. But do people talk about obesity associated with breast cancer, but also other cancers? The answer is they do. And you'll notice when I talk, my talk is data heavy because I try to hold on

to reproducible data that can help form my opinion. I think smoking is bad. I think drinking alcohol is bad. I think being overweight is bad. And I think it's good to give people something positive they can do to empower them

to feel that they're helping themselves. But to look at the benefit from exercise, for example, against the development of breast cancer, those data are softer than the data I am comfortable quoting. Yes, yeah. And I think this is really important because certainly all the work I do, the information that I put out on my website, is all evidence-based and like you say, non-biased as well.

And I think it's very, very important that people know the sources of information because increasingly, certainly over here, there's more companies having an interest in the menopause. And that means there's a commercial interest and that often then creates bias. So there's a plethora of herbal remedies of different treatments that we can buy over here in the UK and I'm sure it's the same in the USA. say, and I urge any person who's considering buying any of these preparations to really look at what they're taking them for. And some of them may help with the flushes sweats, but actually they're not going to increase bone density. They're not going to reduce risk of heart disease

and dementia. So it's very important that you ask yourself why you're taking a certain treatment. And a lot of these treatments are very expensive. And as many of you know, HRT is actually very cheap. So it's very important to look at the bigger picture. I think any of you who want more information buying Avram's book, which like we say is called Estrogen Matters, is very important because it's very heavily referenced, which is really reassuring to read. We recommend it to a lot of our patients,

but also to a lot of doctors who are coming and training with us because it's just such a light bulb moment when you read the book because it all makes sense. And Avram says it's done in a very clear, clear way, it's very calmly written, very beautifully written, and it's great to be supported by so much good quality evidence as well. And it's meant so that women shouldn't be overpowered by a physician who simply dismisses their complaints. They can quote the references and say to the author, well, give me references that counter that instead of odd hominem arguments, which don't work

or dismissing me. Absolutely. I think it's really important. And a lot of the work that I continue to do or try to do is about empowering women. So we have a choice. And certainly, we're not making this podcast saying that every woman should take HRT. But there's a lot of women out there who are refused it for the wrong reasons or don't even consider it for the wrong reasons. So it's very important to have that knowledge so you can be empowered and make the most out of your consultation with your doctor. I'm getting letters from many hundreds of women around the world, talking about how the book helped them deal with what they are forced to deal with. And many of them, regardless of which country it is, are still having trouble getting prescriptions,

as you point out, for the hormones that will in almost places help them. Absolutely. There's so much work that needs to be done. And certainly a lot of the work I do on social media, I'm staggered with a number of countries that women come from who get in touch. So we can only carry on with what we're doing and hope we'll make a change. So before we finish, Averham, this has been amazing

and I think I'm going to invite you to come back and do another podcast at a future date. But could you just say three key messages about the HRT and breast cancer risks and also benefits of HRT, so maybe three points about HRT that would be useful for listeners to take home? Sure. A study that was published out of Harvard about 20 years ago said if every woman in

the United States went on hormone replacement therapy, the median survival of women in this country would be extended by an average of 3.3 years. That's one point. The second point is that the mantra that you hear, well, if you must take hormones, take the smallest dose for the shortest period of time has absolutely no scientific support. And there are now 33 menopausal organizations around the world who have supported what the North American Menopause Society says, which is you take hormones for as long as you need them and don't be frightened by that statement. And the third here, some of the benefits of hormones specifically for bones, seems to last. as long as you take the hormones. And when you stop taking the hormones, bone degeneration

occurs at an accelerated pace so that within several years of stopping hormones, your bones are no healthier than they would have been had you never taken them. So basically, someone said to me recently, the best time to stop taking HRT is the day that you die. I think that's probably right. I'm certainly not going to stop taking mine because I actually really worry about osteoporosis. So thank you ever so much for your time, Avram. It's been absolutely brilliant and I look forward to speaking to you again soon, hopefully. Thank you. Bye. Bye. Take care. Bye-bye. For more information about the menopause, please visit our website www.menopausedoctor.com.