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Peter Attia MD#42–Avrum Bluming, M.D. and Carol Tavris, Ph.D.: A compelling case for hormone replacement therapy
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CHAPTERS
- 0:04 – 9:00
Why the Drive Has No Ads and Peter's Case for Hearing About HRT
Peter Attia explains the listener-support model in place of ads, then introduces his guests and why the topic matters to men and women alike. He describes how polarizing the HRT literature is and previews the interview's scope.
- •Attia explains why he avoids ads, citing trust and his difficulty promoting things he isn't enthusiastic about
- •Members get exclusive show notes, AMA access and discounts on products he already likes
- •Introduction of Carol Tavris and Avrum Bluming and their book Estrogen Matters
- •Attia compares the HRT story to the nutritional guidelines of the 1970s and 80s
- •He states his view that most, but not all, women benefit from postmenopausal HRT
- 9:00 – 14:12
Why a Social Psychologist and an Oncologist Wrote About Estrogen
The guests explain what drew them to the topic. Carol Tavris describes her interest in why people resist better information, while Avrum Bluming describes his decades as a medical oncologist and his challenge to the assumption that estrogen causes breast cancer.
- •Tavris has focused on barriers to critical thinking and on bringing good research to public attention
- •Bluming has spent over fifty years as an oncologist, with breast cancer about 60% of his practice
- •He says he challenged every assumption behind his practice, including that estrogen causes breast cancer
- •He says women have been denied estrogen for decades and many have been hurt by that
- 14:12 – 20:25
History of Treating Women: From Castration to Feminine Forever
Bluming compares how breast and prostate cancer were treated, describing the removal of ovaries, adrenals and pituitaries in women. He then covers the origins of estrogen therapy, the Feminine Forever book, and the benefits he attributes to estrogen.
- •Women had ovaries, adrenal glands and pituitaries removed, which Bluming says was never done to men
- •Prophylactic oophorectomy was tested in seven studies, none of which showed it worked
- •Feminine Forever was written by a doctor funded by an estrogen manufacturer
- •Bluming says menopausal symptoms go beyond hot flashes and last about seven and a half years on average
- •He says estrogen can reduce significant heart disease by up to 50%
- 20:25 – 33:19
What Hormones Do: The Estrogen Cliff and Heart Disease vs. Breast Cancer Risk
Attia explains the female hormone cycle, and Bluming stresses that estrogen drops to about 1% of premenopausal levels at menopause. The discussion covers women's skepticism of medicine, the greater mortality from heart disease than breast cancer, and patient examples of abrupt hormone loss.
- •Estrogen plummets to about 1% of premenopausal levels, which many women don't realize
- •Tavris says women have been given false information and subjected to extensive surgeries, including hysterectomies
- •Attia's decade-by-decade figures show heart disease mortality far exceeding breast cancer mortality
- •Women often present with heart disease differently, for example with an upset stomach
- •Symptoms in perimenopause are often attributed to other causes, as in Katie Taylor's case
- 33:19 – 38:14
Motivations and Personal Stories
The guests state they have no financial ties to drug companies and describe their own backgrounds. Bluming tells of his wife's menopause after chemotherapy, and Attia tells of a breast cancer survivor whose life improved on hormone therapy.
- •Tavris and Bluming state neither has taken money from drug companies
- •Tavris sailed through menopause and was once critical of HRT as a feminist psychologist
- •Bluming's wife had cognitive and physical symptoms after chemo-induced menopause and improved within two weeks on hormones
- •Attia describes a young ER/PR-positive breast cancer survivor who felt better within weeks of starting hormone therapy
- 38:14 – 46:01
Rise and Fall of HRT Use and the Setup of the Women's Health Initiative
Bluming traces HRT from the Premarin era through the uterine cancer finding and the addition of progesterone to peak use in 2002. The conversation turns to the Nurses' Health Study, the WHI's rationale, and the unrepresentative population enrolled.
- •Estrogen alone raised uterine cancer risk, and adding progesterone nullified it
- •About 16 million US women were on HRT in 2002, falling to 5% by 2010 after the WHI
- •The Nurses' Health Study found no increased breast cancer risk over 5 to 15 years of use
- •WHI women averaged age 63, 70% overweight or obese and over half smokers
- •Women with significant symptoms were excluded, so quality-of-life results missed those who benefit
- 46:01 – 57:21
How the 2002 WHI Results Were Announced and Interpreted
Tavris and Bluming describe the press-driven announcement of a breast cancer risk that was not statistically significant. They discuss researcher bias, the rushed review by investigators, and a comparison Attia draws to the 1980s dietary consensus.
- •The finding was announced before the JAMA article was available, and it was not statistically significant
- •Tavris attributes the study's direction to bias rather than conspiracy, noting the lead investigator's 1996 article against the 'HRT bandwagon'
- •Investigators reportedly had until noon to review a paper already published
- •A quoted WHI investigator said 'the statistical police have to leave the room'
- •Attia compares this to a story of a forced NIH dietary consensus
- 57:21 – 1:09:07
Absolute vs. Relative Risk and the WHI Breast Cancer Numbers
The group examines the 26% and 24% increases in breast cancer. They cover the estrogen-alone versus estrogen-plus-progestin arms, the control-group problem, and why the absolute increase was under 1%.
