Special Feature

HRT Wars

By Sarah L. Berga, MD

Do you feel assaulted by information regarding the risks and benefits of hormone replacement therapy (HRT)? Clearly, physicians and patients alike are caught in the crossfire of an information war. Everyone has something to say about menopause and the aging of the American woman. How ironic! A few years ago, the battle cry was that menopause received too little attention from scientists, physicians, pharmaceutical houses, the media, and so forth. Menopause was considered a forbidden topic in polite society or an uninteresting subject. The arrival of the boomer generation to the threshold of menopause has provoked changes of enormous proportions. We have become awash in a sea of information and charter members in the Ponce de Leon Society expected to have the panacea for lost youth. There is a real sense of urgency that imbues the whole topic of menopause. Why? Not to be too cynical, but part of the reason is that corporate America has discovered that menopause is a growth market. Pharmaceutical houses, in particular, want their fair share of the action. And menopause is clearly one area where the action is.

Today’s physician must now figure out how to cope with the enormous flood of information. The quality of information, even from what one would consider reliable sources, varies considerably. Our job is made ever more difficult by the computer revolution. Both patients and doctores are barraged day and night by sound bites and other low-quality information. To complicate matters, most pharmaceutical concerns engage in direct-to-consumer campaigns designed to position their product favorably in the consumer’s mind. How are all of us supposed to discern reality from fantasy, medicine from marketing? How are we supposed to quell the anxieties engendered by the daily fare of mixed messages? Studies show that time with the patient translates into adherence with hormone use, but where are we to find this time? Who on the insurance/coverage side is advocating for physicians and patients to have more time in conversation together?

It is time for new attitudes and approaches. We need to be as critical as possible regarding what we accept as legitimate evidence. We must arm ourselves with a thorough knowledge regarding the rules of evidence and we must be able to determine to what extent scientific reports follow the rules of evidence. If clinical trial evidence is not at hand, then we must resort to understanding and approximating physiology. I realize how difficult this mandate is, but information chaos is seriously hampering us and we must create more order. We need to become selective consumers of information. I am not suggesting that there is no role for discovery, intuition, revision, and individualization. Clearly there is. But we must not become victims of what promises to be a sustained information war. We must insist on an academic stance toward therapeutic options. When weighing therapeutic options, risks and benefits must be acknowledged and put into proper perspective. So often, I feel that information is being used as a weapon, rather than as a guide.

How can we improve our communication skills so that we are able to help our patients through this information maze? Are there ways to communicate more in less time? Should we listen more and talk less, or explain more and listen less? Should we defer to the patient’s mindset, regardless of legitimacy, because of the constraints of time or our own discomfort regarding the certainty of extant information? These are serious questions, with only partial answers. Time spent with the patient matters, but only if it is used appropriately. Evidence suggests that the third question or remark is the one the patient considers most pressing. The first and second questions or reports are "trial balloons." So it is important to get to the third domain if possible. I ask patients to indicate when booking an appointment how much time they think the visit will entail. That gives the patient a chance to delineate her goals for that visit. We also have goals in terms of what must be covered in any given visit and I try to be clear about what those are and what is likely or unlikely to be covered by their insurer.

What if you don’t know the answer? There are many strategies for handling knowledge gaps. If you believe that the answer is known, but not by you, you can indicate that you are willing to search for information or to refer the patient to someone with greater expertise. If you believe the answer is not known, then it is fair to indicate this. Patients are typically relieved to have that type of acknowledgement. In that situation, I also like to talk briefly about "risk" vs. "risk perception." The bottom line here is that what we worry about is often a substitute for existential anxiety about the ubiquitous lack of control and unpredictability inherent in life. Paradoxically, helping patients to understand that anxiety regarding choices is largely unavoidable and part and parcel of human experience seems to allay anxieties. Within reason, patients should be encouraged to keep a list of nagging or lingering doubts. Rather than heightening fear, the process of focusing helps to streamline the next conversation. I believe in having realistic expectations and setting realistic treatment goals. This can only be done if we know how to handle information gaps. Given the great amount of controversial information being discharged into the public domain about menopause, it seems unrealistic to expect that we will be talking less. Ideally, patients will have the option of returning sooner rather than later to report on their reactions to hormone interventions. Side effects engender fear and must also be put into perspective and ameliorated.

The art of HRT is coming up with a plan that prioritizes concerns and health objectives in a way that makes sense to both the patient and the physician. To some extent, this demands that the validity of the information be assessed before it is exchanged. The goal is to avoid premature reductionism while not confusing the patient. Different physicians have different methods for synthesizing information and developing perspective. This is what patients need and want most: our perspective. Naturally, they are overwhelmed by all the information and they need us to help them frame it. They need us to help them decide what is important. If we don’t do this, patients will fall victim to less reliable sources and mindsets. As onerous and difficult as this is to do, this responsibility rightly belongs to physicians. I believe we need to continue to advocate for our role as counselors and patient educators. I am sorry that insurers rarely give much financial recognition to this endeavor, but that alone does not mean it is not our job.

Which one of the following strategies might be considered appropriate in helping a patient to make a decision regarding hormone replacement therapy?

a. Defer to opinions formulated by professional committees.

b. Tell the patient the decision is up to her.

c. Acknowledge that the information we have about the choices is incomplete.

d. Ask the patient to delineate her top concerns.

e. Tell the patient what you think are her chief medical risks.