Doctor of Hope: Is Elizabeth Vliet Selling a Midlife Miracle or a Prescription for Disappointment?
On a hot summer afternoon, the Texas sun is tempered only slightly by a gentle breeze blowing from the south. Texas congresswoman Kay Granger, dressed in a crisp white ankle-length suit with a white orchid pinned to her shoulder, stands outside a women's clinic in Bedford, Texas, awkwardly holding a pair of enormous cardboard scissors in her hands as beads of sweat pop out on her brow. It is 2 o'clock on June 22, and Granger is waiting for psychiatrist Elizabeth Lee Vliet of Tucson to stop signing books long enough for the congresswoman to cut the ribbon that will officially launch HER Place, Vliet's hormone replacement clinic, which moved from Fort Worth to nearby Bedford last October.Behind Granger is a long table stacked high with copies of the doctor's hormone book. "Screaming To Be Heard: Hormonal Connections Women Suspect ... and Doctors Ignore," is moving fast at $24.95. The 51-year-old Vliet, tall and full-bodied, dressed in a neon pink suit, her reddish blonde hair swept up and away from a carefully made-up face that doesn't quite hide her freckles, talks animatedly to each buyer as she signs her name. When Vliet finally appears beside Granger, and the ribbon is cut, the therapist beams at about 40 worshipful supporters, nearly all well-dressed (rather sweaty now) white matrons, and begins her effusive speech, "This is a wonderful day for women ... an empowering day for women. ... Bedford has welcomed us with open arms...."For Granger, it was the second time in a little over a year that she'd been called on to cut this doctor's opening-day ribbon, as Vliet tries to find a niche in this area for her particular brand of hormone replacement therapy. So far it hasn't been easy. She first opened HER Place (Health Enhancement Renewal for Women, Inc.) with great fanfare and Granger's scissors at Fort Worth's All Saints Episcopal Hospital in November 1995, only to be gone in 11 months under a cloud of rumors and speculation over her hormone treatment and management style. And now here she and Granger are again, opening her second facility, eight months after it began accepting patients.Vliet has been called everything from a "courageous medical pioneer" on the cutting edge of women's medicine to a high-priced "diet pill doctor" passing out hormones like M&M's. Is the psychiatrist from Tucson a true pioneer plowing new ground in menopausal turf or just another huckster reaping profits from the worn-out soil of women's ancient fears? Or even worse, is her therapy dangerous?At the beginning of this century American women were living, on average, to the ripe old age of 45. Infectious diseases, childbirth, pneumonia, and exhaustion were killing our foremothers off before most ever felt the first hot flush of menopause. Even as modern medicine began to give women longer life, the abrupt end of fertility was just "that time of life," like the menses that preceded it had been "that time of the month," with little if any attention paid to either by practitioners of the healing arts.As the end of the century approaches, with 45-year-old females looking forward to approximately 36 more years of life, menopausal women -- and the quality of their lives after menopause -- are getting the attention, and for many the relief, their grandmothers never received. Long overdue clinical studies into female diseases and the influence of hormones on women's health and aging are now proliferating, with promising results.The oldest of these is the Nurses' Health Study, which has tracked 122,000 women since 1976. Recent reports from the on-going study indicate that hormone replacement may extend the lives of older women at risk for heart disease by about 10 years, and protect against colon cancer, broken bones, depression and memory loss. Researchers at Johns Hopkins University announced recently that estrogen may also ward off Alzheimer's, findings supported by research in Japan. Dr. Roger Blumenthal, director of Johns Hopkins' Ciccarone Preventative Cardiology Center, who is in the middle of his own five-year estrogen study, said in a recent interview, that the Nurses' Study is "very helpful but not conclusive." Still, Blumenthal said, the results of the estrogen studies are "very exciting" and are driving the research into a form of estrogen for men, "one that won't be feminizing" but will have the same beneficial effects, especially in protecting against heart disease, the number one killer of both men and women. Called "the closest thing in modern medicine to an elixir of youth" by "Time" magazine in a 1995 cover story, estrogen is now the most prescribed drug in America.Some doctors and researchers