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Balanced but biased

August 21, 2016

The BBC’s menopause advice

Is odd (click here), and not just because they chose three men to deliver it; “Imagine I’m a woman” says the interviewer!

For the series Trust me, I’m a doctor the BBC interviewed two doctors with opposing views about long-term menopausal hormone therapy. Klim McPherson an epidemiologist from Oxford, presented the conventional view (click here); it carries increased risks of breast cancer, strokes, and heart disease and therefore should be used for symptom relief only, and in the lowest dose and for the shortest time possible. The absolute risks are low, so women whose symptoms persist may choose to take it for longer, just so long as they know the risks. But hormone therapy should never be used for “health promotion”. Few would quarrel with that.

But the producers wanted controversy, an “expert” who would downplay the risks and say that hormone therapy is good for you. They found John Studd.

Studd’s early enthusiasm for menopausal hormone therapy was at least based on the evidence available at the time. It was hardly his fault that drug companies had concealed adverse cardiac events, and that the “healthy user” effect made observational studies misleading.  But his passion did rather run away with him.  Here he is from 1988 (quoted in “Hot Flushes, Cold Science: A History of the Modern Menopause 2011 by Louise Foxcroft here).

“[There is now] little serious controversy about the devastating effects of oestrogen deficiency or the beneficial effects of hormone replacement therapy in post menopausal women. Pockets of resistance remain, more spiritual than medical, but fundamentally the news concerning heart attacks, strokes and carcinoma of the uterus is good. Some minor skirmishes concerning the dose and route of oestrogens, and the correct progestagens for the prevention of endometrial pathology remain, but essentially the battle has been fought and won.”

As Foxcroft wrote, such “hideously inappropriate, crusading language of prophets and wars” hardly suggested a disinterested seeker after scientific truth.

She was right. When the Women’s Health Initiative (WHI) trials (click here) were suspended because the hormone therapy harms made it unethical to continue, Studd couldn’t, or wouldn’t, alter his opinion. Instead he doubled down on his belief that hormone therapy is good for you, bad mouthing WHI overall, while selectively quoting those subgroup analyses and secondary endpoints which supported his ideas.

His reputation suffered. In the last century his papers regularly appeared in BJOG, the BMJ and Lancet. Now he’s pretty much confined to obscure menopause journals supported by industry and run by his friends. But pharma loved him, and put him on their advisory boards and flew him round the world to spread the word.

Before long he had turned into a single issue campaigner advocating estrogen therapy for everything. On his website (click here) he cites “10 reasons to be happy about HRT”, and even castigates psychiatrists for not treating depression with hormones!  His “10 reasons” include making women more beautiful, more randy and nicer to live with!

Studd performed as the BBC hoped (click here). When asked about the increased risks of breast cancer he first avoided the question, and segued into his polished riff about the WHI trials which, according to him, studied “the wrong patients, with the wrong drug, by the wrong route, using the wrong dose and came to the wrong conclusions”. Of course he’s entitled to his opinion, but it’s him who’s wrong; no-one who knows anything about clinical research would agree with him. The two WHI trials studied more woman for longer than any other, and in the latest Cochrane review (click here) were among the minority accorded a perfect score of 7/7 on trial design.

When the interviewer pushes him, and asks about the claim that long-term HRT doubles the risk of breast cancer he denies that anyone thinks the risk is that great, and suggests that even the most anti-hormone experts only quote a relative risk of 1.1 or 1.2. This provokes incredulity in the interviewer who had just recorded McPherson stating the risk was doubled (click here. It’s at 55 seconds). McPherson is right. The relevant Cochrane review (click here) gives a relative risk of breast cancer death after long-term hormone therapy of 1.98.

When asked if he ever takes women women off hormone therapy, Studd replies: “No, I don’t take women off HRT.” Women must be thankful that he no longer works for the NHS.

Thank you to my colleague Susan Bewley who pointed out this poor choice of “expert”, and persuaded the BBC to add a sentence to indicate Studd’s conflict of interest:

“Professor John Studd now works entirely in private practice, specialising in HRT-based treatments.”

I think this is inadequate. I think the BBC should remove Studd’s interview altogether. If they won’t do that, they should add a much stronger conflict of interest statement. Here’s a suggestion.

“Professor Studd has a conflict of interest. He has received funding for travel, lecture fees and payment to sit on their advisory boards, from many manufacturers of menopausal hormone therapy. He no longer works for the NHS, instead running a private clinic where he advocates and prescribes estrogens, either alone or in combination with other hormones, for pretty much every woman who comes through the door.”

Jim Thornton

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