Nelson Vergel
Founder, ExcelMale.com
From Dr. Peter Attia's podcast:
Avrum Bluming, M.D. and Carol Tavris, Ph.D.: Controversial topic affecting all women—the role of hormone replacement therapy through menopause and beyond—the compelling case for long-term HRT and dispelling the myth that it causes breast cancer
BOOK:
Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives -- Without Raising the Risk of Breast Cancer
Peter Attia: This week I had the pleasure of interviewing two people, Dr. Avrum Bluming and Dr. Carol Tavris. And if Carol's name sounds familiar to you, it's because it should. I've spoken about her often as she is the author of one of my absolute favorite books, Mistakes Were Made (But Not by Me), and if you haven't read it, I recommend you hit pause now, go and buy it, come back. Carol is a social psychologist and an overall great skeptic. Her collaborator in this project, which we'll get to, is Dr. Avrum Bluming, who's a hematologist, medical oncologist and an Ameritas clinical professor at USC. He's also formerly a senior investigator at the National Cancer Institute.
Peter Attia: The book we discuss today is their most recent project, a book called Estrogen Matters, which as its name suggests, is a book about hormones. In particular, it's a book about hormone replacement therapy in women. Now, I realize at this moment about half the people listening to this, i.e, those of you who are guys, are thinking, "Do I really need to listen to this episode?" And the short answer is I think you do. At the very least if you know a woman or care about a woman, you should be listening to this episode. Why? Because in many ways, this topic has created as much confusion and generated as much bad information as any topic in medicine. And yes I am including nutrition science, which is the absolute bottom of our understanding of science. And the parallels between the story of HRT and the nutritional guidelines in the '70s and '80s is almost uncanny.
Peter Attia: And that comes across during this interview when Carol and Avrum tell a story that I had either forgotten or didn't know. The book is written in I think a very clear way and I do recommend that anyone who is interested in this topic not just take our word for it in this episode, but instead get the book and go through the references. I spent a lot of time utilizing my team to help prepare for this interview because as familiar as I am with this topic, and I think I'm more familiar with this topic than most physicians, I still felt the volume of information was just so great that I wanted to make sure I had gone back and read all of the studies in preparation for this. And in many ways, I'm glad I did because it allowed us to really get into some of the details here and hopefully do so in a way that isn't confusing for you but rather at least opens the door to your thinking about this.
Peter Attia: This is a very polarizing topic. It is almost a religion. So you will see that there are people on both sides of this that are pure zealots, and unfortunately, that just makes it that much more difficult to interpret the literature on this. But in the end you will have to be the judge of this. It is certainly my view, and I don't hide that view anymore, that most women do benefit from being on post menopausal hormone replacement therapy, but not all women do. And I think one of the challenges for physicians and patients alike is trying to stratify which patients will receive much more benefit than the risk that is posed to them, and of course, perhaps as importantly, identifying the patients for whom the risk is outweighed or is disproportionate rather to the benefits.
Peter Attia: The interview largely covers the subject material covered in their book, which is to say the history of hormone replacement therapy, the impetus for the women's health initiative, a very serious critique of not just the initial publication, but the subsequent publications, and then a little bit of a deep dive into each of the clinical conditions for which hormone replacement therapy should at least be considered. And of course, I think the most important of these is in not just cardiovascular disease, which gets a lot of attention, but neurodegenerative disease. And I think Avrum makes a very compelling case for that. So without further delay, here's my interview with Dr. Avrum Bluming and Dr. Carol Tavris.
Peter Attia: Before we get to this week's episode, I want to remind everyone that one of the benefits of being a subscriber is a discount program that we've created. Now, the purpose of this was to take the money that companies have offered to pay for advertising and say, look, instead of doing that, I'd rather just talk about the companies that have products that I love and use without being paid to do so and say, take that money that you would have given us in advertising and pass that on to discounts as listeners. So the first one's coming out this Wednesday, and if you're not a subscriber yet, that's okay. You've got plenty of time to sign up. Head on over to peterattiamd.com/subscribe, where you can have access to this discount and future discounts. And now let's get to this week's episode with Carol and Avrum. You guys, thank you so much for making the trip down from LA today.
Avrum Bluming: We're happy to do it.
Peter Attia: This is one of the topics that I have been meaning to explore so deeply over the past two or three years through what was originally going to be a multi-part blog post and a number of other things. And there always was a reason not to do it and then you and I spoke about a year ago, Carol, and I said, "Carol, I'd love to interview you about Mistakes Were Made," and your response was, "I can't talk about that book anymore. I'm so tired of it. All I want to do is think about this new thing that I'm really excited about, which is Estrogen Matters."
Peter Attia: And I must admit, I was embarrassed at that point to acknowledge I didn't realize you had been working on it even though I had read the paper that you guys had written in 2009 which we were talking about a few minutes ago. So it was an aha moment for me and I was delighted because I thought, "Well, you're going to do a much better job than I would have done because you're going to put so much more work into it." So I guess for the listener that's not familiar with you, Carol, let's start with you, Carol. You're a psychologist.
Carol Tavris: Social psychologist, yes.
Peter Attia: Social psychologist. What's a social psychologist writing about estrogen for?