- •Estrogen alone showed no increased breast cancer risk, with a hazard ratio of 0.79
- •Bluming explains the apparent increase with progestin came from a lower-than-expected control-group rate among women who had previously taken hormones
- •The absolute increase was about nine cases per 10,000 even if the 26% figure were true
- •Attia tells patients to treat the WHI as their ceiling on risk
- •Women diagnosed with breast cancer on hormones had a better prognosis stage for stage
- 1:09:07 – 1:22:55
Progesterone, Premarin, Bioidenticals and WHI Follow-ups
The discussion considers whether synthetic progestin explains the WHI findings, the WHI's choice of Premarin and MPA, and the term 'bioidentical'. They then review the 2003 and 2006 follow-ups and later walk-backs, including 'lowest dose for shortest time'.
- •Progesterone has itself been used to treat breast cancer, according to Bluming
- •Bluming calls 'bioidentical' a buzzword and prefers Premarin for its long data record
- •Micronized progesterone appears to be the safest form of progesterone
- •A 2006 follow-up said the increased risk had disappeared, but it didn't make headlines
- •Tavris says there is no empirical evidence for the 'smallest dose for the shortest time' advice
- 1:22:55 – 1:26:54
Alzheimer's Disease and the Brain
Starting with the brain, Attia notes that women are twice as likely to die of Alzheimer's. Bluming argues estrogen is the one potential preventive, citing a 20–50% reduction in incidence, and the guests discuss what 'natural' means.
- •Women are twice as likely as men to die of Alzheimer's disease
- •Bluming says two women are diagnosed with Alzheimer's for every one diagnosed with breast cancer over 60
- •He says estrogen can reduce incidence by 20 to 50% depending on the study
- •Tavris says animal, lab, field and randomized studies converge on benefits for the brain
- •The guests and Attia reject the 'not natural' objection given longer lifespans
- 1:26:54 – 1:38:26
Heart Disease, Timing of Hormone Initiation, and Bone Health
The guests discuss why the WHI population was not cardiovascularly healthy and the 'window of opportunity' for starting HRT. They then cover bone mineral density, hip fractures, and how estrogen compares with calcium, vitamin D and bisphosphonates.
- •Bluming says estrogen can cause platelet clumping, so women with preexisting cardiovascular disease are advised not to start
- •Risk appears mainly during the first year of use, and there is no increased risk when starting near menopause without preexisting disease
- •Women may have symptoms for ten years or more and ask whether they can start later
- •Bluming says estrogen can cut osteoporotic hip fracture risk by up to 50%
- •Bisphosphonates carry an increased risk of atypical femoral fractures after five years
- 1:38:26 – 1:48:31
Colon Cancer, Diabetes, Clots, Gallbladder and Counseling Women
The guests cover other WHI outcomes, including reduced colon cancer risk and the retreat from the Global Health Index. They discuss real downsides such as venous clots and gallstones, and advise women to become informed consumers who weigh benefits and risks with their physicians.
- •Studies show a 20–25% decreased risk of colon cancer among women taking estrogen
- •The WHI's Global Health Index claim was walked back
- •Pulmonary embolism, clots and gallstones are real risks that must be considered
- •The book is meant to make women better consumers of healthcare
- •Tavris argues that under-medicalizing is no better than over-medicalizing, and HRT isn't an ideological question
- 1:48:31 – 1:59:22
RCTs vs. Observational Studies and the Problem of Data Dredging
Attia asks whether a corrected WHI-style trial will ever be done, and Bluming says no. The guests argue that convergence of evidence matters, that RCTs can be biased, and that publish-or-perish pressures produce spurious findings, illustrated by absurd breast cancer risk factors.
- •Bluming says not every truth can be determined by a double-blind randomized trial
- •Cost and complexity stand in the way of repeating a WHI-scale study
- •Tavris argues for convergence of evidence across methods and countries
- •Attia notes healthy-user bias in epidemiology and performance bias in RCTs
- •Spurious findings such as french fries and electric blankets show the problem of subgroup mining
- 1:59:22 – 2:13:51
Rethinking Cancer, Critics, Race and International Views
Bluming uses acute promyelocytic leukemia to illustrate how understanding of cancer can change, and Attia mentions the role of the cellular environment. The conversation turns to the lack of public rebuttal from the other side, race and the post-2002 breast cancer decline, and views of HRT in other countries.
- •Treating maturation arrest in a leukemia with a vitamin A form changed an otherwise fatal disease
- •Bluming says opponents have been silent when he has asked them to explain their disagreement
- •Most studied patients are Caucasian, so little is known about racial differences
- •He argues the post-2002 breast cancer decline doesn't fit the WHI's explanation, and it did not occur among Black women
- •Thirty-three menopause societies have endorsed HRT and the US is described as more anti-HRT
- 2:13:51 – 2:20:36
HRT After Breast Cancer and Closing Thoughts
Bluming discusses hormone therapy after breast cancer, including pregnancy after diagnosis, the 15 studies he cites, and his own 14-year study. Attia and the guests close by urging listeners to read the book and its references and to think critically.
- •Bluming says 14 of 15 studies found no increased recurrence risk with HRT after breast cancer, and the exception was stopped early
- •His own FDA-approved 14-year study of women who had breast cancer found no increased recurrence risk
- •Survivors face increased risk of heart disease, Alzheimer's and osteoporosis
- •Attia urges people to read the book and check its references rather than take the podcast's word
- •Closing quote: 'The more you know, the less you fear'
