This episode of Point of Inquiry, we have two heavily credentialed individuals who I am very excited to talk to, Dr. Avrum Blooming received his M.D. from the Columbia College of Physicians and Surgeons.
He spent four years as a senior investigator for the National Cancer Institute.
And for two of those years, he was director of the Lymphoma Treatment Center in Kampala, Uganda. He organized the first study of lumpectomy for the treatment of breast cancer in Southern California in 1978. And for more than two decades, he has been studying the benefits and risks of hormone replacement therapy. That’s h r t administered to women with a history of breast cancer. Dr. Blooming has served as a clinical professor of medicine at USC and has been an invited speaker at the Royal College of Physicians in London and the Pasteur Institute in Paris. He was elected to Mastership and the American College of Physicians, an honor accorded to only 500 of the over 100 thousand board certified internists in this country. Carol Tavaris received her APHC in social psychology from the University of Michigan. Her books include Mistakes Were Made But Not By Me, with Elliot Aaronson anger, the Misunderstood Emotion and the Miss Measure of woman. She has written articles, op Ed’s and book reviews on topics and psychological science for a wide array of publications, including the L.A. Times, The New York Times Book Review and The Wall Street Journal. She is a fellow of our own Committee for Skeptical Inquiry and also a fellow of the Association for Psychological Science. And she has received numerous awards for her efforts to promote gender equality, science and skepticism. OK. I just want to say something quick about the book. Mistakes were made, but not by me, by Carol Tavaris and Eliot Aaronson. I’ve been in this world of dealing with religious questions and paranormal questions and wild claims for almost 20 years now and been a student of these sorts of things for probably closer to 40 years. There is a short list of books that help us understand how we humans come to believe the things we do and how our minds operate. Once we do hold, those beliefs and mistakes were made, but not by me is one of the books. I think every skeptic, atheist, free thinker, whatever you call yourself, should read this book and you will see parts of yourself in it and you’ll see parts of people in it that hold beliefs that on the surface you can’t believe how someone can believe something so ridiculous.
The book we’re going to talk about today, however, this called Estrogen Matters why taking hormones in menopause can improve women’s well-being and lengthen their lives without raising the risk of breast cancer.
Now, when I first heard about this book, of course, I’m familiar with Carol Tavaris. She’s one of the heroes of the world of skepticism. But it didn’t strike me as something that I would be that interested in. I’m a man. I don’t go through menopause. This didn’t even seem like a subject that was clearly in the wheelhouse of what the Center for Inquiry deals with. But then I started learning more about this book, and, boy, was I wrong. The show is going to be centered around the widespread misconception that estrogen and breast cancer are linked, that taking estrogen can or will cause breast cancer. It’s a wild story about how this misconception came to be. And we had the two perfect people to be talking about it. If you don’t live in a cave, you probably know a woman somewhere in your life. I have a wife, a mother, a mother in law, a sister, a sister in law, nieces and lots of women friends. So anyone who knows a woman who makes it to the age of menopause and cares about her has a stake in her health. And that may involve her taking estrogen at some point in her life. So we take you now to the Hollywood Hills and my fascinating discussion with Avrum Blooming and Carol Tavaris.
We are here with Avrum Blooming and Carol Tavaris. We’re talking about estrogen matters, why taking hormones in menopause can improve women’s well-being and lengthen their lives without raising the risk of breast cancer.
How did this get started? How did you decide? Why did you write this book?
I’m a medical oncologist. About 60 percent of my practice has been devoted to the treatment of patients with breast cancer. And I’ve watched the prognosis in breast cancer improved dramatically so that we are now at a point where approximately 90 percent of newly diagnosed breast cancer patients are cured. And that’s wonderful and is an oncologist. That pleases me no end, although I’d like to get to 100 percent. And I follow patients who were cured of their breast cancer and watched them reach and pass menopause and go through the symptoms of menopause.
And in many cases, I recognized that I was responsible for inducing those symptoms prematurely by giving them chemotherapy, that I’d inactivated their ovarian function. And when they would complain to me about the symptoms, my response was, you’re alive and you’re cured. And women have been given the message that they have to suck it up and deal with it and get on with your life, suck up the menopause, the symptoms and don’t whine. And after a while, I began to hear what they were saying. And it wasn’t just that they were having hot flashes and night sweats. They were having trouble remembering they will have trouble dealing with numbers, even women who are very capable with numbers that were having heart palpitations that their cardiologists couldn’t explain. They were having bloating. They were putting on weight around the abdomen. And after a while, I, I took them seriously enough that I started looking into what might be done. And there are many things that are sold to treat the symptoms of menopause, black cohosh, flaxseed oil. Nothing works like estrogen. Estrogen is responsible for helping 85 percent of women who have menopausal symptoms and nothing comes close to that. But I wouldn’t dare give them estrogen because the thought was that estrogen causes breast cancer. And as the population increased, I was forced to question a lot of the things we were taught about estrogen. For example, we are taught that the reason we know estrogen causes breast cancer is because the earlier you reach menarche, the earlier you start having periods and the later you reach menopause. So the longer the period of time that your body is exposed to estrogen. If you’re a woman, the higher your risk of breast cancer. That’s not true. If you look at the studies that are quoted to verify that it’s not valid. We were told that if women take estrogen, they must take it for the shortest. The lowest. Those for the shortest period of time. And there are no data to support that. A woman who gets pregnant before the age of 20 flooding her body with estrogen decreases her risk of subsequent blessed breast cancer by 75 percent. The more children a woman has gives birth to, the lower her risk of breast cancer. Also, high levels of estrogen. We used to tell women I used to tell women, if you’re diagnosed with breast cancer and you’re pregnant, you must have an abortion because we are concerned about the estrogen in your body. Well, when you look at studies that have now looked at that, that’s not only not true. If anything, and this may not be valid, but if anything, the abortion worsens the prognosis. Having a child after a diagnosis of breast cancer does not reduce the risk of cure it it if anything, reduces the risk of recurrence. And so with all of those questions, I was forced to confront truth that I’ve been given that haven’t been true. And I gave talks about it. I wrote papers about it. I spoke to Carol about it, who was a good friend, Carol. And I wrote papers about it. And we were amazed that although physicians were hearing our papers and hearing our talks and reading our papers, the. Teaching was not changing, anything was changing, and we wanted to approach women and get the word out beyond the wall of the medical establishment just to empower women so that they would have the information that they could use to become more active participants in their own care.