Carol Tavris: My lifelong interest has been in bringing good scientific research in psychology and medicine to public attention. And as you well know, this is an effort that is not always greeted with [inaudible 00:10:22] and cheers, and thank you ever so much for showing us that our beliefs are wrong in our time to be replaced. But it's my lifelong quest and that's what I do. And that's of course what Mistakes Were Made (But Not by Me) was about. Why it is that people resist new information that is better to know, that is beneficial, that improves our knowledge. And that's been my life work. And as a social psychologist, I have always been interested in the barriers to critical thinking and the reasons that people do not accept information when it is in their best interest to do so. So knowing Avrum Bluming for as many years as I have, we have discussed over the years how our shared interest is in medicine and mine in psychology, reflect the same concerns. What happens when research calls into question some established belief that is widespread in our society?
Peter Attia: I know I've told you this before, but I'll repeat it that Mistakes Were Made (But Not by Me) would certainly be on the list of the three books I have recommended and or gifted the most. And in fact, I remember reading it and just somehow finding out how to get ahold of you and just calling you and emailing you and inviting you over for dinner. You must've thought that was the weirdest thing ever.
Carol Tavris: Not at all. I was very flattered and pleased by the way. And by the way, this work on estrogen that Avrum has so excited me about could be a chapter in that book.
Peter Attia: It actually is as are other things that we have discussed, for example, dietary recommendations and things like that that I know you have contemplated going back on and thinking about that. So Avrum, what about you? Tell us a little bit about your background, your training as a clinician and why in particular this issue has become something that's resonated with you.
Avrum Bluming: I'm a medical oncologist. I've spent over 50 years as a medical oncologist and my reason for going into the field was to help people live as long and as well as possible in listing them helping to decide how best they should be treated. And breast cancer constitutes about 60% of my practice. And I've watched the progress in breast cancer very happily noting how many people we now cure. And in fact, early breast cancer now is about 90% curable. And I found that while I was making a lot of people better in terms of the cancer, I was making them worse in terms of the symptoms associated with the treatments they got. And when you treat something for that long, you want to understand what it is so that you can treat it most effectively.
Avrum Bluming: And first, let me say at the beginning, I'm a medical oncologist and I don't yet know what cancer is and I'm in very good company because I don't know anybody who knows what cancer is, even though many will tell you they do and they're wrong. And so it was important that I challenge every assumption on which my practice was based, and I've done that continuously. And the major assumption dealing with breast cancer is that estrogen causes breast cancer and it doesn't. And almost everything we've done in the treatment of breast cancer is based on that assumption so that women have been denied estrogen for at least the last 30 years, but especially since 2002, and the result is that many women have been hurt by being denied that medicine.
Peter Attia: So let's take a step back in history now because in your 2009 paper, it's actually the second table. I was actually reviewing it again this morning. It's a beautiful time course of hormone replacement therapy in women. So I'll let you guys decide how you want to tell the story together, but let's go back to at least the 1940s or the 1950s. How did this idea of, "Hey, women go through a pretty abrupt withdrawal of hormones. Let's take a moment to think about how we can make that better." How did that idea come about?
Avrum Bluming: I think to give us perspective, let's compare men and women. The number of women with breast cancer in the United States is approximately comparable on an annual basis to the number of men with prostate cancer. The number of women who die of breast cancer each year is also approximately comparable to the number of men who die of prostate cancer. We like simple answers all of us, and to think that testosterone is responsible for prostate cancer and estrogen is responsible for breast cancer is a very simple way to go about dealing with this. And what we found is metastatic cancer of the prostate was initially treated with castration. If testosterone causes prostate cancer, taking off the testicles eliminates the testosterone and in fact, it helps. Doesn't cure, but it helps in some cases. Similarly, we castrated women. Estrogen is made in the ovaries. If we remove the ovaries, we can cause breast cancer to regress once it has spread, and it does help. Not in many cases, but in a significant number, it helps.
Avrum Bluming: As far as cancer of the prostate is concerned, that's where we stopped. If castration didn't help, we did what we could to palliate. With breast cancer, what we did if castration didn't help, we went on and removed the adrenal glands of women. Now, the adrenal glands make a small percentage of circulating estrogen, and by the way, they also make a small percentage of circulating testosterone. We never removed the adrenal glands of men, we removed the adrenal glands of women. And as you know, there are hormones made by the adrenal gland that are necessary for survival. So once you remove the adrenal gland, you have to replace the hormones that were necessary for survival and we did that. If the adrenal gland removal didn't work, we then would take out the anterior pituitary gland at the base of the brain because that gland produces a hormone that stimulates either the ovary or the testicle to make the responsible hormone.
Avrum Bluming: And so we used to do hypophysectomies and while I was in practice, we did that. And as you know, the anterior pituitary makes many hormones that are necessary for survival. So we had to replace many of those hormones and we didn't really help too many women with that. Let me reiterate, we did nothing like that for men and we hurt a lot of women by doing that. We did it with good intentions, but we hurt them. What we then found is when women had breast cancer, because we were concerned that it might come back, we prophylactically removed their ovaries saying, "Well, if estrogen causes breast cancer, this will help prevent it from coming back." And we tested that with seven different studies. None of those studies showed that it worked. Did we ever treat men by prophylactically castrating them? Never. And we never will because men still control medicine by and large.
