Pause for Concern

In July 2002, the Women's Heath Initiative (WHI) of the National Institutes of Health announced an abrupt end to its study of so-called Hormone "Replacement Therapy" (used to treat symptoms associated with menopause) because the treatment posed risks of cancer and heart disease. Since this was previously considered the gold standard of menopause science, almost 11 million American women -- 46 percent of users -- stopped taking the treatment and sales plummeted. (In France, some gynecologists still prescribing hormones make patients sign waivers of responsibility.) In December 2006, a new survey from the University of Texas M.D. Anderson Cancer Center found that the number of women diagnosed with breast cancer had dropped dramatically between August 2002 and December 2003. Scientists link this welcome news in part to the fact that fewer women were taking synthetic estrogen in that time period.

Estrogen is a carcinogen. Cancer researchers and French gynecologists understand this even as Americans do not, despite the hormone debacle. Synthetic estrogen joins thalidomide (birth deformations), Vioxx (heart attacks), and testosterone (prostate cancer) as one of many "treatments" approved by the FDA, hyped, and prescribed without being adequately tested. In 2005 the International Agency for Research on Cancer moved synthetic estrogen up from "possibly carcinogenic to humans" to the highest risk category, "carcinogenic to humans." How many papers reported this? Only the Herald Sun of Melbourne, Australia. Not a single British or American paper.

Exposure to estrogen -- even to a woman's own natural production of it -- is an important determinant of the risk of cancer. Researchers are now debating whether estrogen carcinogenesis means that estrogen initiates cancer mutations or that its byproducts stimulate the proliferation of existing cancerous cells. According to the New England Journal of Medicine, the answer is both. Others hesitate. At any rate, the mainstream media rarely mention this crucial controversy. The unspoken rule seems to be that the words "estrogen" and "carcinogen" never appear in the same report.

It is hormone treatment, not menopause, that is the public-health issue. Feminists had long sounded warnings: feminist health activist Barbara Seaman called hormone treatment The Greatest Experiment Ever Performed on Women in 2003. A companion experiment may be on midlife men. Big Pharma has lost so many women customers since 2002 that promoting testosterone (and human growth hormone) is next, according to cultural historian John Hoberman in his 2005 book Testosterone Dreams. Men will be at risk unless they understand that the drummed-up "disease" of menopause has created a model for selling hormones to them as well.

Before 2002, Americans could read about volumes about menopause and never discover that women's health advocates thought hormone treatment dangerous. Far from teaching the controversy, the media acted as if it didn't exist. And even since 2002, despite clear evidence of estrogen carcinogenesis, many in the media are in effect promoting the hormone comeback that Big Pharma wants. Estrogen bias drives what we are told about midlife women, what women are told in advance, the language that gets used, and the facts that remain hidden.

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You would never know from reading the commercial press that the end of menstruation is unremarkable to about 90 percent of American women -- the vast majority that never sought help. Even before the 2002 findings, rates of estrogen use varied -- from a low of 8 percent in Massachusetts to 40 percent in California. Most women soon forget menopause.

Despite all this -- the cancer risk posed by hormone treatment, the small percentage of women with problems, the fact that most problems disappear by themselves -- the "Troublesome Menopause" is still the one the media write about. The complaints of 10 percent are exaggerated and problems are made to seem universal. USA Today ran a piece on menopause in 2005 under the headline "Change of Life Remains Hard." Business Week in 2004 suggested that menopause lasts from the early forties until death. In 2006 the Boston Globe reported on a study tying depression to menopause, although two of its authors have financial ties to anti-depressant manufacturers. The term "perimenopause" continues to be used -- invented to construe menstrual problems as actually stemming from early menopause, the term pushes female sickliness down the life course to apply to younger women.

