http://www.ethicsweb.ca/papers/Alternativization2002.pdf

You should check my links, too. Eternal vigilance is the price of online journalism.

On the natural v. synthetic point, you comment:

I wrote: “Many women believe that bio-identical hormones are safer because they are made from plant sources. In fact nearly all replacement hormones both bio-identical and the ones in regular HRT come originally from plant sources (although Premarin comes from horse urine). It’s not the source that is the key but how the chemicals are tweaked in the lab.”

This is why attempting to score points by suggesting Premarin is “natural” is irrelevant too. The issue with Premarin, as with progestins, is that the hormones it supplies are different to those your body makes.

It has been explained to you that Scott’s description of natural v. synthetic bio-identical hormones (which you seem to accept as accurate) was made with reference to the issue of medicalisation and “alternativization”, you characterise it as “wrong and misleading”. Likewise, I fail to understand your point here.

[A] variety of bioidentical hormones are already available on the NHS. A fact on its own which indicates that they have a sensible evidence base.

Magnetic leg wraps are available on the NHS: the evidence for them is less than compelling. And, again, the point at issue is scholarship, not BHT.

Raising awareness by providing information that is built on a shaky foundation does not help an evidence-based discussion. How does it help a woman to visit her Menopause Clinic and ask about BHT based on the information in your article, only to have the Clinic look up the Holtorf review and then discuss the flaws with her before providing her with different information?

I would be very surprised if the Daily Mail were willing to endorse your attitude to their readers and the need to provide correct information to them. As for your implication that newspapers provide mediation between readers and experts, I shall defer to Ben Goldacre:

Firstly, they can’t get journalists to directly link to their studies. I suspect newspapers like to fantasise that they are mediators between specialist tricky knowledge and the wider public, but I wouldn’t be so flattering. In fact, if you have access to the original journals, you can see just how rubbish things can get.

Why should the public trust the information in newspapers when journalists who write for them say:

it was not part of my brief to go investigating the data that some expert has spent years compiling…

and appear to deprecate the need for accuracy when writing for a newspaper?

As for adding in detail, I re-iterate, it is the quality of the scholarship that counts, not its volume.

As far as Spect scans were concerned, I’m afraid this is another case of you asking newsapers to do things that they are not designed to do. the article was an extract from a book…In such a case it was not part of my brief to go investigating the data that some expert has spent years compiling.

It wasn’t clear to me that this was just a book extract. The article’s in your name, refers to Amen in the 3rd person, etc.

As to an expectation that newspapers doing things they’re not designed to do – the article even misdescribes Amen’s role at UCal. This type of fact-checking is not (or should not be) something alien to newspapers – and this type of checking is especially important if you’re relying on a source’s expertise, rather than analysing his data and work independently.

Beyond that – very basic research (e.g. a simple Google search) shows that there are a number of concerns with certain applications of SPECT and Amen’s work – including the type of applications discussed in your article. I don’t think it would have been unreasonable to expect a newspaper to consider this (or to contact critics such as Harriet Hall for comment).

In such a case it was not part of my brief to go investigating the data that some expert has spent years compiling. That is the job firstly of the editors of the publishing house and secondly of reviewers, in this case most likely in scholarly publications.

If you have issues with the author’s scholarship I suggest that you take it up with him.

I also thought, I may be wrong, that Patrick Holford and his merry FFTB-ers were asking for more money to run more projects in schools despite some criticism of the standards of their last report (apparently, the literature review had some errors and the statistics were flawed-to meaningless in spots – apart from that, it was fine).

Again, this may be just something I heard, but iirc, then the Brain Bio Centre is touting for business from private health insurers and PCTs in matters relating to mental health and nutrition.

I might be wrong, but isn’t Patrick Holford still lecturing from time to time at the ION? Aren’t IONistas, as per BANT, trying to get some of their people accepted by the NHS for various lifestyle programmes? People from courses on which certain books are regarded as reference texts despite the flaws in them, the standard of their scholarship and the fact that some of the people who originally endorsed them have asked for those endorsements to be removed?