Avrum Bluming: So we were doing a lot with good intentions and hurting women. We then were looking at what estrogen is capable of doing, and this goes back to your question. Back in the 1940s, there was a book written called Feminine Forever that essentially said, "Well, women should take estrogen forever and it'll be an eternal fountain of youth." That's not true. That book was oversold. The doctor who wrote that book was paid for by the drug company who made estrogen and we didn't know that until his son told that to the press after he died, but estrogen did do some very good things. And what we found estrogen is capable of doing is first, estrogen can relieve the symptoms of menopause. The way menopausal symptoms are viewed as well it's hot flashes and night sweats and it'll usually last a year or two and tough it out lady and you'll get through it. And point the fact, there are many symptoms associated with menopause that are inches to hot flashes and night sweats. It includes palpitations, it includes cognitive decline, it includes joint pains-
Peter Attia: Sleep disturbances.
Avrum Bluming: Right.
Peter Attia: Yeah, lots of things.
Avrum Bluming: And it usually lasts about seven and a half years, not two years, and in some women it goes on for decades. And women are taught to suck it up and deal with that. Estrogen is also capable of reducing significant heart disease by up to 50%. There was an article in the New England Journal of Medicine in 1991 by Goldman and Tosteson that said, Time for Action, Not Debate, saying if women took estrogen, they would live longer, they would be healthier. That was 1991. And we now know that estrogen has been shown repeatedly to help diminish the risk for significant heart conditions.
Peter Attia: So let's pause for a moment because I want to make sure that people listening to this, and I hope it's not just women, but it should be men as well. Unless you're a man who finds himself not knowing any women, then maybe you won't listen to this. But let's explain what these hormones do a little bit. So there are not many papers that I have printed out in my office because we just don't print papers up that much anymore. We don't physically have a paper copy, but there are a handful that I have printed up and one of them of course is the WHI, both the 2002 and then some of the republications because I do like to show people the actual data, which I think speak for themselves, but another thing that I have printed up is the hormone cycle for a woman during her reproductive years.
Peter Attia: And I started doing this about three years ago and I was surprised how many women didn't know what estrogen was doing in their body. How it would rise during the follicular phase, peak during ovulation, decline during luteal phase and come up for a second bump before declining at their period, and similarly how progesterone would follow the smoothing out. We're going to link to images of that in the show notes, but the point I want to make is, women go through this for, what? 35 years of their lives, maybe longer, maybe 40 years of their lives, and I guess I was just surprised that, I remember having a patient who was complaining of horrible PMS.
Peter Attia: And so I said, "Well, it has to do with the reduction of progesterone. And in some women, the fall of progesterone during the end of the luteal phase is so rapid that for reasons we don't understand, that's going to produce a change in something and you can ameliorate that by doing x, y, and z." And the woman looked at me and she was like, "This is incredible. You've made me feel like I'm not crazy because you've shown me this graph that explains what's happening with my progesterone levels." So I do want to make sure that someone listening to this spends a moment to understand what we're actually talking about.
Peter Attia: You have these hormones that we're going to hear. We're going to talk about luteinizing hormone, follicle stimulating hormone. You've alluded to these already coming out of the pituitary, telling the ovaries to make these other hormones and really is it safe to say at the risk of oversimplifying, the reason it seems that women only experience this during a finite period of their life, is that's when evolution wanted women to be able to reproduce? Without this cycle of rising estrogen, progesterone falling levels, women wouldn't be able to reproduce. Is the risk of oversimplifying, is that a fair statement of why we have this finite window.
Carol Tavris: Finite window of [crosstalk 00:22:58]?
Peter Attia: During which time women have these hormones versus men who have kind of-
Carol Tavris: Of finite.
Peter Attia: Men have a much more gradual decline in their reproductive hormones.
Carol Tavris: This is a crucial thing to say, Peter. This is really important. This was something I didn't realize until we began working on this book. I assumed that in menopause, estrogen declines. I think that's the way women see it. It just declines the way testosterone declines in a slow, moderate way. No, estrogen plummets to 1% of what it was before menopause. I think most women have no idea that it's that great a drop in estrogen levels and no wonder that many of the symptoms that women have, which by the way, include depression and they attributed to, "Well, it's a midlife crisis I'm having." No, it could be an estrogen depletion crisis as well, and so I think it's really important for women to understand that this is not just a little fall off, it's really a major drop.
Carol Tavris: I want to add one thing here to this because as the social psychologist of this duo, what interests me is the way women have been given false information for so many years about so many aspects of their reproductive cycle and experience that it's no wonder that many women have a great skepticism about what medicine has to offer them in reproductive issues. Just what Avrum was saying about there was so little hesitation in cutting women up and removing this part and removing that part. Let's try this other thing. Things that would never have been tried with men that men would just never have agreed to.
Carol Tavris: And so women have had an understandable skepticism about the medical establishment advice. And starting with Feminine Forever, Robert Wilson's ridiculous song of praise to estrogen, women began to think, "Well, you know what? The hell with all of you on this. Estrogen is, I don't need it, it doesn't make me feminine forever and who dares to think that I need to be feminine forever in that traditional way? And menopause is just a natural phase of life and I can deal with it as I dealt with the onset of menstruation." So what I want our conversation to bring here is an understanding of why women have been whipped back and forth on whether estrogen is good for them or bad for them.
Peter Attia: And tying onto that, we left out another grotesque example of this, which Sidd Mukherjee has written about so eloquently in The Emperor of All Maladies, which is the radical mastectomy, which ties into all of this. Avrum, the points you brought up a moment ago, I wasn't even aware of the pituitary resections. I was aware of the oophorectomies of course, I had no idea they were resecting adrenal glands, which strikes me as ridiculous, but to actually resect the pituitary gland, that's macabre. Yeah, exactly, transsphenoid resections, it's just hard to believe. And yet lost in that story which should be added just to complete the sentence is, and up until Bernard Fisher came along, it was viewed as completely nonsensical that you would do anything other than disfigure a woman with breast cancer by removing every piece of tissue above her rib cage. It's an interesting point you raise, one I'd never really had contemplated truthfully, which is could that have taken place if the roles were reversed gender wise? I'd never really thought of it.