See, this is one of these assumptions that estrogen causes breast cancer that is so widespread among physicians and of course, many women promoted further by the Women’s Health Initiative. That is really hard to dent. We say in the book it’s comparable in a way to what it took to overturn the view that if a woman has breast cancer, what you have to do is remove the entire breast. When the evidence was growing that a lumpectomy would be just as effective, then not disfiguring what it takes to overturn a paradigm in medicine that is so widely held. Is the challenge for all scientists and skeptics. And this has really been a difficult one. And by the way, I want to say right at the outset, neither of us has a vested interest here. Nobody’s taken any money from the drug company. And and I actually never took HRT myself, so.
OK. So you’re not in the pocket of Big Pharma, I’m sure a receipt for how you paid for this house or not.
Big Pharma did not pay for the house. I have to say, and I’ve been an outspoken critic of Big Pharma, and actually Adam and I are both quite angry at the prices they are charging for Premarin and other medications.
That’s a separate issue for me.
The basic question is what is best for women?
And to try to separate that from two constituencies who believe strongly that estrogen is bad or harmful for women. One is the medical establishment has often said this pervasive paradigm that estrogen causes breast cancer. But the other comes from many women’s health activists and feminists who have been arguing against estrogen since the awful days of feminine forever decades ago. The idea that women aren’t, you know, natural or healthy or something unless they unless they take estrogen. And so many women have opposed the notion that there’s something the matter with women once they enter menopause, that they need some kind of. Correct, correcting, correcting. But for me, as a feminist skeptic and scientist, the unifying question is what is best and healthiest for women? And I have had to face my own dissonance in looking at the evidence that often first presented for me so many years ago about the benefits of hormone replacement therapy.
Well, and I mean I mean, I’m sure there is this issue of because the medical establishment, establishment elite traditionally has been mostly male where there is might be this risk, as you alluded to, Avrum, that just get over it. What? It’s just a little bit of swearing. We’ll see what that’s, you know, what are you complaining about and not taking some of these real symptoms seriously? They’re disruptive.
Well, and they weren’t the symptoms. So many of them aren’t associated with menopause, such as depression, joint pain, muscle aches, you know, and certainly sexual dysfunction, sexual dissatisfaction, loss of libido, vaginal dryness and so forth. And, you know, just just try saying to men, OK, guys, you’re 50, you’ve had enough sex.
Now, you don’t need any more sex for the next thirty seven years of your life. Just get on with it. Okay. How many men would say that? They’re certainly not.
They’re rushing off to take testosterone, which by the way, what what that is a terrible irony in this is that today many women are more likely to be given testosterone for sexual functioning than estrogen when estrogen would be more beneficial and testosterone has far more risks.
And we used to be told that menopause symptomatic menopause lasts approximately two years in over 50 percent of women. It lasts over eight and a half years. And some women have it for decades. And so even the teaching there was sloppy. And as long as you mention men, of which I happen to be one, as about as many men die in this country each year of prostate cancer as women die of breast cancer and testosterone is linked more closely to prostate cancer than estrogen is to breast cancer. One of the ways we used to treat women who had breast cancer under the assumption that estrogen causes breast cancer is we used to take out a woman’s ovaries if she was premenopausal to help prevent recurrence. There were seven large studies in the medical literature looking at that, and none of them showed that it decreases the risk of recurrence. Do you know how many studies of orchiectomy castrating men who had prostate cancer to prevent recurrence have been conducted? Probably not. And there never will be.
Are you going to get volunteers that so many.
That so many. And by the way, let’s just throw this one and two, because this was a real shocker to me.
People think that estrogen diminishes at menopause, declines in the way testosterone declines over time. It doesn’t decline. It plummets. It vanishes. The levels of estrogen for women after menopause declined to one percent of what they were premenopausal. That’s not a mild slope. That’s a drop off the cliff. And I think that is one of the reasons that the kind of symptoms that women have during menopause can be so severe. And by the way, not all women have all of these symptoms or truly suffer for a long time.
There’s immense variation among women, which is one of the reasons we’re not saying this is a one size fits all. You know, the suggestion that we are saying that a lot of women have suffered from symptoms that deeply affect their lives. And the fear of estrogen is preventing them from taking the one thing that can be beneficial. They turned to the supplements, which we all, as skeptics, have been fighting so noisily about forever.
Give me a supplement.
Now, it’s not going to help you. And so they try bioidentical switch and muse, abdomen, knee, because it’s the idea that you can take something that’s identical, but not the same. I mean, it’s a funny idea. Bio identical. Yeah. So.
And so, you know, as skeptics, we all know the research, the placebo effect of these natural medications. Some are useless and some are harmful.
And and none of them are as effective disaster. And in the book, we spend the chapter talking about symptoms which we think are very important. But that’s only one of the issues we address menopausal symptoms.