warn that the growing body of published articles on the beneficial effects of hormones should be read as a cautionary tale rather than the promise that women may beat the aging process. They fear that the pause that doesn't always refresh has become a growth industry fueled by the baby boomer generation of women who, unlike their 1900 counterparts, are feeling that first hot flush, don't like it one bit, and are willing to pay a lot of money to make it go away. Understanding this vulnerable generation, the new snake-oil salesmen are selling everything from the "all natural" Miracle Cream you can order over the Internet that guarantees to increase your libido and cure "migraines in 16 minutes" to books promising "extended youth," a theme first propounded by gynecologist Robert Wilson in his 1966 bestseller Feminine Forever.There is, however, a dark side to hormone therapy, especially long-term estrogen use, that can not be ignored: breast, uterine and ovarian cancer, excessive bleeding and blood clots. Blumenthal cautioned that before starting estrogen therapy, "any abnormalities must be ruled out," because of estrogen's ability to promote the growth of cancerous cells and cause abnormal uterine bleeding.Two of Vliet's early patients from All Saints wound up as emergency cases with that kind of severe uterine bleeding. They had been on estrogen without the balancing hormone progesterone, according to the gynecologist who was called by All Saints to treat them because Vliet was in Tucson. The gynecologist had not seen either woman before, and asked that his name not be used to protect confidentiality. One woman required a dilation and curettage to stop the bleeding, the doctor's records show; the other had uterine fibroid tumors that had to be removed.According to the records, Vliet was contacted in Tucson by an assistant at All Saints after one of the women began experiencing profuse, heavy bleeding. Vliet, by long distance, told her assistant to give the woman a shot of progesterone. She then started to hemorrhage, the gynecologist's nurse said. "We were called from All Saints and asked to see her right away," she said. "A sonogram revealed that the lining of her uterus was huge, and thick, and by the time she got to surgery her hemoglobin (blood count) was extremely low," the nurse said, reading from the records. "The doctor had to give her four pints of blood prior to the surgery." The gynecologist "stopped all hormones, immediately," his nurse said.What startled the gynecologist and his nurse even more, she said, was that when Vliet was contacted in Tucson by the gynecologist, she suggested that the doctor go ahead and do a hysterectomy, because Vliet believed the woman would have to have one eventually. The doctor didn't take her advice, and both women are doing well today, the nurse said. The women's experiences point to the concern raised by several doctors here who say that Vliet is an "absentee practitioner" who initiates a treatment protocol and then "leaves town.""We're here for the long haul," said one gynecologist. "If our patients have to call in the middle of the night, we're going to be there for them ... these are potentially life-threatening hormones for some women...." The powerful nature of estrogen was underscored in the Nurses' Study in its finding that after 10 years of estrogen use, a woman's risk of dying of breast cancer began to increase dramatically over a non-user's. Most doctors have always screened carefully for this hidden killer and other reproductive cancers through mammograms, regular breast exams, pap smears, complete physicials, sonograms and a thorough family history before prescribing hormones. This is the critical point where many local doctors and academics begin to diverge from Vliet. A native of Virginia's Tidewater, Vliet has a 1978 medical degree from Eastern Virginia Medical School. A residency in 1981-1982 at Johns Hopkins followed that. Vliet is the owner and medical director of a HER Place hormone clinic in Tucson, where she lives most of the year with her husband, George. She only spends one week out of four at her Bedford Clinic, just as she did at All Saints.However, little is known about her in Tucson. The health reporter for the "Arizona Daily Star" and "Tucson Citizen" has never heard of HER Place, Vliet or the book. HER Place is not listed in the Tucson phone book, and an employee at Tucson's Cerelle Center for Women's Health, which specializes in mammograms, said Vliet never refers patients to the center. "We know nothing about her," she said. Vliet's book jacket says that she is "currently on the clinical faculty in the Department of Family Medicine at both the University of Arizona College of Medicine and the