Buckle your seatbelts, friends. This one is going to be a little grim. In conversation with a dear colleague and his wife in Bethesda, MD, in early March, I was somewhat surprised to hear my colleague's wife, a breast cancer survivor, say that she would rather die of a "nice clean heart attack" than go through the agonies associated with death from cancer.
She was citing this sentiment as a reason why she would not want to take estrogen treatment, even if, in the long run, estrogen does prove to protect women against heart disease. As heart disease kills four times as many women as all cancers put together, I was trying to make the point that even a small increase (up to 30 percent) in the risk of breast cancer might be worth a 40 percent reduction in the risk of cardiovascular disease.
I had heard other women express the same sentiment, but I assumed that my colleague's wife would be better informed regarding heart disease. The fact is that in more than 60 percent of those affected by coronary heart disease, the condition is a progressive, chronic illness that damages the heart. Eventually, the heart cannot pump enough blood to sustain normal activities. Patients become progressively disabled and short of breath. Fluid accumulates in their legs and lungs. Physicians can call upon a large pharmacopoeia of highly effective drugs (beta-blockers, statins, ACE inhibitors, diuretics) to draw this process out over many, many years, but in the end, sufferers succumb to a relentless loss of heart function, drowning in their own body fluids.
Does this sound like a "clean" exit? Unfortunately, few modes of dying would fit this description.
And while we are talking about end games, are you aware that hip fractures are a major cause of death and disability in women older than 65? Approximately half of women who fracture a hip become permanently disabled, and a third die within three months from complications (usually pneumonia). In the 70+ age group, death from complications of hip fracture is about as common as death from breast cancer.
This bring up another advantage of estrogen treatment: It is highly protective against osteoporosis and bone fractures; by some estimates, it reduces fractures by as much as 60 percent. Yet the risks associated with hip fractures are never factored into risk/benefit assessments of estrogen treatment.
Here is the bottom line: Until we find a cure for aging (we gerontologists are working very hard on this), there is no guaranteed good way to die. The best strategy is to pursue a course designed to optimize health and longevity. This includes regular exercise and healthy nutrition, along with appropriate dietary supplements and preventive medications when indicated. For some women with a high risk for osteoporosis and a low risk for breast cancer, this might include hormone therapy. For me, the weight of evidence indicates that estrogen can help protect the heart when given at the right dose and by the right route. But this remains to be confirmed (or disproven) by well-designed new research.
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