That’s correct. I feel Perot’s this is a thinning of the bone that’s associated with the increased risk of hip fracture. As many women die in the United States each year of complications related to hip fracture as die of breast cancer and estrogen can reduce the risk of osteoporotic hip fracture by 50 percent. Calcium and vitamin D, which are widely advertised. Do absolutely nothing for postmenopausal women. The bisphosphonates, which is a form of medicine that is used to treat osteoporosis, works really well for about five years and is then associated with an increased risk of unusual fractures of the femur. Estrogen continues to work as long as you take it. Heart disease kills seven times as many women in this country as breast cancer does. And what we usually hear when we say that is, well, old women die of heart disease. Young women die of breast cancer. No, actually, in every decade of a woman’s life, her risk of dying of heart disease is greater than her risk of dying of breast cancer. And the difference grows with each successive decade. Estrogen reduces the risk of heart disease by up to 50 percent. Statins, which are widely recommended for women, actually work in men to help prevent heart attacks. Statins do not prevent an initial heart attack in women, and yet women take them and feel, well, I’m covering myself.
Is there a pocket, an age pocket where women get breast cancer most often?
Interestingly, yes. It’s between the ages of 45 and 65.
But it can happen as early as 20s, although that’s uncommon. And the older a woman gets, the greater her risk of breast cancer. So that one of the arguments against estrogen being associated with breast cancer development is, as Carol pointed out, estrogen plummets around the early 50s when a woman reach menopause. And yet her risk of getting breast cancer continues to increase up through age 85.
Yeah, it doesn’t seem like a logical correlate out if you’re going to think logically, but it’s easier to think by rote instead of really analyzing data, see analyzing data.
This is the key thing.
You can see why Adam and I are such great pals about this. We do love to analyze data and of course and then we will call each other up in a fury because we have learned that just by presenting the evidence, people don’t say why. Thank you so much for this incredibly important information. Right. They say, I know. Sort of take your stupid study with you.
It’s it’s it’s a very hard wall to to penetrate. But one of the things the Avrum in medicine and I and social psychology have in a way been doing the same thing all of our lives, which is which is trying to bring the best empirical research in our respective fields to the public in psychology. So many people are subjected to sort of pop, psych, goofy psycho notions.
And I run valiantly after them, trying to swap them with the slaughter of data, you know.
And here’s Ibram doing the same thing in medicine.
Well, and that’s what science is supposed to do, right? It’s supposed to pull the emotional attachments and they’re your predisposed opinions out of the mix and see what the data should find when that science isn’t supposed to prove us right.
It’s supposed to prove us wrong. And it’s only if we can’t disprove a hypothesis that we have that we are forced to accept that maybe it’s saying something.
But, you know, see, here’s the psychologist coming in here.
I told the story of a woman I met who had had breast cancer and decided that the reason was that she had been on hormone replacement therapy. She attributed the breast cancer to having taken estrogen. And so I thought she would be relieved and reassured to know the evidence that that would not have been the cause of her breast cancer.
Takes her off the hook, takes her off the hook. And she turned to me with full knowledge and she said, Carol, don’t you understand? I want to believe that estrogen caused breast cancer, because now by stopping the hormones, I can control the likelihood of reoccurrence.
She was even aware that she wanted to hold on to that belief because it gave her some control over the disease. So we understand how psychologically powerful it is to overturn a belief that you really hold seriously. We had a woman doing some publicity for us who said she’s in her 60s. She’s been taking estrogen right along happily and healthily and so forth. But you said Bertino, there was a little niggly feeling that maybe I was harming myself. You said your book has been so reassuring.
Look at I mean, the great example is the the the bogey’s connection between autism and vaccinations. People are trying there. They don’t want to hurt their kids, of course. It’s you can understand that their hearts are in the right place. But once this connection is made in their mind, I’m a good parent.
Now you’re telling me that not vaccinating my kid is what a bad parent does? No, thank you. I’ll take the belief that I’m a good parent.
Yeah. We’ve been without the serious measles epidemic for a little too long in this country. Maybe people got to see what some of these diseases are that we’re vaccinating there.
Maybe they would be horrified into the vaccination.
And talking about the book, I was asked to give a talk at the Royal Society in England. And when you walk into the Royal Society of very impressive building that Darwin’s spoken, you see a motto emblazoned on the front, which is nullius e Verber, which means take nobody’s word for.
What a wonderful, adaptable state meant. And so when we wrote the book, we didn’t write it as just two opinionated people who wanted to get our voices heard. We wrote the book The Way We write a paper so that it is extensively referenced by peer reviewed studies so that if somebody disagrees with the book, show us your data. And if we’re wrong, of course, we’ll say we’re wrong, but recognize the the depth of proof that we brought to bear on this book.
I want to add one thing, too, which is that the evidence for the harms of hormone replacement therapy comes largely from the Women’s Health Initiative. This massive one billion dollar study that came out in 2002 with one of these stop the presses.
We have found this increased risk of breast cancer, a kind of alarm thing, and it caused prescriptions for HRT to plummet all over the world.
There was a time when hormone replacement therapy was fairly common, right?
Yes, that’s at least 40 percent. The American population of appropriate women would take.
So what? What is that period? And then it changes in a change your life. 2002, that’s when the Women’s Health Initiative group makes this blockbuster announcement. Where, yes, there is a connection between taking an estrogen and breast cancer and heart disease and dementia.
None of that is valid.
Scares the hell out of everybody. Everybody knows it. Doctors say it increases mortality from all causes. It doesn’t even affect Netto symptoms. It does.