University of North Texas Health Science Center." Spokespersons at both colleges said that Vliet is in reality an unpaid "adjunct faculty member" who conducts seminars from time to time. Neither college could find any record that she had been on its campus in recent months.Vliet said that she became interested in the hormonal connections to women's diseases when gynecologists began sending more and more female patients to her for psychiatric treatment, when in fact, she believed, many were menopausal or suffering from severe PMS (pre-menstrual syndrome) or thyroid deficiencies. "They needed hormones," she said. Since the publication of her book in 1995 -- which touts natural hormone therapy as a boon for mid-life female problems from low libido to depression, plays down the estrogen connection to breast cancer, and bashes male doctors for dismissing menopausal women as "hysterics" -- the psychiatrist with no practicing clinical background in gynecology has developed a loyal following here as well as a growing number of local critics."Hormone replacement is an excellent mode of treatment from 35 (years of age) on up," said Fort Worth gynecologist Joseph McWherter, in practice for 20 years, "but it is a powerful medication and should be prescribed by people very qualified in the field of gynecology ... it is not a psychiatric drug."Screening for cancer through regular pap smears and mammograms after age 50 are standard for most gynecologists, but before prescribing hormones, McWherter also orders vaginal sonograms which are "much more accurate" in detecting tumors, he said. "If a woman has a uterus, she has to have a sonogram." And "a doctor must give a complete physical," before starting a woman on hormones, he emphasized.During an interview in her office this spring, Vliet dismissed the importance of physicals, which she doesn't give. Nor does she offer pap smears, mammograms or sonograms as part of a patient's work-up. "We're not just walking vaginas," she said. "I've had women tell me that their doctors say their vaginas are 'well estrogenized' when I'm finding hormone levels very low in these same women. Fifteen years ago, doctors were telling my patients, 'you're crazy.'"Little has changed, she said, in doctors' attitudes towards female hormonal problems. Vliet's local office and clinic is located in a one-story brick office complex just off of the Airport Freeway in Bedford, close to a large number of pricy apartment complexes. It houses Vliet's office, her nurse's office with a bone density machine along one wall, a large, well-furnished room for group sessions, and a second office for a doctor who contracts with Vliet. "We are close to the airport," she said, "which makes it convenient for my patients who come from all over the country." How do these women find out about her? "Word of mouth, and my book, of course," she said. She didn't mention that she also has a marketing director.Late one recent afternoon, Vliet is dressed in a dark green suit with a brightly colored scarf at her neck. The softly lit office is furnished in dark woods with thick, expensive carpets underfoot. Posters on the walls read of self-help and "empowerment." She has positioned herself in the center of the room with the light at her back. Questions she doesn't want to answer, such as "how much does your program cost," are dismissed with wide-eyed responses such as, "I really don't keep up with that, you'll have to ask Sheila." (She's referring to Sheila Burston, her office manager, and a patient who formerly worked at All Saints.) Vliet's voice ranges from condescending to kittenish to tough. Burston says the therapy costs $1,300 for the full HER Place package, with "a la carte services" ranging from $295 for a one-time, new-patient visit with Vliet -- talk only -- to $500 for a bone density test. Payment is by check, cash or plastic up front. HER Place doesn't take insurance. There are no payment plans.Vliet said she doesn't take insurance because it is a "very serious intrusion into the doctor-patient relationship." Insurance companies can get access to patient records, she said, spreading those records "all over the place ... and I am very picky about my patients' records." Vliet's diagnostic methods rely on expensive and wide-ranging hormone level tests, from one blood sample drawn in her office and sent to a local laboratory, a bone density test performed in her office, along with a woman's detailed health history and a monthly diary of her mood swings and libido to determine a patient's "optimal hormone level needs." She then prescribes replacement hormones to fit the woman, she said, hormones which must be specially compounded.The compounded prescriptions are a separate cost and run as