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‘She does not get bored and unattractive’: The charming story of menopause and HRT | New Zealand

For centuries, the symptoms of menopause were documented, but women went through it with little intervention. It was not until the advent of science as we know it that doctors (all men at the time apparently) began to more commonly "treat" its symptoms. It is clear now that they had no idea what they were dealing with as the treatments ranged from benign (cupping, cold water) to direct mutilation (clitoridectomy, anyone?).

Suffice it to say, the story of misogyny in medicine goes far, far back; all based on the idea of ​​women as inferior and of menstrual blood as evil and toxic. Fast forward to the beginning of the 20th century, when it was discovered that estrogen in the form of conjugated equine estrogen - yes, from horses - could be used as hormone therapy for the symptoms of menopause. In 1942, the first estrogen product was marketed under the name Premarin.

Premarin was marketed as not only a "cure" for menopause (which by this time had begun to be framed as a disease to be treated), but as a source of youth. And it was promoted in ways that in our modern eyes are quite sexist. Today's commercials talk about women's misery and fear. An ad I found spells it: "[A woman] will probably feel that her charm is gone and the golden days of her femininity are irrevocably over ”.

There were also ads targeting men who were obviously the real victims here. "Men like Premarin, too," said a 1950s ad. The hormone pills, the men assure, make a woman "comfortable to live with again". A particular low point was the 1966 release of Feminine Forever by Robert A Wilson, an American gynecologist. In the bestseller book, he called menopause "a serious, painful and often paralyzing disease". Even more alarming: "All postmenopausal women are castrated." Charming.

But no worries - everything could be solved. HRT meant that a woman's "breasts and genitals will not shrink. She will be much more comfortable to live with and will not become dull and unattractive." These misogynistic allegations did the trick: the pharmaceutical companies that manufacture HRT - one of which, it was later revealed, had paid Wilson for his inconvenience - gained great value from their stealth salesman. book.

One of the most prescribed drugs in the United States

From the 40s until the mid-1970s, menopausal estrogen was given to women alone. But in 1975, evidence began to emerge that without another hormone - a progestogen - "reverse" estrogen therapy led to an increased risk of endometrial cancer.

Sales of Premarin declined until it was found that adding progestogen to a lower dose of estrogen reduced this risk. The result was combined estrogen-progestogen therapy, marketed as Prempro.

Sales of HRT picked up speed again along with aggressive marketing. This was helped by popular culture that promoted the idea of ​​menopause as a terrible recurring disease that needed to be treated. In the early 90's, Premarin was one of the most prescribed drugs in the United States.

Evidence during the first decades of its use supported HRT as an effective therapy, not only for the symptoms of menopause, but also as a preventive treatment for some chronic diseases. Studies have shown that it is beneficial for bone and heart health. In 1988, it was approved by the U.S. Food and Drug Administration as a preventative treatment for osteoporosis. There was new evidence about the possible benefit of HRT in preventing heart disease, and therefore in 1991 a major study was started that changed the course of how HRT would be perceived in the next 30 years.

A 'huge bear service' for women

The Women's Health Initiative (WHI) trial was the largest randomized study to date on HRT, and it would be a game changer. Unfortunately not in the good way. It was, according to endocrinologist Megan Ogilvie, "one of the worst things that has happened to women's health in a long time. It did an entire generation of women, and probably two generations of women, a huge disservice."

The reasons for this are many. WHI was created to find the effect of HRT (along with other, non-HRT-related interventions) on the most common causes of death and disability in postmenopausal women: things like cardiovascular disease, cancer, and osteoporosis. It is important to note that this study was not about testing the effectiveness of HRT in treating actual menopausal symptoms. What the researchers wanted to know was whether HRT could be used in other ways - to prevent other diseases that happened to women after menopause.

New Zealand author Niki Bezzant.
New Zealand author Niki Bezzant. Photo: Reuben Looi

In 2002, a shocking message came from the researchers who ran the WHI study: The HRT part of the study was stopped early after only five years.

In these initial experimental results, the researchers had observed that there was an increased incidence of coronary heart disease and breast cancer in women with a uterus that took combined HRT. Incidentally, there was also some good news: a reduction in osteoporotic fractures and in the incidence of colon cancer. Still, they concluded that the risks outweighed the benefits, and the trial was discontinued prematurely.

At the time, this was big news. The media published stories with sensational headlines, and the message women - and doctors - took from them was that HRT was dangerous.

The effect was large-scale cessation of HRT. Women threw out their pills, and doctors - recently afraid of prescribing something that could do more harm than good - stopped prescribing HRT. The drug companies were also appalled - not least because they, predictably, began to be sued.

There is nothing like a lawsuit to make a drug company wary of developing new drugs in the same area. Predictably, funding for and interest in research and development for HRT and women's health declined in mid-life in general.

'Panders to women's biggest fears'

However, the results of the WHI survey were misreported - even by the people who wrote the first results paper.

This emerged as a bit of a scandal in a 2017 paper written by one of the WHI study's authors, Professor Robert D Langer. In it, he revealed that "highly unusual circumstances prevailed" when the WHI trial was stopped prematurely.

He went on to detail how he and other researchers were "appalled" at what they read in the newspaper that had been submitted in their names to the Journal of the American Medical Association, which they first saw for the first time when the newspaper was about ca. to be published. Although they tried to submit edits to correct the misinterpretations and reformulate the press release, it was too late. The newspaper was published, the press conference held, and the rest is history.

"That headline," Langer wrote, "panning to women's greatest fear — the fear of breast cancer — ensured that word of the study would spread like wildfire, and it ensured that the conversation would be driven much more by emotion and politics than by science. "

The WHI report meant that many doctors were too scared to continue prescribing HRT to any woman. Now they told the women that you are basically alone. The state health authorities did not help; they issued new advice to doctors to prescribe HRT only to the most severely affected women and then in the lowest possible dose in the shortest possible time.

Printing rates dropped worldwide. What this also meant was that doctors stopped learning much about menopause and its potential treatments.

"One of the things the WHI report did is that it allowed menopause education to be removed from medical schools," Ogilvie notes. "And it lost us funding on a lot of different HRT products."

Cover of This Changes Everything by Niki Bezzant.
This Changes Everything by Niki Bezzant. Photo: Penguin Random House

Even now, there is limited teaching about menopause for trainees and general practitioners, unless they seek it out or are particularly interested. It's really sad because it can lead to women suffering unnecessarily. As Langer noted in his 2017 paper, "the 'facts' that most women and clinicians consider when deciding whether or not to use HRT are often wrong or misused."

This is an edited excerpt from This Changes Everything: The Honest Guide to Menopause and Perimenopause by Niki Bezzant (Penguin, NZ $ 37)

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