I mean, one thing after another with scare stories, scare stories, scare story, the any good news was buried, never became a headline, was never picked up worldwide. Now, what’s important about this for skeptics is that the Women’s Health Initiative promoted itself as the gold standard study. The thing we’ve all want in medicine, evidence based medicine, all of us, and the skeptical double-blind, respectively, randomized to right and huge and very big. So it is considered the gold standard. This is not an observational study and blah, blah. And to us, what it shows don’t believe just because nobody nobody’s word for it. This study was so biased in that in the most extraordinary ways, it it abandoned some basic rules of scientific reporting, analysis and publication. Only a very few of the 40 original principle investigators were involved in writing this sensational Stop the Presses report. Many of the findings did not reach statistical significance and were not very strong in statistical terms. And yet got all of this attention without reaching statistical significance. And when you have the principal investigators saying, well, yeah, but, you know, with breast cancer and we’re also worry, we we just lower the bar on what’s acceptable evidence, you know, meaning if there’s any possible thing we can squeak out of here to scare women, we’re going to do this. So as we looked into that study, I mean, this was the emperor’s new clothes. This emperor marching down the streets of Washington, D.C., was completely naked.
It didn’t do any study and prematurely it was stopped prematurely because some of the investigators have few of them said, well, the data are so worrisome that it would be unethical to continue the study. And it’s just to elaborate on what Carol said. It was set up as a study of typical women so that it was generalized to all perimenopausal and menopausal women in the United States. Well, not exactly typical women. In fact, 50 to 70 percent of them were overweight or obese. Half were smokers.
The median age was 63. That’s now after. Yeah, well, after. Yes, that’s right. And when you ask them about that, what they said, what the investigators said is, well, we wanted to take women at increased risk of things like heart disease to see if hormones really helped heart disease. And we purposely chose a population where we would see that result sooner rather than later. And that way, this study wouldn’t cost us as much. Fair enough. But what they ignore is heart disease is diminished by estrogen. Unless you’re going to start it, you start the estrogen over 10 years past menopause. And then for at least a year, you may get an increased incidence of heart events. And as far as breast cancer goes, which was the stop the presses story, the increased risk of breast cancer was not a real increase. Yes, it was not statistically significant. But when it was reanalyzed, it didn’t even hold up as a difference. And we put on our website later study that shows that the way they analyzed that data to find the increased risk was faulty, that there really was no increased risk, even though they reported the increased risk was only with the progesterone and estrogen combination. And in fact, estrogen alone never showed an increased risk of breast cancer. And in one subsequent study showed a 30 percent decreased risk of breast cancer.
Well, the the the statistic I heard was a 26 percent increase, and that’s what scared everybody.
And what’s so interesting is estrogen alone. There was no increase there, 26 percent, which. Progesterone and estrogen was when progesterone and estrogen were compared to their control group as part of the randomized study. If you look at the control group for the estrogen alone. Same population, but they were the control group identified for estrogen alone. And compare that to the incidence with the combination. There’s no increased risk even with the combination. It’s only the control group for the combination, which, by the way, had a lower than expected risk of breast cancer. That’s how you got the non statistically significant increased risk. And the question is, well, why does that control group have a low increased risk of breast cancer? Well, that control group had women who were taking estrogen before they were randomized to placebo. And if you remove the the women who took estrogen before being randomized to the no treatment group, that 26 percent, which was not significant anyway, disappears.
Now, see, this is stunning, Jim. This is just stunning. Stunning because it suggests that they were really working overtime with their statistics to manufacture these scary findings that were not there and that vanished and reanalysis in subsequent years. This is dazzling. This should be front page news when we see the the news of, you know, any scientific fraud or shenanigans or, you know, business with Big Pharma. This is we’re all aware of the dangers of misinterpretation and mis analysis of data. The Women’s Health Initiative, people had to resort to data mining.
You get a finding, OK? There’s no no danger here of hormone replacement therapy. OK, let’s rummage around. There must be a pony in here. Let’s rummage around until we find it. It’s women who took estrogen.
Between the ages of forty one and forty three and a half.
I mean, we feel if you do that, you can squeak out some little finding. But it’s not. It’s a big no no.
Where are the investigators who are part of this? Why isn’t someone raising their hand and saying, wait a minute?
Well, we are. We all raise our hands. And by the way, our book has been endorsed by many very responsible world leaders in medicine. And they recognize that what we’re saying is, is valid. And some of the investigators have written articles saying, well, we generalize too much. One of the investigators wrote 13 years after the study. Let me tell you the way that study came out. We were all invited to Chicago when this study was announced. We hadn’t seen the data yet. And we were given the data saying that the paper has been written and submitted to the Journal of the American Medical Association. And those of us in the room in Chicago said, wait a minute. First of all, we think that’s a hurried conclusion. Second, we haven’t had a chance to analyze the data. And they were told by the writing committee, well, we’re in Chicago and the editorial offices of the Journal of the American Medical Association is just down the block. So why don’t you take a few hours, go over the paper here and tell us what your objections are. And they did. And they ran to the office of JAMA and they were told, I’m sorry, it’s already been printed and it’s waiting to be shipped.
So we don’t know why this is. We have been raising our hands and making noise and so have, by the way, thirty one international menopause societies around the world.
So what’s dry? I mean, what’s driving this is it.
We spend so much money on this, we have to have some kind of headline.
That’s my view. That’s my view. We know from psychological research that sexy news sells bad news, sells good news, does not sell. You know, in the in the. The sex differences field, if you do a study and you find that men and women are more alike than different. Nobody will be interested at all but find some sex difference. And boy, that’s headlines. But here, this is bad news. I mean, I think actually the lead investigator of the Women’s Health Initiative said we needed to make a dent in the overexcitable news cycles, you know, where there’s no new news report. You know, every every day we had to we had to make some noise. We had to come out with a finding that made some noise to interrupt the news cycle. Well, the noise would not have been, hey, hormone replacement, say, for women. Isn’t that a great, reassuring thing? Everybody would have said, well, we’ve known that for 25 years. Thank you very much. And so I think it was a way.