high as $60 for a two-month supply of Estrace, a synthetic estrogen. By contrast, a 60-day supply of .625 Premarin, the most commonly prescribed estrogen derived from pregnant mares' urine, costs $24.99 at Eckerd's. One-milligram Estrace tabs, which are not compounded but taken "off the shelf," run $35. Vliet said that in determining what women need, she also relies on "the old-fashioned wisdom of listening." In that $1,300 package, a woman gets 45 minutes of the psychiatrist's ear. If the patient can't wait the three to four months it usually takes to see Vliet, she can see Dr. Anna Duncan, an osteopathic family practice physician who has a contractural relationship with Vliet.Vliet uses three druggists to compound her medications. One is in Fort Worth: Spence Pharmacy. Owner Maurice Spence said of Vliet, "I think she's on the cutting edge" of hormone therapy. And yes, she's controversial, he said, because "anytime you're trying to declare the world is round instead of flat, you stir controversy." Spence also said that there are only three or four druggists in the area who compound prescriptions. In fact, there are at least 20 in this area. Her therapy -- combinations of estrogen, testosterone, and progesterone custom-designed by Vliet for each woman -- is not all that different than what they have been doing for years, say local OB gyn docs, except that at $1,300, hers costs a lot more money, and comes without benefit of a physical.By comparison, local gynecologists' fees range from $135 to $200 for the first visit, which includes a pap smear, blood tests and urine analysis, colon cancer screening, a detailed history, and a complete physical with pelvic and breast examinations. The more expensive hormone level tests are rarely done.In fact, some of the more expensive hormone level tests that Vliet orders, need to be analyzed from blood drawn over a period of time, say, 10- to 180-minute intervals, because "hormone levels undergo such rapid and large oscillations," said a local hospital laboratory supervisor who asked not to be named. "That means the woman either has to be in the hospital or someplace like a feritlity clinic, where there's a staff trained to draw the blood. We seldom if ever do these tests ... they're rare, and usually done for infertility." It would be hard, she said, to tailor-make hormones from a shot-in-the-dark blood test. Several doctors here were quick to acknowledge, however, that what Vliet preaches about hormonal connections in many female diseases, along with the refrain that male docs don't listen to their female patients, is often on target. Gynecologist Hugh Lefler would even like to join her in a research effort."I've referred patients to her," Lefler said, "I think she has an inquisitive mind about what's going on" in hormone therapy. "But you can't simply rely on the numbers (from hormone level tests), you have to treat the symptoms," Lefler said, indicating that's where he parts company with Vliet. "A lot of concerned gynecologists are put on guard by her ... she's challenging the conventional wisdom." For her part, Vliet accuses some breast cancer researchers of putting out "misinformation." In public forums and in her book, Vliet dismisses the growing body of research that points to estrogen's contribution to breast cancer as politically motivated "fear tactics," fueled by the media which only see women as a market for "beauty, sex, or breast cancer." In her book, Vliet cites unattributed "data," which she says show that "women on estrogen at the time of breast cancer diagnosis have a better survival rate than women not on estrogen." As for cancer screening, a staffer at HER Place said, "If women have their latest pap smears or mammogram results, they can bring them in, but we don't require (a patient) to get a pap or mammogram or sonogram before treatment."Some warn that her clinical protocol is not sound practice, especially for women at risk for breast cancer. Dr. Bruce Carr, professor of OB gyn at Southwestern Medical School in Dallas, said, "A mammogram is the most important test" a woman should have before receiving hormones. "We're proponents of HRT (hormone replacement therapy.) And based on all the studies, the only risk is breast cancer," which is why, Carr said, "a mammogram is definitely required."Dr. James Watts, a Fort Worth gynecologist since 1968 is one of the local doctors concerned about Vliet's methods. "Some things you can find only through a physical. It's imperative to know what's going on with the ovaries (by feeling.) If you can't feel an ovary, then it's normal." Watts said that Vliet's hormone therapy pretty much parallels his own, with hers having an added emphasis on testosterone. As for the tests, "I'd love