Dear Dr. Roach: In a recently published column, you stated, “As always, the decision belongs to the patient,” while addressing a concern about the benefits and risks of stopping a statin drug. Oh, really? Why is it then that no doctor will prescribe hormone replacement therapy to stop my debilitating post-menopausal symptoms once I turned 60? After suffering from menopausal symptoms starting at age 42, I was finally prescribed HRT at age 57. What relief I had, as it was the only remedy to alleviate my hot flashes, weight gain, lack of sleep and vaginal dryness.
Once I hit 60, I was ordered to stop the HRT, and no one since will prescribe it for me now. I am 66 now, suffer daily with hot flashes and have my sleep interrupted at least five times a night with terrible night sweats. I have tried just about every over-the-counter offering with zero effectiveness.
I will gladly trade the greater risk of heart attack and stroke, and the possible shorter life span, for relief from symptoms that affect my daily quality of life. Clearly, the choice is not mine, because if I had a choice, I would ask for continued prescriptions of HRT to give me relief. Why don’t I have that choice as a patient? — R.M.T.
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Answer: A patient always has the right to refuse a treatment recommended from a physician. However, the physician has the obligation to consider the risks and benefits of a treatment and is not obliged to prescribe a treatment they do not think is appropriate.
If a patient asks me for a treatment that has been shown not to be effective and has the potential for serious adverse effects, I don’t prescribe it, but will work with the patient to find alternative treatments. For example, some non-hormonal prescription treatments are moderately effective for hot flashes and sleep disturbance, and topical estrogen is very effective for vaginal dryness.
However, the case of hormone replacement therapy for symptoms of menopause is more complicated, because estrogen is the most effective treatment we have for menopausal symptoms, particularly for hot flashes. There are risks to hormone therapy, but the benefits for some women are so great that they are willing to accept some risk of treatment.
You mentioned the risk of heart disease and stroke. A landmark study, the Women’s Health Initiative, helped to define and quantify those (and other) risks. Its effect has been to dramatically reduce the prescribing of menopausal hormone therapy, but the results should not be interpreted to mean that hormone treatment is always inappropriate, even with women in their mid-60s where risks are higher.
Moreover, a woman’s entire health status should be considered when deciding whether to prescribe hormone treatments. In women with a history of an estrogen-dependent tumor (like many breast cancers), a history of a blood clot or a stroke, or a few other issues, the harms almost certainly outweigh the benefits. Otherwise, a wise clinician looks at the patient’s risk for heart disease, blood clots and other conditions. Women at a very high risk for heart disease should probably avoid estrogen; otherwise, using lower-dose estrogen by patch (rather than pill) is wise for women at moderate risk, such as those in their 60s.
Physicians do not want to prescribe medications that will harm their patients, and most have stopped prescribing menopausal hormone therapy entirely for women, to prevent disease. However, it still has a role in treating symptoms. I recommend you seek out an expert in treatment of menopausal treatments and have a frank discussion about your willingness to assume risk in order to have a better quality of life.
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