To justify the massive cost and time and investment they had and one of one of the statements that the Women’s Health Initiative investigators said is we entered this study thinking that we’re just going to show that estrogen is good, as other studies have shown. Well, that’s a lie, because four years before the Women’s Health Initiative was published, that senior investigator wrote, it’s time we put a halt to the estrogen bandwagon.
Oh, my God. We invited one of the senior investigators to a local hospital at which I was working to address the group of physicians. This was about six months after the Women’s Health Initiative first came out. And after he gave his talk, I’m E.A. Doctor raised his hand and said, you know, I’m just an E.A. doctor. He didn’t say that he had APHC in math. He said and it just seems to me that the numbers that you just presented to us, the numbers on the basis of which prescriptions for hormones fell by 75 percent around the world were not even showing a statistically significant difference.
What am I missing? And the investigator said, you know, this was the most expensive study ever done. By the time we’ve finished, this study will cost a billion dollars. We will never get a chance to do a study like this again. So if we think we have found something and the numbers don’t quite add up and this is the quote, the statistical police have to leave the room. And there was absolute silence among the physicians in the audience.
So there you have the difference between a belief when confronted by evidence that does not support the belief. And what a tragedy that this was so true in this massive medical study that’s so ingrained was their belief that it just has to be the case that estrogen is harmful.
It’s so disappointing because we go around the world trumpeting how science is the best method for discovering anything about how our universe works and our bodies.
And then you find out about these sloppy procedures going on and it takes away from the credibility which, by the way, in the United States has taken so many hits. Nobody believes any expert any way. We certainly don’t need the true experts to be fudging their data.
That’s you know, I think that’s really the big tragedy here, because I have talked to a number of physicians in the skeptics world. Who? I don’t know. I guess they think I’m a crank in whatever they think. I mean, they know I’m. I’m, of course, affiliated with the skeptics movement and so forth. But I’ve I. I see their reaction, which is a kind of. There, there, dear. The Women’s Health Initiative was a randomized controlled trial. That’s all I need to know. That’s all I need to know. I’m used to criticizing badly designed studies, biased studies. But this was a nasty. So I’m just taking it at its word and with them, as with every other critic, we say, read our argument here. Our our book has the has a takeaway for women to bring to their physicians with ten things wrong with the Women’s Health Initiative. Just look at these. Just look at these, won’t you, how the thing was conducted, how it was analyzed, what was really found, as opposed to what they said they found. Just look at those one, two. And tell us where we’re wrong.
When excellent example is. Two years after the initial study came out, the Women’s Health Initiative came out saying, and by the way, estrogen has no effect on women’s quality of life.
And the first question is, what planet was this study done on and how men had to say that?
Right. Well, there were women and part of the investigators, but there were women as part of the investigation. And when you look at the study, you see, as Carol pointed out, that it is a prospective double blinded randomized study. And the investigators wisely said that if a symptomatic woman enters the study, she will know in less than a week whether she’s taking a placebo or hormones. And if she’s on a placebo, she will probably drop out of the study and go find a doctor who will give her history. We intentionally eliminated any symptomatic women from joining this study so that only 13 percent of the many thousands of women who were studied were overtly symptomatic. And do you know what? Among those women who had no symptoms, they had no improvement in the symptoms. They didn’t have. And that was what they published, although they didn’t say it as clearly as I just did. And it was headline in The New York Times with Gina Kolata writing, Not only do hormones cause harm, they don’t even cause the benefits. We thought they cool.
How are you going to get a go from no problem to a benefit or is there to go from no problem.
And by the way, you probably know Harry at all, got dark as a fan of yours and was totally on board with Jennifer Gray.
We like to look at the three dude in evidence based medicine on their website. Yeah, yeah.
Well, it’s I mean, one of the things I and I consider myself a lay person in a lot of these matters.
It’s not an easy thing to do to read a study carefully and understand if it was done right and the conclusions were properly drawn.
Ray, great ad that Jamal Cox. Great that there are people who know you’re good at that. There are people who know how to do that.
And you expect. I mean, you have to have someone on your team that’s going to provide that service and do it dispassionately and be honest and say, hey, we can’t say this.
Well, we all have to rely on it.
Nobody can check every fact every morning, can’t read all the study and read all the studies, especially complicated ones like this one. So we do have to rely on our best sources of evidence.
I mean, one of the things Ibram and I have discussed over the years is how many people who are clinical practitioners, psychotherapists in my field, physicians, medical oncologists in his. Don’t read. They don’t read the studies.
They get their information from their organizations or from their guidelines, telling them what the latest something is or from Web M.D. like everybody else.
Very few will take the time to go and read original research. The JAMA article, which comes out by press release. OK, and everybody, doctors panic and stop prescribing, but they don’t even have the time. They don’t even have JAMA in front of them to go and read. And they have so much to do. There’s so many constraints on physicians times these days. They are they often don’t have the time to go and look up these studies directly. My gynecologist did. I remember talking with him at the time. He said that Women’s Health Initiative is preposterous, but he had taken the time to go see if it was really worth telling his patients to.
To follow up on the story. I started telling you about why we wrote the book in 1992. After doing a great deal of research, I decided it was worth trying a clinical study offering hormones, especially estrogen, to women who is symptomatic after a diagnosis of primary breast cancer. And I reviewed the medical literature and published the review and surprise. The medical literature supports that.
