Advancing Women’s Health Care-Part Two

Following is the contuation of the Bay Area Women’s Journal interview with Dr. Nancy Milliken, Vice Dean UCSF School of Medicine and Dir. UCSF National Center of Excellence in Women’s Health. If you missed part one, you can find it here.

BAWJ: What is the latest thinking on Hormone Replacement Therapy?

Dr. Milliken: There’s been a huge sea change in our understanding of HRT. In fact we don’t call it HRT anymore. We call it HT for hormone therapy to emphasize that it is a therapy with risks and benefits that should be used to treat symptoms. Menopause is not a deficiency state that needs to be corrected.

In the recent past we routinely recommended HT to women without menopausal symptoms as good prevention. Now we know HT (which most commonly is estrogen combined with a progestin) may put an older woman at risk of heart disease, stroke and pulmonary embolus.

The lesson of this story is the importance of good clinical trials to good health care. The earlier hypothesis that estrogen must be good was based on the fact that women don’t get heart attacks as early as men. Heart disease is the number one killer of women, but not until later in life, after menopause.

At first, most but not all, observational studies seemed to confirm the common sense notion that hormones might have a protective effect against heart disease. Unfortunately observational studies can mislead, as they did in these studies, in which women who choose to take hormones were compared with women who hadn’t taken them.

Given the new findings, we think there may be something about women who choose to take a pill for prevention that is different from those who don’t. Perhaps those women are more health conscious and do more beneficial things for their health. Perhaps they have better access to health care and more money to pay for medications.

To control for those factors, we needed a good randomized controlled study. We finally got that with the Women’s Health Initiative (a major 15-year research program launched in 1991 to address the most common causes of death, disability and poor quality of life in postmenopausal women — cardiovascular disease, cancer, and osteoporosis). This study showed that traditional HRT is not helpful for heart disease and can increase the risk of blood clotting and stroke. Plus after a period of time on HRT, risk of breast cancer goes up.

I think we can clearly say that hormone therapy for prevention is contraindicated.

However, hormones remain one of the most effective treatments for hot flashes and other menopausal symptoms. Its benefits may out weigh the risks in younger women having symptoms. I would advise these women to use hormones at the lowest dosage and for the shortest period of time as necessary.

The good news is that there are ongoing studies and data analysis. We know more and more each year. The information is so much better than before. So we need to weigh the pros and cons for each woman. It’s not one size fits all.

BAWJ: What about the current concern about cosmetics?

Dr. Milliken: We are starting a new research and policy program on women’s reproductive health and the environment. There are a number of potential toxins in the environment that we will be looking at and we don’t know what the results are going to be.

It is possible that some cosmetics may be found to be harmful to reproductive health – they have not yet been rigorously tested. The European Union has already restricted over 1,000 chemicals found in personal care products. It is something for women to pay attention to and to go with the safest alternatives.

BAWJ: Are you seeing an increase in women going into medicine?

Dr. Milliken: The shift has been dramatic since I was in Medical School.

This year’s entering class at UCSF was 59% women; nationally the percentage is now over 50%. In ob-gyn the gender mix has changed even more significantly over the past 20 years.

It is healthy to have diversity within the healthcare community. Diversity is essential to excellence in research and health care. Our workforce should mirror the people we are treating so we hope to attract students of diverse gender, racial and ethnic backgrounds, LGBT identity and those who are differently-abled.

BAWJ: You have accomplished, and continue to accomplish, tremendous achievements in advancing the state of healthcare for women. How has that dedication and focus affected your personal life? Do you feel you have a work life balance?

Dr. Milliken: When there is so much to improve, it is an enormous challenge to find the right balance. I feel fortunate to have a community at work where my colleagues are my friends. As professional women with young children and aging parents, we are often juggling the same family/work issues; we support each other in finding solutions and covering for each other when time is needed at home. I have always lived close to the hospital so my husband and sons could visit when I was on call, which was great for them and me. I have a wonderful family and my time with them is a great balance to my time at work.

I feel incredibly blessed by having found a passion that I continue to care about and a profession that has allowed me to make a difference in people’s lives. I am thankful about that every day.

BAWJ: Thank-you Dr. Milliken for your time today and for your amazing efforts to improve women’s healthcare!