If you are an older woman, modern medicine would have you believe you've basically got two choices: take a drug for an indeterminate amount of time, or turn into a humpbacked, sexless, dottering old prune, whose husband is justified in leaving you and whose bones are likely to crumble to dust.
This Hobson's choice all has to do with the falling off in the production of female hormones, oestrogens and progestogens, which affect all systems of the body but particularly regulate the rhythms of, as American writer Joan Didion once starkly put it, "blood and birth and death" the monthly cycles, pregnancy and birth and the cessation of the reproductive capability.With the onset of menopause, the change in the production of these hormones (which will eventually adjust to a lower level) results in all the familiar symptoms of the menopause: hot flushes, night sweats, vaginal dryness, cervical, vaginal and uterine atrophy and lack of interest in sex. These hormones also affect the density of bones; after menopause, many women experience a thinning of the bones, called osteoporosis, which can eventually result in the dowager's hump of female old age or even potentially fatal fractures of the spine or hips.
Recently, help has supposedly arrived in the form of hormone replacement therapy, medicine's equivalent of the female fountain of youth. HRT employs artificial hormones, oestrogens and more recently progestogens, the same two hormones used in the birth control pill. The idea is to trick the body into thinking it is still pre-menopausal, in order to postpone, reduce or eliminate the symptoms of the change. It is now available in tablets, a cream or a patch, which gets changed about twice a week, the idea of which is to provide a continual "drip feed" of hormone at the site.
Although enthusiastically taken up in the States (the best estimates are that about 50 per cent of all post-menopausal women are on hormones) British women have been more cautious that is, until recently.
Although a survey last year showed that only 5 per cent of British women are taking hormone therapy, numerous recent campaigns by the Amarant Trust, a pro-HRT non profit organization, spearheaded by MP Teresa Gorman, the emergence of menopause clinics, symposiums on osteoporosis, the drug company's disease of choice at the moment and special booklets prepared by the Independent are increasing uptake over here.
Furthermore, the recent attention paid to osteoporosis has got many women worried about the possibility that they will develop it unless they take the drug as a preventative. There has also been a great deal of attention paid to the idea that HRT lowers your chances of dying from cardiovascular disease.
A recent "educational evening on the menopause", sponsored by GP Dr Michael Harris and his partners in Radstock near Bath, was jam packed with 200 of their female patients who came (a drug company, incidentally, paid the cost of mailing out the invitations) to hear that "osteoporosis could be prevented by HRT," said Harris.
Perhaps most worrying is the zeal being attached to the campaign to get British women to swallow this particular new pill by blaming the British GP, who sensibly is unwilling to prescribe. Although touted as an "independent medical charity aiming to provide a better understanding of the menopause", the Amarant Trust unabashedly proselytizes on behalf of the benefits of HRT.
Started up by the ob/gynae department of Kings College School of Medicine, it also appears to be a charitable means of helping Kings College fund further research into the menopause.
The covert message of their newsletter, entitled "Feeling Good" with vibrant looking 50 year olds, is that you will be sexier and more attractive if you take HRT; "The insidious part of HRT is that it changes a woman's character and her personality. . . " they quote a Devon reader saying, delivering a backhanded complement, who warns of the likelihood that a "nice, dignified and respectable person (will) change into a brash, bold, self centred 'trendy'. "
They quote testimonials from women saying they are permanently raunchy, according to an Independent article, or one husband saying "She became nice to come home to again. "
The Independent article also quoted a gynaecologist saying "At a party I can usually spot the women on hormone replacement. They have more sparkle and bounce, which adds up to greater attractiveness."
The problem with the mindset that looks upon HRT as a feminist issue a case of women claiming their rightful due is that in its enthusiasm it tends to overlook or explain away any real medical evidence and there is plenty of it of the risks of this kind of radical treatment over time. Under its front page banner headlines "HRT SAFE TO USE! EXPERTS REASSURE GPs", the Trust explained that it is holding a series of study days to "update" doctors on the menopause and the use of HRT. It also described the first two, in which King's College Hospital doctors the hospital that has lead the pro-HRT crusade and has the most to gain in self justification of further research described that after reviewing 23 papers, published between l974 and l989, the evidence about cancer was "inconclusive".
Most particularly they were attacking a Swedish study, published in l989, which followed 23,000 women over time and claimed that HRT doubles a woman's chances of getting breast cancer. They tended to rely on an earlier, "highly regarded" American study which showed that risk for users up to l0 years was not significantly increased.
This no increased risk stance tends to be fairly standard at the burgeoning number of menopause clinics popping up around the country. At the Oxford Menopause Clinic, a highly defensive "Miss Reese" who refused to divulge the rest of her name would say only that "blanket statements cannot be made" about cancer risk and that "The potential for cancer depends on whether the hormones are opposed or unopposed" ie, whether the therapy employs oestrogen alone or oestrogen and protestogen. They also claimed the Swedish study is "inconclusive".
With so many people interpreting the study results, we decided to have a look at some of the largest published studies ourselves, to see what the authors themselves had to say. Here is what they and a few lone voices warn about the use of this sort of powerful therapy simply as a "feel good" measure.
At least three major studies show that the risk of breast cancer doubles with the use of HRT after six years. According to the Swedish study, 23,244 Swedish women using oestrogen for non contraceptive purposes were followed for six years. After six years on estradiol, the most common oestrogen, the incidence of breast cancer nearly doubled. In a l987 study published in the British Journal of Obstetrics and Gynaecology, , 4544 British women were followed for an average of five and a half years. The study found that breast cancer risk was more than l and a half times increased. Dr Klim McPherson, a university lecturer at the Department of Community Medicine at Radcliffe University, one of the authors of the study, also said that a third, about to be published study, which followed these same British women, shows that long term use of HRT increases your chances of developing cancer by 50 per cent.