It is a reasonable thing to do, that it would not increase the risk of recurrence. But it was sketchy. And so I wanted to do this study. I spoke to physicians in my community whom I’ve been speaking to for quite a while, and they said, well, we’d be willing to participate in this study. But frankly, we’re afraid of being sued because some women are going to recur. And if we’re giving them hormones, we’d be sued. So I went to the head of the California Bar Association who said to me, anybody can sue anybody for anything. But if you get an informed consent form, you’re covering yourself as best you can. So I did. And then I called the Food and Drug Administration and I said, I want to do this study and do I have to ask you for permission? And they said if you call it a study, you do. But if you’re going to just say it’s treatment. There were doctors doing this now and no, you can do that. So I said, well, I’m calling it a study. And they said, well, then send us an application. So I sent them an extensively reference application. I didn’t hear anything for a month. And after a month, I got a call saying, we’re putting a hold on your study because we think you’re exposing women to an unacceptable risk. And I said, did anybody read what I had sent? And the man on the phone said, Don’t shoot me. I’m just the messenger. So I said, well, why don’t you put me in touch with. You can make a decision. Right. And instead of doing that, they invited me to the FDA headquarters in Maryland and they invited two other people, a surgeon from UC Irvine and the head of the North American Menopause Association, to address a committee put together to hear this. And we spent the whole day giving them the data. And at the end of the day, the chairwoman of the committee stood up and said it would be unethical not to do this study. So I flew back with the surgeon from UC Irvine, Alan, while and he said to me, you know, they didn’t give us permission to do this. And I said it sounded like permission. And the way we had set it up, I was going to do a pilot study of 300 women, a single arm study so that I wouldn’t be randomizing women. But we have. Extensive information about prognosis based on staging. And if we saw on that single arm study that we were not exposing women to an excess risk, we weren’t pouring kerosene on a fire. UC Irvine would do a prospective double blind randomized study of 5000 women. And a month after I came back and started the study. I got a letter from the FDA saying, even though we gave you permission to do this study, we objected to this single arm study that you’re planning to do. We want you to do only the 5000 prospective double-blind, which I thought was absurd. So I flew back to the FDA on my own dime. They reconvened the committee and we spoke for a whole morning together. And one participant said to me, why do you want to do this study? Why don’t you do other studies? I said, I am doing other studies, but this is an important study. Another woman physician said, well, most of your patients are going to die of breast cancer anyway, aren’t they?
And I said, don’t you leave? She said, I guess I ought to catch up. Fine. At the. But they didn’t give me permission. At the end of the meeting, the chairman I asked the chairman what would happen if I just go back and continue this study that I’m doing? He said, Dr. Blooming, we can’t tell you how to practice medicine. Terrific. And then he said, I hope you found our comments, have some help. And I said to him, I’m very grateful that you reconvened the committee and gave me this time.
But your comments were of no help whatsoever.
And I went back to Los Angeles. I continued the study. Seven years later, I presented the results of this study, which showed no increased risk of recurrence. I presented it at a plenary session in front of eighty five hundred oncologists from around the world. And the meeting? My presentation was followed by a presentation from the National Cancer Institute. And after I spoke, the doctor from the National Cancer Institute got up and said at the NCI has decided that it would be unethical to give hormones to women with a history of breast cancer. And so my presentation was met with seven questions, all of which were complimentary. And he was almost stoned. And his answer was, don’t shoot me. I’m just the messenger. Terrific. When I got back from that meeting, I got a letter from the FDA saying, even though we know that you don’t need our permission to do this study, we are willing to give you retroactive permission to do this study. I thank them for that. And I told them I would use that because on the informed consent form I had written, even though the FDA approved the study, in principle, they object to the single arm study. And I was able to remove that paragraph, but it’s been that kind of battle for over 20 years.
And let me add why this is so crucial at this time in our history. It’s precisely because 90 percent of all women who will be diagnosed with breast cancer will be cured. What this means and many women don’t realize this, what this means is that millions of women will be living healthy lives, post breast cancer, post breast cancer long enough to develop heart disease, osteoporosis, dementia and other problems of old age.
In fact, some of the treatments for breast cancer increase the risk of heart events. And so there is now a new specialty called cardio oncology, which is how do we treat women who have had breast cancer most effectively? So Adam’s question, can we safely give estrogen to women who have had breast cancer to reduce their risk of dying of heart disease? Osteoporotic fractures and developing dementia is more crucial than ever. And Ivan is already getting letters from women saying the treatment for breast cancer threw me into menopause and to all of these terrible symptoms. My doctors won’t give me estrogen. What can I do? So this question is powerfully relevant to women now.
But it’s important to add that this is not a mail order pitch and we are not looking to advise every woman to take it. The issue of hormones after breast cancer is still a question. And while it’s worth looking at and we review the data in Chapter six of our book, it is still a question. But women can go into their physicians empowered by data so they not simply put off by a shrug on the part of the doctor. And the letters we’re getting now from around the world are women who say. I’m wearing sunglasses because I am crying tears of gratitude when I go out that you wrote this book. And at last, somebody is beginning to listen to what I’ve been saying to you.
You’re trying to pry people off this knee jerk reaction of denial of estrogen and even at the high levels here.
So what’s the are there are those is it risk aversion that people just don’t want to.
They feel like they’re taking a chance on unnecessary care? Well, sure. But as you pointed out in the vaccine study. Not doing something can be riskier than doing something.
And we think certainly in women with no history of primary breast cancer. That’s really where we are now. And one area that Carol touched on is cognitive decline or in its most severe form, Alzheimer’s disease. For every woman in this country diagnosed with breast cancer, at least two will be diagnosed with Alzheimer’s disease. And unlike breast cancer, which has a 90 percent cure rate when it’s diagnosed early, there is no treatment and there is no cure for Alzheimer’s disease. And estrogen can decrease the incidence of Alzheimer’s disease proactively. Twenty five to 60 percent, depending upon the study you read. Nothing else works.