Carol Tavris: Think also about hysterectomies. The routine use of hysterectomy on the assumption that a woman, once she's had her children, doesn't need to have her uterus. And by the way, since we're removing your uterus, let's remove your ovaries as well because what the hell? They're just there. Let's take them out, as if they have no function. That casual attitude of let's just get in there and get rid of them.
Peter Attia: And the term hysterectomy, you want to maybe provide a bit of context for the listener on what that means.
Carol Tavris: Well, hysteria was thought to be caused by the wandering womb which detaches itself and wanders through the female body causing mayhem and despair. Yeah, yeah, part of her... More ludicrous notions about the female body.
Avrum Bluming: The point is women weren't treated fairly and they're still not being treated fairly. And just to amplify one point I made, I mentioned that estrogen can significantly decrease the risk of heart disease. What many women tell me at that point is, "Well, old women die of heart disease, young women die of breast cancer, I'd rather not take estrogen if estrogen causes breast cancer." And the answer to that is two fold. First, estrogen does not cause breast cancer, and we'll get into that in detail, but more than that, in every decade of a woman's life, the incidence of death from heart disease is greater than the incidence of death from breast cancer.
Peter Attia: I want to reiterate this point. It's like you were reading my mind. In preparing for this discussion, I did something I normally don't do. I normally don't put as much time into prep, but this is such a data driven discussion and the data are just so voluminous that I really had to spend a lot of time preparing and my team helped me greatly, but I have a chart that we will include in the show notes which makes your point very eloquently. If you begin at the age of 25, you take a cohort of 25 year old women and you forward-looking, project their 10 year mortality from breast cancer and from cardiovascular disease by decade. I'm going to read off the difference in favor of cardiovascular disease. So if the number is greater than one, you're more likely to die of a heart attack than breast cancer. If it's less than one, more breast cancer.
Peter Attia: Starting at the age of 25 going up in five year increments with a 10 year forward look, 3.5X, 3.5 times more likely to die of heart disease, 2.4X, 2.1X, 2.3X, 2.5X, 2.8X, 2.4X, 2.1X. We're now at 35 years old, 2.3, 2.5, 2.2, 3.3 by 55, 4.1 by 60, 5.6 by 65, 8.1 by 70 and 12.4 by 75. When you do the math on aggregate across lifetime, it's 7X difference in favor of cardiovascular disease over breast cancer. Where are the red ribbons?
Avrum Bluming: Heart disease kills more women than the next 16 causes of death, including all forms of cancer, AIDS and accidents.
Peter Attia: The only thing people listening to this know near and dear heart disease is to my heart because it is the number one killer for both men and women. There's another area where I think women get a bit of a short straw here, which is women present with disease quite differently. Do you want to say something about that?
Avrum Bluming: Sure, the typical presentation of a man is crushing chest pain, pain that goes down the left arm starting at the left shoulder. Women can often present with an upset stomach. And because we generally don't think of women as suffering from heart disease, the diagnosis is initially missed quite often, although doctors are getting more and more sensitive to that now.
Peter Attia: All right, so I took us off a bit of a detour. Carol, your point's a great one. I want to come back to make... For the first time in my career because I don't treat many women going through menopause, but any woman who's a patient of mine who's going through it I'm going to be a part of it, but this past year, I got to see firsthand how quickly a woman can enter menopause because if you happen to do labs on women frequently enough, you can see the drops. So I had a patient who in August of 2017, I like to check labs on what would be day five so I can really standardize where the FSH and estradiol should be, she had what looked like completely normal levels. Her FSH was something in the neighborhood of 10, her estradiol was maybe 90.
Peter Attia: She was starting to have symptoms though, so I said to her, "Look, you are very likely in a perimenopausal state. I expect you will enter menopause in the next three or four years." She was probably 47. Rechecked her blood in November, her FSH was 68, her estrodiol was unmeasurable. I rechecked the labs because I couldn't believe it, same result, reached out to one of my mentors, a gynecologist named Riley Lloyd in Chicago and I said, "Riley, what has happened here?" And he goes, "You just happened to see her fall off the cliff. This happens all the time. It's just we usually aren't looking at laboratory tests that frequently." So it's an interesting point that I'm glad you emphasized it.
Carol Tavris: And also you cannot say exactly at what age. One of the women we describe in the book who wrote a blog about this, Katie Taylor, who said she was 42, she was extremely depressed, she was having all sorts of symptoms. She was treated for her depression with antidepressants. That didn't do anything. Her doctor said, "Maybe you should quit your job. That will help your stress levels low sure." And fortunately, her father is a leading breast cancer specialist in England, and he said, "You know what? You could be in perimenopause." And she was. And she was.
Carol Tavris: So many of the symptoms that women begin to develop in their 40s, they don't associate with menopause. Muscle pain sends them to rheumatologists and depression sends them to therapists and fighting with their spouses sends them to family therapy, and they don't think that their changes of menopause might be involved. I want to say, by the way, that I am one of the minority of women who sailed through menopause with no symptoms and my mother as well. And so I underestimated how many women really suffer. It's not a verb I like to use much, but many women suffer with the symptom...