to do all of those, but I can't afford it ... you can generally balance (hormones) without the expensive lab work ... so much of hormone replacement is a matter of on-going history with your patient." There's nothing mysterious or magical about hormone replacement, Watts said, it's simply logical. "Women live longer now, and we're just replacing what is missing so that the quality of life continues," he said.The criticisms of the Fort Worth physicians seem to throw Vliet over the edge. In a recent interview from her car phone in Tucson, she suddenly cut it off before any of the questions raised about her therapy were answered, saying "this is potentially pretty sticky ... if this article is negative, I will take actions" against "FW Weekly," then she dissolved into tears. "I have been maligned by Fort Worth's medical community," Vliet sobbed, refusing to name names. "You don't know what a hard row I've had...."Vliet's first clinic at All Saints was the result of a joint effort by a hospital staff physician, Dr. George Kimbell, a number of leading community women such as travel consultant Carol Minker, and Vliet to establish a women's center that would focus on hormone replacement therapy for women "from 25 to 65" with hormonal, menstrual and menopausal problems. She was brought here after Minker heard one of Vliet's lectures at Canyon Ranch spa in Arizona in 1992. Minker began to "talk her up here," she said, "and the rest is history." From the beginning, the relationship was rocky, sources say, with questions raised about Vliet's long absences, her staff's slow response to telephone inquires, and the four-month wait for women to see Vliet. And there were the two women seen by the local gynecologist with severe bleeding.By the following October, Vliet's relationship with All Saints ended. The hospital announced that HER Place was moving out of All Saints "due to a rapidly changing healthcare marketplace" and "diminishing reimbursements for hospital services." While neither the hospital nor Vliet will talk about the split, people close to both say that Vliet's cavalier attitude toward the local medical community and her long absences from the clinic contributed to the hospital's decision to pull the plug. Burston, Vliet's office manager, said, "They (All Saints) only gave us a week's notice ... it was awful." Ann Watkins was one of the women whose calls weren't returned at All Saints. At a recent Vliet book signing in Hurst, Watkins said she suffers from fibromyalgia syndrome, a chronic aching pain in the muscles and tissues of the body. After reading Vliet's book, which claims rapid improvement in the syndrome after hormone replacement therapy, Watkins became excited, she said, only to be disappointed. "When she was at All Saints, I left my name four times," Watkins said. "I couldn't get anyone to answer my calls."Becca Norman, marketing director for HER Place, blamed All Saints. "It's one of the reasons we left," Norman said. "The phone systems were bad. There was no way to handle the volume of calls we were getting." Vliet appears uncomfortable with any criticism of All Saints. "Don't write what Becca said," she asked a reporter. "(All Saints) made a decision to down-size ... it was very far-sighted of All Saints to bring the program here in the first place."But there was another issue, one that the lone African-American female on Vliet's HER Place advisory board raised again and again, to no avail. Roy Laverne Brooks said Vliet and her supporters excluded a large portion of the community in the All Saints' program: minority women. Brooks, a longtime political leader here, was an early member of the board. "We're supposed to work as a team," Brooks said in a recent interview, "and this didn't happen. There were no women of color on the (HER Place) staff, and the program was too expensive for minority women" to participate. "This was not geared to the have-nots, and there was no outreach to the minority community. Brooks said she hasn't heard of a board meeting in months.Karen Perkins, director of the Women's Center, is also on the board, but hasn't attended a meeting for a long time, she said. Perkins recalls that there were early discussions to provide scholarships for poor and low-income women, but said she doesn't know if it ever happened. "It hasn't yet," said Minker, who headed up the board and said that there had been a "goal to set up a scholarship fund, but so far there are no sponsors and no one is actively seeking any, " she said. Minker indicated that the advisory board is now one in name only, with no meetings and no plans for any.Still, Vliet, in the interview in her office, talked as if it is a viable group. When asked about her program not being financially