Well, and see, you know, Jim, you said it’s this risk aversion about things that, you know, most people and quite wisely have a view. Why should I take anything in women? Keep away from all medications. Every medication has a risk, including aspirin. As Ivan points out, everything we do in life is a risk. Crossing the street has a house leaving the house as a risk.
So, of course, it’s a matter of balancing benefits and risks always. But what I see is that women are so many women, not all are so unhappy and have so many uncomfortable, difficult symptoms at the time of menopause that they’re drawn.
It’s interesting that they’re drawn to estrogen. They know estrogen is what they want, but they’ll look for it in any other possible form. Yeah. I’m going to eat yams. I’m going to have soy. I’m going to have to have all these supplements. The supplements range from the benign and useless to the harmful. And these, quote, natural supplements, as we all know from the skeptics world, can can be harmful to you know, they’re doing something.
They’re not always benign and they’re barely regulated. Right.
I mean, well, it depends when we talk about bioidentical hormones. And as Carol pointed out, bioidentical is more of a sales term than a scientific term. It can come from a yam heavily concentrated. It doesn’t mean it’s coming from the same source. Premarin, which is the most widely used estrogen in this country, comes from pregnant mare urine, which sounds terrible, but it’s the best studied and thus far the safest form of estrogen administration. But there is bioidentical estrogen that is FDA approved and that is marketed and we have no problem with that. It is the compounded estrogen which is not regulated, which is done in local pharmacies without good control. That has a very strong following and that we are seriously concerned about.
Is that also a prescription?
It yes, it’s a prescription, but it’s prescription without the appropriate regulation that we take for granted when we buy medication.
And there are many concierge doctors now who are devoting a practice to women in midlife and menopause who are prescribing some of these compounds and so forth, because they they know what the kind of symptoms that women have that they want relief from and that many women have been frightened of HRT.
So in the book you talk about two weird statistics can be misconstrued as being important.
And so these are some other factors that you noted were associated with breast cancer, and that is the amount of multivitamins you eat, the amount of alcohol you drink, which all of that sounds kind of science.
See what French fries?
Well, it’s only an extra portion of French fries in your early childhood once a week that’s been reported in the medical literature as increasing the risk of breast cancer.
I have to tell you, I’m screwed either way. Well well, since since, you know, I work on cognitive dissonance. That was the most dissonant moment for me, was watching him do this lecture on the benefits of HRT. And he starts it’s a wonderful table. We have the table in the book of my favorite table of him. As you know, I practically tattoo it on my arm.
The bottle was here’s what the Women’s Health Initiative found, an increase of twenty six percent at one point to say that’s a that that’s at the bottom. And then we have everything that has a greater risk of causing breast cancer that has been published, the French fries being a finished flight attendant, being a Scandinavian flight attendant, using electric blankets, but only less than six months a year, but for more than 10 years.
And only if you’re African-American. That’s an actual true thing.
Every morning, lefthander, everyone has been published in peer reviewed medical journals. Although nobody takes them seriously. And yet the statistics they take seriously.
I mean, this is the whole reason I got into skepticism, everything. It’s because you find out something that the whole world believes and it’s completely wrong.
And it’s so mind blowing. Thank goodness there are people like you all like.
Dig deep into something like this.
I mean, we do we dig deep into other wacky, you know, psychics and flatter theories and ever all the other insanity in the world. We’re on Mars. We have machines running around on Mars and we’re still believing stupid things. This is why we have a challenge ahead.
When Carol is asked, why aren’t more people debating this with you? Her answer is twofold. Her first answer is, well, if somebody dragged that your sleeve and wanted to talk to you about the earth being flat, you would just brush them off and you wouldn’t talk to them.
And if people view us as flat earth theirs, that would explain why they’re not objecting to what we’re saying. You’re too crazy even to do. But we’re not flat earth ours. And the people who have endorsed the book are highly respected people within the scientific community.
And in spite of that, we’ve heard no response to the.
To the extensive discussions we’ve had about this and, you know, we say we’re at pains in the book to not only mention not only describe the studies that support the argument we’re making, but to examine the studies, the disconfirm our argument. There have been you know, there are a couple of major studies that seem to suggest that hormones were, in fact, really harmful, that at the end of him, with his meticulous assessment of these studies, would would look at them more closely and find a lot of data dredging and efforts to find a pony that was not. There was no pony. And so we are we are careful to look at those studies and say, because if we’re wrong, we need to know where we’re wrong. Are we talking here about something where the weight of the evidence is two to one? Ten to one? I mean, what’s what’s the balance of supportive versus disconfirming evidence?
And so one of the really interesting things from the two of us is that we write to colleagues, I write to feminist health activists, and I say, please read this book.
You’ve been opposed to HRT. I understand all the reasons you have been. I supported those reasons myself many years ago.
Just tell me where we’re wrong. Well, that’s the hallmark of, you know, transparency and self-criticism and, you know, taking a disinterested approach. You pointed out people are busy.
Mistakes were made.
It’s just tough to get people to to pry them off over a long held belief, especially, I’m sure, with with doctors.
You know, if you’ve been doing something for 20 years or something, it’s an admission of. Being wrong about.
That’s why Carol pointed out the history of lumpectomy, radiotherapy versus mastectomy for the treatment of breast cancer, which was used for over 100 years. And the thought was that breast cancer spreads contiguously, which means that if you just take a wide enough excision of the breast tumor, which is better done with a mastectomy, your cure rate would be better. That was popularized by HOLSTEAD William Halstead, who stated did not support that.