Part 2 follows
Avrum Bluming, M.D. and Carol Tavris, Ph.D.: Controversial topic affecting all women—the role of hormone replacement therapy through menopause and beyond—the compelling case for long-term HRT and dispelling the myth that it causes breast cancer
BOOK:
Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives -- Without Raising the Risk of Breast Cancer
Peter Attia: This week I had the pleasure of interviewing two people, Dr. Avrum Bluming and Dr. Carol Tavris. And if Carol's name sounds familiar to you, it's because it should. I've spoken about her often as she is the author of one of my absolute favorite books, Mistakes Were Made (But Not by Me), and if you haven't read it, I recommend you hit pause now, go and buy it, come back. Carol is a social psychologist and an overall great skeptic. Her collaborator in this project, which we'll get to, is Dr. Avrum Bluming, who's a hematologist, medical oncologist and an Ameritas clinical professor at USC. He's also formerly a senior investigator at the National Cancer Institute.
Peter Attia: The book we discuss today is their most recent project, a book called Estrogen Matters, which as its name suggests, is a book about hormones. In particular, it's a book about hormone replacement therapy in women. Now, I realize at this moment about half the people listening to this, i.e, those of you who are guys, are thinking, "Do I really need to listen to this episode?" And the short answer is I think you do. At the very least if you know a woman or care about a woman, you should be listening to this episode. Why? Because in many ways, this topic has created as much confusion and generated as much bad information as any topic in medicine. And yes I am including nutrition science, which is the absolute bottom of our understanding of science. And the parallels between the story of HRT and the nutritional guidelines in the '70s and '80s is almost uncanny.
Peter Attia: And that comes across during this interview when Carol and Avrum tell a story that I had either forgotten or didn't know. The book is written in I think a very clear way and I do recommend that anyone who is interested in this topic not just take our word for it in this episode, but instead get the book and go through the references. I spent a lot of time utilizing my team to help prepare for this interview because as familiar as I am with this topic, and I think I'm more familiar with this topic than most physicians, I still felt the volume of information was just so great that I wanted to make sure I had gone back and read all of the studies in preparation for this. And in many ways, I'm glad I did because it allowed us to really get into some of the details here and hopefully do so in a way that isn't confusing for you but rather at least opens the door to your thinking about this.
Peter Attia: This is a very polarizing topic. It is almost a religion. So you will see that there are people on both sides of this that are pure zealots, and unfortunately, that just makes it that much more difficult to interpret the literature on this. But in the end you will have to be the judge of this. It is certainly my view, and I don't hide that view anymore, that most women do benefit from being on post menopausal hormone replacement therapy, but not all women do. And I think one of the challenges for physicians and patients alike is trying to stratify which patients will receive much more benefit than the risk that is posed to them, and of course, perhaps as importantly, identifying the patients for whom the risk is outweighed or is disproportionate rather to the benefits.
Peter Attia: The interview largely covers the subject material covered in their book, which is to say the history of hormone replacement therapy, the impetus for the women's health initiative, a very serious critique of not just the initial publication, but the subsequent publications, and then a little bit of a deep dive into each of the clinical conditions for which hormone replacement therapy should at least be considered. And of course, I think the most important of these is in not just cardiovascular disease, which gets a lot of attention, but neurodegenerative disease. And I think Avrum makes a very compelling case for that. So without further delay, here's my interview with Dr. Avrum Bluming and Dr. Carol Tavris.
Peter Attia: Before we get to this week's episode, I want to remind everyone that one of the benefits of being a subscriber is a discount program that we've created. Now, the purpose of this was to take the money that companies have offered to pay for advertising and say, look, instead of doing that, I'd rather just talk about the companies that have products that I love and use without being paid to do so and say, take that money that you would have given us in advertising and pass that on to discounts as listeners. So the first one's coming out this Wednesday, and if you're not a subscriber yet, that's okay. You've got plenty of time to sign up. Head on over to peterattiamd.com/subscribe, where you can have access to this discount and future discounts. And now let's get to this week's episode with Carol and Avrum. You guys, thank you so much for making the trip down from LA today.
Avrum Bluming: We're happy to do it.
Peter Attia: This is one of the topics that I have been meaning to explore so deeply over the past two or three years through what was originally going to be a multi-part blog post and a number of other things. And there always was a reason not to do it and then you and I spoke about a year ago, Carol, and I said, "Carol, I'd love to interview you about Mistakes Were Made," and your response was, "I can't talk about that book anymore. I'm so tired of it. All I want to do is think about this new thing that I'm really excited about, which is Estrogen Matters."
Peter Attia: And I must admit, I was embarrassed at that point to acknowledge I didn't realize you had been working on it even though I had read the paper that you guys had written in 2009 which we were talking about a few minutes ago. So it was an aha moment for me and I was delighted because I thought, "Well, you're going to do a much better job than I would have done because you're going to put so much more work into it." So I guess for the listener that's not familiar with you, Carol, let's start with you, Carol. You're a psychologist.
Carol Tavris: Social psychologist, yes.
Peter Attia: Social psychologist. What's a social psychologist writing about estrogen for?