As it happens I do go to considerable lengths to look at the evidence and talk to experts but there is no pretence that such an article is a work of scholarship. The point about Holtof’s is that it was an example of a fairly detailed article published in a respectable and peer reviewed journal that was favourable.

I could also have referred to another equally detailed article by Holtorf and Schwartz – (Prim Care Clin Office Pract 35 (2008) 669–705) as well as the two others mentioned in my previous post. But as far as “serving my readership better” goes they would have added nothing

That is because the the purpose of the article was not to conduct a review of the scientific literature. It was firstly to alert people to the existence of bioidentical hormones – the fact that an equal number of Americans take them as do regular HRT means that they are an issue that deserves far more discussion and coverage in the UK than they have so far.

The second was to very briefly skim over some of the high points of the evidence, not to painstakingly build a scientific case. The third and this feeds directly into the second point – to alert people to the fact that a variety of bioidentical hormones are already available on the NHS. A fact on its own which indicates that they have a sensible evidence base.

That point is further reinforced by the support given to them by the gynaecologists. You say you are “not really impressed by arguments from authority. We emphasise access to primary sources and scrutiny of them.”

All very well and good but – and I’m sorry to keep repeating this – not in a daily newspaper. You are looking at a fish and keep pointing out that it does not ride a bicycle very well. The point of authoritative experts in newspapers is that they act as a kind of short hand, this person whose job it is to know about this, supports it. As far as serving readers goes, that is one way of doing the job.

I don’t understand your point about the comment about natural v. synthetic hormones being with reference to the issue of medicalisation and “alternativization”. It may well have been but that doesn’t affect the fact that it is wrong and misleading.

It is a pity that in your efforts to discredit the article that you fell into the hoary old trap of confusing natural with bioidentical.

Given that the headline of the article is “Should middle-aged women be taking natural HRT”, it did seem to invite this type of interpretation. I appreciate that this may have been down to the sub-editors – but, if so, have you raised this with the Mail?

By the way, I’d welcome details of the research backing up the claims made in your article on SPECT scans.

It’s a shame that you didn’t realise that the comment about natural v. synthetic hormones was with reference to the issue of medicalisation and “alternativization” of women’s health rather than your article. Had we intended to comment on your article at that point, we would have mentioned it.

Not really impressed by arguments from authority. We emphasise access to primary sources and scrutiny of them.

From your comments, it rather seems as if you accept that the review on which you ground your work was less than optimal. In which case, why cite it? It does not empower women to tell them what someone thinks that they want to hear rather than give an accurate precis of the state of the evidence. If you had better grounded evidence then it might have served your readership better to use it.

Entertained that you are focusing on “cavalier attitude to evidence” – note the claim about the NNT for statins in the book you co-authored with Patrick Holford.

The claims about AZT and vitamin C in re: effective interventions for HIV are not minor or trivial claims. It is not good enough that there is a minor note correcting this in the latest version rather than an update to the text.

Holford talks about himself in terms of ‘De Vinci’, I don’t know how thrilled he might be that you compare his millionaire status and standing as CEO of various charities and position with Biocare to that of a ‘kid with a catapult’.

So, to specific points.

*You object to having to “resort to a treasure hunt to identify the primary sources”. See above.

*”Burne gave generous amounts of detail as to one of the major sources” – Not sure what your definition of “generous” is but in an article of 2000 words I actually devoted fewer than 150.

Your essential point here is that the author Holtorf has been a supporter of bio-identical hormones for years and uses them in his centre and that he did not declare this interest. He probably should have done and there are doubtless criticisms that can be made of his review but the point is that an article in a daily paper health feature is not the place to look for such detailed discussions.

As usual with your concentration on minutiae you miss the broader point which is that the reiteration by official bodies such as the AMA and others in the UK that there is no evidence for bioidentical hormones is just not true. There is not conclusive evidence and there is disputed evidence but to claim that there is none is simply wrong. The effect of this has been to deny many women who want HRT for various reasons – mostly help with distressing symptoms – an alternative. This wilful ignorance seems to me a far more serious failure than your point about the author of one piece having an undeclared interest.