And in spite of that, Holstead went on to say, believing that that as surgery improves, what we should be able to do is remove the woman’s shoulder together with her breast if it’s spread to the shoulder, and that way will cure it. And if it’s spread to the hip, we should be able to remove the hip in contiguity with the breast. That’s crazy. But that’s that was used as the basis for the treatment of primary breast cancer for over 100 years.
And when Avro first moved from New York to California, I mean, he knew physicians in his community who were still performing mastectomies that were unnecessary once the evidence on lumpectomy had was conclusive because they felt how I.
You’re telling me I’m a breast surgeon and you’re telling me that I have been unnecessarily harming my patients all these years with a major operation, right?
Yeah, we are telling you. So you won’t do it in the future. That’s what we’re doing.
Yeah. What about the next person who walks in the door doors? Is that person.
Well, it’s interesting you say it that way, because what the surgeon would say to me is how do I tell the last woman on whom I did a mastectomy that it wasn’t necessary?
Well, I started this discussion by explaining that I recommended abortions to women. And I was wrong.
But I learned in the history of medicine.
Every previous age, as Barbara, as compared to what we’re doing now, I’m sure in 300 years they’ll look at most of what we’re doing and say, oh, we don’t do that anymore.
Thank goodness that I went to. I blew my knee out in football in high school, and I was having a little problem with that and went to an orthopedic guy and he puts the x ray up on the up on the flight and sees this little staple in there, which is holding my medial collateral ligament in place. And he says, oh, they don’t do that anymore.
I thought, all right, it was thirty five years ago or whatever. And so, you know, you move on. Thank goodness we’re getting better.
There are many things that you would argue that estrogen therapy in the right patients would actually help or prevent.
And that includes symptoms, osteoporosis, heart disease, Alzheimer’s disease.
And those are huge. Those are big, major causes of death and much more than breast cancer.
So there’s sort of two elements of this. One is that for the hormones, either estrogen or estrogen with progesterone to be effective, they should be begun in the window of opportunity, as it’s called, at the onset of menopause. And for at least a decade thereafter. But what is increasingly evident because of the killer diseases, that the diseases that kill women in their later years like osteoporosis, heart disease and Alzheimer’s, there is no indication that a woman need to stop taking hormone replacement therapy. That’s, I think, major, major news. And because women think this idea take the lowest does for the shortest time. That is a delusional compromise that some doctors came up with knowing that estrogen could be beneficial. But also thinking it might be harmful. Well, you can’t have it both ways if you think estrogen is really harmful. A small dose. I’m going to give you a small dose of asbestos. A small dose of anthrax. So this smallest dose for the shortest time was a kind of an effort at a compromise between giving women the estrogen that doctors knew is beneficial but that they worry might be harmful. Now, the evidence of its long term benefits, we think, is unmistakably clear. And I like to cite Barbara Sherwen when we mentioned in the book list that she’s now retired to work for years and years and years on Estrogen’s cognitive benefits. And one of the things she said is women say to me, well, it’s not natural to be taking hormones a lot. And she says, what’s not natural is for women to live 30 years after menopause. That’s what’s not natural in human evolution.
I think James Randi pointed out to. By the way, the bird shit is natural, it’s not natural, not necessarily good.
So so is arsenic and cyanide.
Just for the sake of clarity, we’ve mentioned estrogen and we’ve mentioned estrogen with progesterone. And it’s just worth mentioning that the benefits that we’re talking about are estrogen related benefits, that estrogen is administered alone to women who no longer have a uterus. If a woman still has a uterus and you give her estrogen alone, you significantly increase the risk of uterine cancer. And if you give her estrogen with progesterone, another female hormone, that increased risk is nullified. And so what has happened is people have gone from saying estrogen causes breast cancer to know it’s caused by estrogen and progesterone, not by estrogen. No, in fact, we’ve already explained that the data don’t support that either. And it’s worth noting that when Tamoxifen was first introduced, progesterone was tested against Tamoxifen, against active breast cancer. And it appears to be as effective as Tamoxifen in controlling active breast cancer. The recent Tamoxifen one is progesterone causes fluid retention and weight gain and nausea when it’s given in high dose. And so it wasn’t used. But to now blame it for breast cancer is simply not understanding the data.
There is a stage called perimenopause, Harry menopause.
Is that the beginning when a woman starts having irregular periods and sometimes that could be more than once a month or less than once a month up when she starts having some symptoms like palpitations that are unexplained or night sweats, and she’ll say, well, that can’t be menopause up around the age, usually between the early forties and the mid 50s, that can be perimenopause. That’s an interesting story of Oprah Winfrey, who says, I went to my physician because I was having palpitations. And so he referred me to a cardiologist. I saw a five cardiologists and they said, my heart is fine and nobody could explain it. And I’m Oprah Winfrey. Nobody wants to miss a diagnosis on me. And nobody could give me an explanation. And then either her trainer or her secretary said, you know, I just read a book and it might be a symptom of menopause. And Oprah’s physicians didn’t know about it, nor do many cardiologists today. And when she started hormones, they went away.
So how are we getting better at connecting the dots between menopause and some of these other symptoms that may otherwise seem unrelated to menopause?
Depends on who the we are. We certainly are. But what we’re trying to do is empower women with this information so that more of us get better.
And one of one of the mantras that we use is the more you know, the less you fear. And that is so important for the general public to understand.
The book is Estrogen Matters Why Taking Hormones in menopause can improve women’s wellbeing and Lengthen Their Lives Without Raising the risk of breast cancer.
What’s not to like about it? If you’re female or happened to know one, you should read this book.
It is trying to turn back a great misunderstanding that both in our own our world. Thank you both. Thank you, Jack. Thank you so much. And this.
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