Carol Tavris: My lifelong interest has been in bringing good scientific research in psychology and medicine to public attention. And as you well know, this is an effort that is not always greeted with [inaudible 00:10:22] and cheers, and thank you ever so much for showing us that our beliefs are wrong in our time to be replaced. But it's my lifelong quest and that's what I do. And that's of course what Mistakes Were Made (But Not by Me) was about. Why it is that people resist new information that is better to know, that is beneficial, that improves our knowledge. And that's been my life work. And as a social psychologist, I have always been interested in the barriers to critical thinking and the reasons that people do not accept information when it is in their best interest to do so. So knowing Avrum Bluming for as many years as I have, we have discussed over the years how our shared interest is in medicine and mine in psychology, reflect the same concerns. What happens when research calls into question some established belief that is widespread in our society?
Peter Attia: I know I've told you this before, but I'll repeat it that Mistakes Were Made (But Not by Me) would certainly be on the list of the three books I have recommended and or gifted the most. And in fact, I remember reading it and just somehow finding out how to get ahold of you and just calling you and emailing you and inviting you over for dinner. You must've thought that was the weirdest thing ever.
Carol Tavris: Not at all. I was very flattered and pleased by the way. And by the way, this work on estrogen that Avrum has so excited me about could be a chapter in that book.
Peter Attia: It actually is as are other things that we have discussed, for example, dietary recommendations and things like that that I know you have contemplated going back on and thinking about that. So Avrum, what about you? Tell us a little bit about your background, your training as a clinician and why in particular this issue has become something that's resonated with you.
Avrum Bluming: I'm a medical oncologist. I've spent over 50 years as a medical oncologist and my reason for going into the field was to help people live as long and as well as possible in listing them helping to decide how best they should be treated. And breast cancer constitutes about 60% of my practice. And I've watched the progress in breast cancer very happily noting how many people we now cure. And in fact, early breast cancer now is about 90% curable. And I found that while I was making a lot of people better in terms of the cancer, I was making them worse in terms of the symptoms associated with the treatments they got. And when you treat something for that long, you want to understand what it is so that you can treat it most effectively.
Avrum Bluming: And first, let me say at the beginning, I'm a medical oncologist and I don't yet know what cancer is and I'm in very good company because I don't know anybody who knows what cancer is, even though many will tell you they do and they're wrong. And so it was important that I challenge every assumption on which my practice was based, and I've done that continuously. And the major assumption dealing with breast cancer is that estrogen causes breast cancer and it doesn't. And almost everything we've done in the treatment of breast cancer is based on that assumption so that women have been denied estrogen for at least the last 30 years, but especially since 2002, and the result is that many women have been hurt by being denied that medicine.
Peter Attia: So let's take a step back in history now because in your 2009 paper, it's actually the second table. I was actually reviewing it again this morning. It's a beautiful time course of hormone replacement therapy in women. So I'll let you guys decide how you want to tell the story together, but let's go back to at least the 1940s or the 1950s. How did this idea of, "Hey, women go through a pretty abrupt withdrawal of hormones. Let's take a moment to think about how we can make that better." How did that idea come about?
Avrum Bluming: I think to give us perspective, let's compare men and women. The number of women with breast cancer in the United States is approximately comparable on an annual basis to the number of men with prostate cancer. The number of women who die of breast cancer each year is also approximately comparable to the number of men who die of prostate cancer. We like simple answers all of us, and to think that testosterone is responsible for prostate cancer and estrogen is responsible for breast cancer is a very simple way to go about dealing with this. And what we found is metastatic cancer of the prostate was initially treated with castration. If testosterone causes prostate cancer, taking off the testicles eliminates the testosterone and in fact, it helps. Doesn't cure, but it helps in some cases. Similarly, we castrated women. Estrogen is made in the ovaries. If we remove the ovaries, we can cause breast cancer to regress once it has spread, and it does help. Not in many cases, but in a significant number, it helps.
Avrum Bluming: As far as cancer of the prostate is concerned, that's where we stopped. If castration didn't help, we did what we could to palliate. With breast cancer, what we did if castration didn't help, we went on and removed the adrenal glands of women. Now, the adrenal glands make a small percentage of circulating estrogen, and by the way, they also make a small percentage of circulating testosterone. We never removed the adrenal glands of men, we removed the adrenal glands of women. And as you know, there are hormones made by the adrenal gland that are necessary for survival. So once you remove the adrenal gland, you have to replace the hormones that were necessary for survival and we did that. If the adrenal gland removal didn't work, we then would take out the anterior pituitary gland at the base of the brain because that gland produces a hormone that stimulates either the ovary or the testicle to make the responsible hormone.
Avrum Bluming: And so we used to do hypophysectomies and while I was in practice, we did that. And as you know, the anterior pituitary makes many hormones that are necessary for survival. So we had to replace many of those hormones and we didn't really help too many women with that. Let me reiterate, we did nothing like that for men and we hurt a lot of women by doing that. We did it with good intentions, but we hurt them. What we then found is when women had breast cancer, because we were concerned that it might come back, we prophylactically removed their ovaries saying, "Well, if estrogen causes breast cancer, this will help prevent it from coming back." And we tested that with seven different studies. None of those studies showed that it worked. Did we ever treat men by prophylactically castrating them? Never. And we never will because men still control medicine by and large.
Avrum Bluming: So we were doing a lot with good intentions and hurting women. We then were looking at what estrogen is capable of doing, and this goes back to your question. Back in the 1940s, there was a book written called Feminine Forever that essentially said, "Well, women should take estrogen forever and it'll be an eternal fountain of youth." That's not true. That book was oversold. The doctor who wrote that book was paid for by the drug company who made estrogen and we didn't know that until his son told that to the press after he died, but estrogen did do some very good things. And what we found estrogen is capable of doing is first, estrogen can relieve the symptoms of menopause. The way menopausal symptoms are viewed as well it's hot flashes and night sweats and it'll usually last a year or two and tough it out lady and you'll get through it. And point the fact, there are many symptoms associated with menopause that are inches to hot flashes and night sweats. It includes palpitations, it includes cognitive decline, it includes joint pains-
Peter Attia: Sleep disturbances.