Even the study quoted by the Amarant Trust carried out in the States and published in the British Journal of Cancer, claiming that the risk only increases after many years (to 30 per cent after l5 years) nevertheless cautions: "Given the extensive population exposure to menopausal oestrogens and the frequency of breast cancer in the general population, even a slight excess risk association with hormone use is cause for concern. For instance, if the relationship is causal, a 50 per cent elevation in risk among oestrogen users of l5 or more years would result in an approximate cumulative absolute excess risk of 2 per cent for women aged 65-79."
Three of the studies show that "opposed" oestrogen use does not protect against cancer, and many even increase your chances of developing it. Because oestrogen stimulates cells in the breast and womb to develop, it was thought that you could keep the risk of breast cancer in check by adding progestogens, which then put a rapid halt to all this extra cell growth. Most combinations of the Pill, are combinations of the two hormones. But the Swedish study shows, to the general surprise that, far from protecting against breast cancer, the addition of progestogen actually quadruples the risk after four years! This supports the hypothesis of Malcolm Pike that the cycling of hormones would only give the breast cells even more stimulus to grow and eventually become malignant.
Evidence shows that both "opposed" and "unopposed" HRT combinations increase the incidence of endometrial cancer. In the British study published in the British Journal of Obstetrics and Gynaecology, the risk of endometrial cancer nearly trebled. "Many of the women concerned had taken therapy which was predominantly or entirely opposed although only one woman had received an opposed regimen which would now be considered adequately protective to the endometrium," the study concluded. For unopposed oestrogens, that risk increases five times to from 4.5 to l3.9 times that of women not taking medication. In the American Physician's Desk Reference, where drug companies are required by law to state risks of their drugs, Wyeth-Ayerst, manufacturers of best selling Premarin, announces in a special box:
"OESTROGENS HAVE BEEN REPORTED TO INCREASE THE RISK OF ENDOMETRIAL CARCINOMA. Three independent, case controlled studies have reported an increased risk of endometrial cancer in post-menopausal woman exposed to exogenous oestrogens for more than one year. This risk was independent of the other known risk factors for endometrial cancer. These studies are further supported by the finding that incidence rates of endometrial cancer have increased sharply since l969 in eight different areas of the United States with population based cancer reporting system, an increase which may be related to the rapidly expanding use of oestrogens during the last decade. "
Widespread use of oestrogens appears to be responsible for a massive increase in endometrial cancer in the US. According to Ellen Grant, author of The Bitter Pill and a lone voice in Britain decrying the use of oestrogens for contraceptive or menopausal purposes, American women have about 40 per cent more breast cancer and, among those aged 50 to 60, three times more endometrial cancer than those women in England and Wales. The peak of endometrial cancer in American went up to l30 women per l00,000 per year, compared to 30 per l00,000 women in Britain. This disparity can be expected to shrink once HRT becomes widely accepted here. Furthermore, the risk of developing one of a number of cancers increases if a woman on HRT has also taken oestrogens before, for birth control, endometriosis, lactation suppression or to regulate periods.
Opposed HRT therapy also carries the same risks of blood clots and strokes carried by the Pill. Because opposed therapies contain combinations of oestrogens and progestogens which make up the Pill, not surprisingly many of their side effects are similar to that of oral contraceptives. These include, to quote Wyeth-Ayerst again, gallbladder disease (two to three times increase); stroke, pulmonary embolism, thrombophlebitis and heart attack, high blood pressure, liver damage, and a decreased ability to tolerate glucose, possibly bringing on latent diabetes. As the America's Health Research Group points out, some research has suggested that oestrogen protects women from heart attacks and problems of blood vessels. "There is cause for concern, however, because oestrogen in birth control pills used by younger women has been shown to increase the risk of heart and blood vessel disease." This is doubly true of women who smoke. HRT causes, as Ellen Grant puts it, "medical castration" in young women and a false sense of youth in older women. It is commonly assumed that HRT causes a woman to continue to have menstrual periods. In fact, with both young and older women, periods stop on oestrogen progestogen therapy. "Two days after the pills are stopped the fall in artificial hormone levels induces withdrawal bleeding," writes Ellen Grant.
Far from preventing osteoporosis, there is some evidence that HRT may precipitate it. Dr Kitty Little, formerly of the Nuffield Orthopaedic Centre at Oxford, has done extensive published studies on the effect of the Pill on bone. In laboratories studies on rabbits, she was able to remove practically all bone (well over 50 per cent) by administering oestrogen and cortisols, administered to represent the effect of daily stress. She also saw evidence in one study that a group of women in their 20s and 30s taking the Pill had as little bone density as those in their 70s. "There's a direct action of corticosteroids on removing bone that includes all but one of the main progestogen compounds," she said. "And if you alternate it with oestrogen there is more bone loss than with oestrogen alone."
Mounting evidence shows that combined hormones affect the way the body uses important vitamins and minerals. According to research by Dr Stephen Davies, published in Nutritional Medicine, the Pill adversely affects absorption of vitamin B, K and E, causes more vitamin A to circulate in the body, creates an increased need for vitamin C, and may have something to do with deficiencies of zinc, magnesium and iron.
With all these serious questions surrounding use of oestrogens, WDDTY cautions all GPs and women to continue to look at them with a jaundiced eye. In the view of Ellen Grant and other doctors working with nutritional therapies, a good vitamin and mineral regime will work wonders in overcoming problems of the menopause and keep you young looking and healthy.