Frontiers in Women’s Health Symposium
Twenty-two leading experts in the fields of law, science, health and public policy gathered from around the nation at UC Hastings on Friday, February 25 to give voice to issues surrounding hormone replacement therapy (HRT). They came to participate in the "Frontiers in Women's Health: The Role of Hormones in Aging and Disease" Symposium.
The Symposium was presented by the UCSF/UC Hastings Consortium on Law, Science, and Health Policy and the Hastings Women's Law Journal. UC Hastings Professor Lisa Faigman, the impetus behind and organizer for the event, referred to the Symposium as an "interdisciplinary high-wire act."
"What I read in the popular press did not begin to cover what a lay person should know," Faigman said in describing the need to create this public forum. "Women want and deserve the whole truth and the whole story. Women want the information to take care of themselves."
In the keynote speech, Marianne J. Legato, M.D., F.A.C.P. presented an overview and history of the study of women's health. In 1900, the average life expectancy was 48. Women had little direct control over the world around them. It was not until the period from 1985 to 1998 that women's health came into its own. According to Legato, this transformative period became a turning point for the health care of women.
Estrogen therapy was first investigated in the 1920s, said Cynthia Stuenkel, M.D., M.P.H. Hormone therapy is the most effective option for menopausal symptom relief. Stuenkel believes that what made this an interesting story was that estrogen might help with other symptoms of aging. For a long time, we've been operating on the basis of observational studies.
Then along came the Women's Health Initiative (WHI). The combined therapy arm of the study showed a higher risk of cardiovascular disease, stroke, and breast cancer. Two key lessons learned were that it is important to consider age and duration of menopause.
"What people don't realize is that most women will die from cardiovascular disease," said Marcelle I. Cedars, M.D. Women polled perceived that breast cancer is the number one killer. "We haven't gotten very far in telling women what to do. Women who go through menopause early are at higher risk for cardiovascular disease."
A "Timing Hypothesis" suggests limiting initiation of hormone therapy to women ages 50 to 55 or within 10 years of menopause. Stuenkel advised prescribing lower doses and limiting duration of hormone replacement therapy to a few years after menopause to minimize breast cancer risk.
S. Mitchell Harman, M.D., Ph.D. says there is a window of opportunity for using hormones to prevent cardiovascular disease, and if you miss that window, you may do more harm than good.
Harman suggested that we need more trials and research. The Kronos Early Estrogen Prevention Study (KEEPS) design hypothesis is that a window of opportunity exists in early menopause for a cardioprotective effect of menopausal hormone therapy in the 42-58 age range.
Legato urged researchers to look beyond women's health and also "focus a gender-specific lens on men so that we can better understand their greater vulnerability compared with that of women." Men live, on average, five years less than women, with cardiovascular disease being the number-one cause of death.
Sixty-eight percent of people who get Alzheimer's disease are female. This increase has been attributed to the ability of women to live longer than men, yet Roberta Diaz Brinton, Ph.D. suggests that that may not be the whole story. By 2025, California and Florida will have the predominant incidence of Alzheimer's disease. Los Angeles is the epicenter of Alzheimer's in California. Currently, in California, 66,000 people have AIDS. In 2025, in Los Angeles alone, it is projected that 238,280 will suffer from Alzheimer's.
Brinton described estrogen as the energy capacity of the brain. She said that the energetic system of the brain is regulated by estrogen. Individuals with a maternal history of Alzheimer's show a deficit of estrogen. Data show an increased risk if there exists a maternal history of Alzheimer's. Estrogen promotes the cognitive function, and loss of estrogen can have a significant impact on the ability of the brain to maintain cognitive function.
It has been difficult to document (relatively short term) cognitive impairment as a direct consequence of natural menopause, said Victor W. Henderson, M.D., M.S. Long-term cognitive consequences of menopause, particularly as related to Alzheimer's, remain of concern. Two studies on the critical window hypotheses are now underway. They should answer the question of whether there is an impact on cognitive effect and memory.
The courts have struggled over issues surrounding sex differences in health policy and in law, noted Julie Seaman, J.D.. Some lessons for law that we might learn from the biosciences include the need to keep an open mind, as the state of the science is rapidly evolving. It's important to consider evidence-based medicine and avoid the danger of basing decisions on an incomplete model. The ultimate ideal is individualized medicine.
Harman stressed that it is good for the legal community to understand the complexity of these issues.
"Science is really complicated; it's hard to learn about and pay serious attention to," said Cynthia Gorney, professor at UC Berkeley's Graduate School of Journalism. "We have to be willing to deal with complication and nuance. What we really want to do here is keep paying attention and stay focused on what happens next. We can push forward in this gray area. "
"I have never sat at a conference with a better qualified set of panelists in my life," Legato said.
To listen to the panelists' talks, visit the live-stream video of the Symposium.