The Cutting Edge of Continuing Confusion


Boston -- Funny how easily you can become nostalgic for the good old days, that halcyon era when women of a certain age were merely accused of suffering from raging hormonal imbalance. Now what's driving women berserk is raging hormonal debate.

There is even more hot news, yet another flash, or should I say bulletin, just in from the cutting edge of continuing confusion.

The latest of the serial researchers in the New England Journal of Medicine report that women who use hormone-replacement therapy for five or more years have a 30 or 40 percent greater chance of developing breast cancer than women who don't.

This front-page bad news about hormones and breast cancer follows the front-page good news about hormones and heart disease. In January we heard that the same therapy lowers the risk of heart disease by 50 percent. It lowers the risk of osteoporosis as well.

Thursday's missive also reports that adding progestin to the hormone mix doesn't protect against breast cancer. But an earlier study said it does help protect against cancer of the uterus. And a still earlier study said uterine cancer is more likely to occur in women taking estrogen.

Are you still running with me? Where shall we go? To the nearest professional risk-assessor?

We have here another addition to what I imagine as the salad bar of personal health. The average patient a.k.a. medical consumer or medical customer is now expected to step up to the bar with her personal plate and set of tongs and pick the health items as she chooses.

Which would you rather have today, ma'am? Breast cancer or heart disease? Broken bones or perhaps just a sprinkling of uterine cancer? We don't get a whole lot of help as we warily try to choose our fate.

The doctors who were asked what to do in light of the new research offered tidbits of advice like, "You have to balance all of the information," and "It's a very tough decision to make." The folks who did this study gave the following helpful hint to bewildered women: "These findings suggest that women over age 55 should carefully consider the risks and benefits of estrogen therapy."

Thank you so much.

I'm not trashing research itself. The studies are in a state called high flux. The latest is just one of 30 that looked at the link between estrogen and breast cancer with wildly incomplete and conflicting results.

There are now some 12 million women taking estrogen, and the entire baby-boom generation is beginning to experience the joys of night sweats and medical flip-flops. This is a generation of women who are medically savvy and medically frustrated because the stakes are so high and the certainties are so low.

It's easier to assess risks of long-term hormone-replacement therapy when you look at the big public health picture. The big picture people say that heart disease kills 235,000 women a year, and breast cancer kills 46,000. Anything that helps prevent heart disease, saves more women.

But the small picture, the close-up, becomes far more dicey. It increasingly looks as if cancer and heart disease are more "personal," more individual, than we thought. The private health portrait is an intimate one of a woman and her own "risk factors." Her genes, family history, blood pressure, diet, environment and who knows what else. We each have more variables than we have shoes.

I once assumed that my generation of middle-aged women would be the guinea pigs of menopause. Surely, before our daughters grew to be our age, we'd have the answers. I am no longer remotely sure of that.

There isn't one study that covers all or one therapy that fits all. And there isn't likely to be. Indeed, the uncertainties that typify the debate about estrogen are becoming a medical norm. That leaves us making decisions with little to help us but our factors -- especially our fear factor.

So here we are -- still. In the raging hormonal debate that is sure to be ratcheted up by this study, we are talking about odds, not cures, about trade-offs, not remedies. Women have become responsible for making mid-life decisions against a background of shifting and conflicting information. Without even a risk assessor to call our own.

The bottom line of all the research is this: "It depends." But the tough part is when your life may depend on "it depends."

Ellen Goodman is a syndicated columnist.

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