Another worrying tendency is to fault the state-of-the-art WHI study on behalf of those supposedly desperate women with hot flashes. The main thrust -- as in a January 11 article in The Wall Street Journal by Tara Parker-Pope -- is that the WHI overstated the risks and that women are now too frightened of hormone treatments. This is the line that Wyeth, the makers of the hormone treatment on trial, pushed to 500,000 health-care providers the day the report broke in 2002. They convinced 81 percent of gynecologists, according to Sheila and David Rothman in their 2003 book The Pursuit of Perfection, that women's fears were overblown. Parker-Pope said in an interview in 2007 that taking synthetic estrogen poses as much risk as drinking a glass of wine and that there are risks for some women from not taking hormones. This is absurd. Journalists often describe the WHI data as "confusing" or "controversial." The program director for the National Women's Health Network worries that doctors now "find reasons why the [WHI] findings shouldn't apply to their patients."

Complicit with industry, journalists present its newest products -- creams and gels -- as if they were tested breakthroughs, without warnings. In The New York Times in 2003, Gina Kolata faulted Barbara Seaman for holding estrogen critics to a "looser standard" than promoters, as if even-handedness were still obligatory. Innumerable column inches are devoted to touting lower-dose versions of hormone treatments, which has helped to stabilize sales even though a Wyeth spokeswoman admits in WomenseNews, "We do not have data evaluating those particular risks." Far from getting decreased attention, "Menopause," a 2003 Washington Post headline pronounced, "Has Become the New Hot-Button Topic in Women's Health."

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All this ginned-up controversy helps to maintain estrogen nostalgia: the illusion the pharmaceutical companies created long ago that people aging into their middle years could recapture youth in a pill. The promotion of untested products, the deliberate creation of muddle and debate about WHI's test results, the construction of deprived "menopausal women" -- all depend on (and maintain) the Estrogen-Good hypothesis of the infamous 1968 book Feminine Forever, in which Robert Wilson wrote of menopause, "no woman can be sure of escaping the horror of this living decay."

The medicalization of midlife revved up with the diffusion of synthetic estrogen and the belief that menopause was an ovarian "deficiency" disease, something like hypothyroidism. The "medical model" of the life course interprets aging only as a physical and mental decline. Midlife decline ideology is the background for the menoboom.

The menoboom began in the 1990s, shortly after a heavily-lobbied Congress let Big Pharma advertise directly to consumers. Although evidence was absent or misread, doctors prescribed estrogen to prevent heart disease and ward off Alzheimer's. It was prescribed for off-label uses overblown in fashion magazines. Estrogen became a kind of faith. Prescriptions grew from 23 percent of women fifty or older to 34 percent in the 1990s, when estrogen was heavily promoted to women who had no symptoms. The goal of the drug industry, write Sheila and David Rothman, was for women to take synthetic estrogen from the pill to death.

The belief that estrogen is good enabled a century of hormone hype, fueling the belief in midlife decline and the cult of youth that hurts both older women and, increasingly, older men. When the media helps to fuel such notions, the climacteric becomes the centerpiece of an ideology of decline, driving the ever-expansive aging industry. Presentations of midlife women as passive and damaged victims desexualizes women at ages significantly younger than men. Indeed, menopause discourse makes it seem as if only women age. Studies commissioned in 2003 found that a quarter of the women who had stopped using hormones had resumed. If true, that doesn't bode well for the next breast-cancer data from 2004, which will be published in April of this year.

What should happen, now that estrogen is making a comeback and testosterone treatment is being cranked up? Congress should forbid direct-to-consumer advertising. The FDA has to become reliable again. It needs independent scientists influencing it rather than research funded by the pharmaceutical companies. The FDA "mandates" that there be follow-up tests after drug approval, but 65 percent of the 1,231 studies the companies promised to do are still pending years later.

Some midlife women will still want to take estrogen, but now -- if they have responsible doctors -- only for more serious symptoms, at lower doses, for shorter periods, warily. To help women and men make better decisions, the media and the medical community have to get a grip. It is time for estrogen nostalgia to go the way of whalebone corsets and bound feet.

Margaret Morganroth Gullette is the author of Aged by Culture, chosen a Noteworthy Book of the Year by the Christian Science Monitor, and Declining to Decline, which won a prize as the best feminist book on American popular culture. She is a Resident Scholar at the Women's Studies Research Center, Brandeis University.

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