I could have used various other papers instead of Holtorf’s which made the same general point. For instance: “Could transdermal estradiol + Progesterone be a safer postmenopausal HRT? A review by Marc L’Hermite et all in Maturitas – July/August 2008. The conclusion was that it “might offer significant benefits and added safety.”

Or how about a case control study from France involving 271 consecutive cases with “a first documented episode of idiopathic VTE (venous thromboembolism). Conclusion: “oral but not transdermal estrogen is associated with increased VTE risk. In addition our data suggest that norpregnane derivates may be thrombogenic whereas the micronized progesterone and pregnane derivatives appear to be safe with respect to thrombotic risk.” Circulation Feb 20 2007

Your nitpicking critique misses not only the general point that there is sensible evidence supporting bioidenticals but also the even stronger one that there are now a number of senior British gynaecologists – quoted in the article – who also believe, with the usual caveat about more research, that bioidentical hormones may well offer a superior option to many women. Now that seems to me to be a point well worth making. They also constitute and argument from authority – they are experts, they will be familiar with a range of evidence of which Holtorf is just one example – and as such can be taken as supporting his general conclusion.

*It is a pity that in your efforts to discredit the article that you fell into the hoary old trap of confusing natural with bioidentical.

You state: “There are no bioidentical hormones that do no undergo some sort of laboratory manipulation. Consequently there are no truly “natural” bioidentical hormones.”

This is one of the canards regularly wheeled out against bioidentical hormones. The implication is that all those woolly people rooting for bioidenticals don’t know their science. Not only is it utterly wrong but I specifically dealt with it in the article.

I wrote: “Many women believe that bio-identical hormones are safer because they are made from plant sources. In fact nearly all replacement hormones both bio-identical and the ones in regular HRT come originally from plant sources (although Premarin comes from horse urine). It’s not the source that is the key but how the chemicals are tweaked in the lab.”

This is why attempting to score points by suggesting Premarin is “natural” is irrelevant too. The issue with Premarin, as with progestins, is that the hormones it supplies are different to those your body makes.

*Finally I am always amazed at the narrowness of your focus. Is the aim of your site and considerable time you must put into it simply to try to point out, fairly ineffectually, errors in my articles or in publications by Patrick Holford? If you are concerned about the perversion of science for commercial ends why do you persist in nagging away at the kids with the catapults and ignore the passing tanks?

You must know that a cavalier attitude to evidence has been a hallmark of drug company marketing, frequently with fatal results. In light of the repeated (and incorrect) assertions that there is no proper clinical trial evidence for bioidenticals it is worth remembering that until the WHI study there was none for HRT either – lots of observational stuff but no long term trial and the pills were prescribed in their millions.

But the fiddling was far more specific. Recently a particularly striking example fudging figures on HRT came to light as a result of investigations by Senator Grassley of the American Congress into “ghost-writing”. A report in the New York Times showed how Wyeth Pharmaceuticals and a medical writing firm produced ghost-written journal articles–all signed by prominent gynaecologists—that were designed to deceive doctors about the safety of Prempro. (THE NEW YORK TIMES December 12, 2008 “Drug Maker Said to Pay Ghostwriters for Journal Articles”)

One of these was published in The American Journal of Obstetrics and Gynecology in May 2003 – a year after the WHI study had found the increased the risk of breast cancer – saying that there was “no definitive evidence” that progestins cause breast cancer, adding that hormone users had a better chance of surviving cancer. An article that was distributed to large numbers of doctors. Why not do something useful and chase up dangerous distortions like that?

Finally although the anti bioidentical camp keep on playing down the HRT risks there is growing evidence that a falling incidence of breast cancer among postmenopausal women in the United Kingdom may be linked to lesser use of hormone replacement therapy (HRT). (See BMJ 2009;338:b791)