Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [19]
After completing my training in endocrinology and metabolism, I became interested in the issue of hormone replacement for menopausal women. In the 1980s and early 1990s, treatment with estrogen, usually in combination with another hormone called progestin, had become standard practice, not only to ameliorate menopausal symptoms of hot flashes, but also to protect women from osteoporosis and most important to prevent heart disease, stroke, and dementia. As a doubter, I remained skeptical that these hormones could prevent so many of the consequences of aging. And being risk-averse, I was concerned about the downsides of estrogen, especially the risk of breast cancer.
In researching this topic for lectures to physicians and lay audiences, I was bothered by the fact that the Framingham Heart Study, the largest and one of the best long-term epidemiological surveys, didn’t show a clear benefit of estrogen on the heart. It became difficult for me to recommend estrogen treatment to all my patients, and I felt the decision to prescribe it needed to be individualized. In 2002, the Women’s Health Initiative found through a controlled trial that hormone replacement therapy (HRT) for menopausal women did not prevent heart disease; in fact, it appeared to increase the risk of heart attack. Similarly, HRT did not prevent Alzheimer’s disease or other forms of dementia. Finally, the risk of breast cancer was increased with hormonal treatment. The issue of hormone therapy for menopause is still much debated.
When it comes to my own health, I am a minimalist, and I don’t like to take medicines or supplements unless absolutely necessary. I worry about side effects from medications and from diagnostic and therapeutic procedures for myself and for my patients.
Nearly ten years ago in the winter, I began to lose weight. At first I was delighted, attributing it to my increased hours of tennis and skiing. But the weight loss persisted over several months despite eating more and cutting back on exercise. And I noticed that my endurance was less than usual. I tried to ignore or explain away my symptoms. But finally, when I became so short of breath during a tennis match that I had to stop playing and sit down on the court, I realized that something was really wrong. The diagnosis turned out to be Graves’ disease, an overactive thyroid gland. Although it was not a big surprise because many of the women in my family have thyroid disease, the diagnosis was not immediately obvious to me or to my physician husband, Jerry. Once the diagnosis was made, I had to face the reality that therapy was unavoidable. I had treated many patients with Graves’ disease in my endocrinology practice, and I was well versed in the benefits and risks of each treatment approach. In addition, I had the benefit of many patient stories to call upon in making the decision that was right for me.
Several years later, I was injured in a ski accident. While waiting for my children at the bottom of a hill, a young man came bombing out of the trees, smashed into me, and knocked me over. Fortunately no bones were broken, but my ankle was twisted, painful, and swollen. For months I was sidelined from playing tennis, and even walking was uncomfortable. Restless from lack of exercise, I went to the hospital on a Sunday to clean out my office. I did a deep knee bend to pick up a large pile of books and heard a loud pop in my knee. The joint immediately swelled to the size of a grapefruit and was exquisitely painful. I tried ice and a knee brace, but the pain and swelling persisted. Finally, after a week of hobbling around, I made an appointment with an orthopedic surgeon. He examined me, pointed out my flat feet that put me at risk for knee injury, and