Avrum Bluming: Right.
Peter Attia: Yeah, lots of things.
Avrum Bluming: And it usually lasts about seven and a half years, not two years, and in some women it goes on for decades. And women are taught to suck it up and deal with that. Estrogen is also capable of reducing significant heart disease by up to 50%. There was an article in the New England Journal of Medicine in 1991 by Goldman and Tosteson that said, Time for Action, Not Debate, saying if women took estrogen, they would live longer, they would be healthier. That was 1991. And we now know that estrogen has been shown repeatedly to help diminish the risk for significant heart conditions.
Peter Attia: So let's pause for a moment because I want to make sure that people listening to this, and I hope it's not just women, but it should be men as well. Unless you're a man who finds himself not knowing any women, then maybe you won't listen to this. But let's explain what these hormones do a little bit. So there are not many papers that I have printed out in my office because we just don't print papers up that much anymore. We don't physically have a paper copy, but there are a handful that I have printed up and one of them of course is the WHI, both the 2002 and then some of the republications because I do like to show people the actual data, which I think speak for themselves, but another thing that I have printed up is the hormone cycle for a woman during her reproductive years.
Peter Attia: And I started doing this about three years ago and I was surprised how many women didn't know what estrogen was doing in their body. How it would rise during the follicular phase, peak during ovulation, decline during luteal phase and come up for a second bump before declining at their period, and similarly how progesterone would follow the smoothing out. We're going to link to images of that in the show notes, but the point I want to make is, women go through this for, what? 35 years of their lives, maybe longer, maybe 40 years of their lives, and I guess I was just surprised that, I remember having a patient who was complaining of horrible PMS.
Peter Attia: And so I said, "Well, it has to do with the reduction of progesterone. And in some women, the fall of progesterone during the end of the luteal phase is so rapid that for reasons we don't understand, that's going to produce a change in something and you can ameliorate that by doing x, y, and z." And the woman looked at me and she was like, "This is incredible. You've made me feel like I'm not crazy because you've shown me this graph that explains what's happening with my progesterone levels." So I do want to make sure that someone listening to this spends a moment to understand what we're actually talking about.
Peter Attia: You have these hormones that we're going to hear. We're going to talk about luteinizing hormone, follicle stimulating hormone. You've alluded to these already coming out of the pituitary, telling the ovaries to make these other hormones and really is it safe to say at the risk of oversimplifying, the reason it seems that women only experience this during a finite period of their life, is that's when evolution wanted women to be able to reproduce? Without this cycle of rising estrogen, progesterone falling levels, women wouldn't be able to reproduce. Is the risk of oversimplifying, is that a fair statement of why we have this finite window.
Carol Tavris: Finite window of [crosstalk 00:22:58]?
Peter Attia: During which time women have these hormones versus men who have kind of-
Carol Tavris: Of finite.
Peter Attia: Men have a much more gradual decline in their reproductive hormones.
Carol Tavris: This is a crucial thing to say, Peter. This is really important. This was something I didn't realize until we began working on this book. I assumed that in menopause, estrogen declines. I think that's the way women see it. It just declines the way testosterone declines in a slow, moderate way. No, estrogen plummets to 1% of what it was before menopause. I think most women have no idea that it's that great a drop in estrogen levels and no wonder that many of the symptoms that women have, which by the way, include depression and they attributed to, "Well, it's a midlife crisis I'm having." No, it could be an estrogen depletion crisis as well, and so I think it's really important for women to understand that this is not just a little fall off, it's really a major drop.
Carol Tavris: I want to add one thing here to this because as the social psychologist of this duo, what interests me is the way women have been given false information for so many years about so many aspects of their reproductive cycle and experience that it's no wonder that many women have a great skepticism about what medicine has to offer them in reproductive issues. Just what Avrum was saying about there was so little hesitation in cutting women up and removing this part and removing that part. Let's try this other thing. Things that would never have been tried with men that men would just never have agreed to.
Carol Tavris: And so women have had an understandable skepticism about the medical establishment advice. And starting with Feminine Forever, Robert Wilson's ridiculous song of praise to estrogen, women began to think, "Well, you know what? The hell with all of you on this. Estrogen is, I don't need it, it doesn't make me feminine forever and who dares to think that I need to be feminine forever in that traditional way? And menopause is just a natural phase of life and I can deal with it as I dealt with the onset of menstruation." So what I want our conversation to bring here is an understanding of why women have been whipped back and forth on whether estrogen is good for them or bad for them.
Peter Attia: And tying onto that, we left out another grotesque example of this, which Sidd Mukherjee has written about so eloquently in The Emperor of All Maladies, which is the radical mastectomy, which ties into all of this. Avrum, the points you brought up a moment ago, I wasn't even aware of the pituitary resections. I was aware of the oophorectomies of course, I had no idea they were resecting adrenal glands, which strikes me as ridiculous, but to actually resect the pituitary gland, that's macabre. Yeah, exactly, transsphenoid resections, it's just hard to believe. And yet lost in that story which should be added just to complete the sentence is, and up until Bernard Fisher came along, it was viewed as completely nonsensical that you would do anything other than disfigure a woman with breast cancer by removing every piece of tissue above her rib cage. It's an interesting point you raise, one I'd never really had contemplated truthfully, which is could that have taken place if the roles were reversed gender wise? I'd never really thought of it.