within reach of low-income women, Vliet said, "I have a community advisory group, and we are developing a scholarship program ... I've had women of all income groups come in, I want to make this available to all women." Margie Bird would like for Vliet to do just that. She was at the Bedford opening hoping to find a way to get to see Vliet. Bird, a woman in her early 50s, said she has a severe hormone imbalance and has been through about eight doctors over the last two years and is still suffering, she said, from sleeplessness, low libido ("I feel dead inside") and severe depression. "I read her book and said, 'This is me.' I went to her book signing and told her that her staff said there would be a four-month wait to see her, and I begged her to get me in sooner ... what I'm going through is not living."She told me that she would tell her staff to get me in," Bird said, "but no one has returned my calls." Bird's biggest problem is the cost of the treatment, she said, disappointed that the clinic doesn't take insurance. "I told her we aren't rich and this will be hard, but I'm willing to try and raise the money, that's how desperate I am." Unlike Bird, money isn't a problem for G.H., a 58-year-old patient of HER Place, who has been on Vliet's hormone therapy for the past three months and asked to remain anonymous. Because she's already enrolled in the program, she asked for anonymity. "Sure, I can afford it, but I'm not sure yet that what I'm getting is worth it ... I still have what I came in to clear up, which is dry skin and hair loss." She has had the full range of Vliet's therapy, from bone density tests to the extensive blood tests for hormone levels, plunking down her initial $1,300. When she couldn't get an appointment with Vliet "for months" she chose to see Dr. Duncan, who runs a separate Well Woman clinic at HER Place."I like Dr. Duncan, and we're working well together," G.H. said, "but my first hormone level tests came back and we discovered that some of the tests that had been ordered hadn't been done." The retesting has cost G.H. an additional $500.Normally, if requested lab work isn't done, for whatever reason, local labs do not charge the doctor or the patient to redo the tests. G.H.'s bone density tests "showed a greater loss than the one that my primary physician did a few months ago." The difference lay in the way Vliet makes comparisons. Most doctors compare women's bone loss to that of women within their own age groups. Vliet's test compares her patients' bone density -- no matter what their age -- to that of women at 30."That will make a considerable difference," said Watts, who says comparisons of bone loss should be made within age groups. "The aging process, after all, is going on, and we can't deny it, or reverse it," he said with a smile. "A bone density test is a screening tool, a wonderful luxury that I'd like to do for all my patients, but I can't afford it and neither can they."At the Bedford opening, there were no critics to rain on Elizabeth Lee Vliet's parade as she basked in the sun and the almost worshipful praise from her supporters, a mix of well-dressed, upper-middle-class white women and pharmaceutical company reps. "She saved my life," gushed a female friend from Virginia. "What she does takes courage and guts," said the owner of Spence Pharmacy, which had underwritten the expensive food catered from the Restaurant at Botanic Gardens in Fort Worth. (The pharmacy's name was plastered all over the clinic as a "Platinum Sponsor" of the day's event.) Even the real rain, which poured suddenly from a dark sky with gale-force winds and lightning, sending well wishers scurrying for shelter, waited until Granger had cut the ribbon. The Republican congresswoman from District 12 made a few perfunctory remarks about how the opening of the clinic shows Vliet's "concern as a woman, for mid-life women," and then patted herself on the back for continuing to be a "proponent for women's health and women's issues" in congress.As Granger hurriedly left that June day, she was asked why Vliet left All Saints. "I have no idea," she said. "Truly, I don't know." Is she a patient? "No," Granger said, and then she was gone. Announcing the positive results of the Nurses' Study to cheers and applause, with no mention of its cautions regarding breast cancer, Vliet threw her arms into the air and shouted, "I have been validated." Then the rains came.In the meantime, Margie Bird still waits for HER Place to call. "I'm really disappointed. Why do they say they're concerned about women like me, and not return my calls?"Bird's husband thinks he has the answer. "He said that because Vliet doesn't take insurance, 'she's just interested in the rich and the wealthy.'"