Carol Tavris: Think also about hysterectomies. The routine use of hysterectomy on the assumption that a woman, once she's had her children, doesn't need to have her uterus. And by the way, since we're removing your uterus, let's remove your ovaries as well because what the hell? They're just there. Let's take them out, as if they have no function. That casual attitude of let's just get in there and get rid of them.
Peter Attia: And the term hysterectomy, you want to maybe provide a bit of context for the listener on what that means.
Carol Tavris: Well, hysteria was thought to be caused by the wandering womb which detaches itself and wanders through the female body causing mayhem and despair. Yeah, yeah, part of her... More ludicrous notions about the female body.
Avrum Bluming: The point is women weren't treated fairly and they're still not being treated fairly. And just to amplify one point I made, I mentioned that estrogen can significantly decrease the risk of heart disease. What many women tell me at that point is, "Well, old women die of heart disease, young women die of breast cancer, I'd rather not take estrogen if estrogen causes breast cancer." And the answer to that is two fold. First, estrogen does not cause breast cancer, and we'll get into that in detail, but more than that, in every decade of a woman's life, the incidence of death from heart disease is greater than the incidence of death from breast cancer.
Peter Attia: I want to reiterate this point. It's like you were reading my mind. In preparing for this discussion, I did something I normally don't do. I normally don't put as much time into prep, but this is such a data driven discussion and the data are just so voluminous that I really had to spend a lot of time preparing and my team helped me greatly, but I have a chart that we will include in the show notes which makes your point very eloquently. If you begin at the age of 25, you take a cohort of 25 year old women and you forward-looking, project their 10 year mortality from breast cancer and from cardiovascular disease by decade. I'm going to read off the difference in favor of cardiovascular disease. So if the number is greater than one, you're more likely to die of a heart attack than breast cancer. If it's less than one, more breast cancer.
Peter Attia: Starting at the age of 25 going up in five year increments with a 10 year forward look, 3.5X, 3.5 times more likely to die of heart disease, 2.4X, 2.1X, 2.3X, 2.5X, 2.8X, 2.4X, 2.1X. We're now at 35 years old, 2.3, 2.5, 2.2, 3.3 by 55, 4.1 by 60, 5.6 by 65, 8.1 by 70 and 12.4 by 75. When you do the math on aggregate across lifetime, it's 7X difference in favor of cardiovascular disease over breast cancer. Where are the red ribbons?
Avrum Bluming: Heart disease kills more women than the next 16 causes of death, including all forms of cancer, AIDS and accidents.
Peter Attia: The only thing people listening to this know near and dear heart disease is to my heart because it is the number one killer for both men and women. There's another area where I think women get a bit of a short straw here, which is women present with disease quite differently. Do you want to say something about that?
Avrum Bluming: Sure, the typical presentation of a man is crushing chest pain, pain that goes down the left arm starting at the left shoulder. Women can often present with an upset stomach. And because we generally don't think of women as suffering from heart disease, the diagnosis is initially missed quite often, although doctors are getting more and more sensitive to that now.
Peter Attia: All right, so I took us off a bit of a detour. Carol, your point's a great one. I want to come back to make... For the first time in my career because I don't treat many women going through menopause, but any woman who's a patient of mine who's going through it I'm going to be a part of it, but this past year, I got to see firsthand how quickly a woman can enter menopause because if you happen to do labs on women frequently enough, you can see the drops. So I had a patient who in August of 2017, I like to check labs on what would be day five so I can really standardize where the FSH and estradiol should be, she had what looked like completely normal levels. Her FSH was something in the neighborhood of 10, her estradiol was maybe 90.
Peter Attia: She was starting to have symptoms though, so I said to her, "Look, you are very likely in a perimenopausal state. I expect you will enter menopause in the next three or four years." She was probably 47. Rechecked her blood in November, her FSH was 68, her estrodiol was unmeasurable. I rechecked the labs because I couldn't believe it, same result, reached out to one of my mentors, a gynecologist named Riley Lloyd in Chicago and I said, "Riley, what has happened here?" And he goes, "You just happened to see her fall off the cliff. This happens all the time. It's just we usually aren't looking at laboratory tests that frequently." So it's an interesting point that I'm glad you emphasized it.
Carol Tavris: And also you cannot say exactly at what age. One of the women we describe in the book who wrote a blog about this, Katie Taylor, who said she was 42, she was extremely depressed, she was having all sorts of symptoms. She was treated for her depression with antidepressants. That didn't do anything. Her doctor said, "Maybe you should quit your job. That will help your stress levels low sure." And fortunately, her father is a leading breast cancer specialist in England, and he said, "You know what? You could be in perimenopause." And she was. And she was.
Carol Tavris: So many of the symptoms that women begin to develop in their 40s, they don't associate with menopause. Muscle pain sends them to rheumatologists and depression sends them to therapists and fighting with their spouses sends them to family therapy, and they don't think that their changes of menopause might be involved. I want to say, by the way, that I am one of the minority of women who sailed through menopause with no symptoms and my mother as well. And so I underestimated how many women really suffer. It's not a verb I like to use much, but many women suffer with the symptom...
Part 2 follows
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