The Women’s Health Inititative: A Discussion (2002)

ERT: If it’s so great, why aren’t we all on it? or From non-compliance to new understanding (1997)

ERT: If it’s so great, why aren’t we all on it? Part II (1997)

Women's health concerns through the eyes of a midlife feminist (2000)

Medicalized Menopause: Critique and Consequences (2001)

This article was published in the Network News (Jan/Feb 1997), a publication from the National Women's Health Network. (With permission)

ERT: If It's So Great, Why Aren't We All On It? or, From Non-Compliance to New Understanding.

Members of the Network Board of Directors organized a panel discussion of ERT at the annual meeting of the American Public Health Association. Held in New York on November 18, the discussion was attended by over 150 people. The Network's goal was to spark discussion about the reasons why most clinicians routinely recommend long-term ERT/HRT and yet the majority of older women are not taking hormones. This article includes excerpts from the presentations on breast cancer and osteoporosis. Presentations on heart disease and Alzheimer's will be published in our next issue.

Convincing Evidence that Estrogen Increases the Risk of Breast Cancer
Network Board members were joined by Carol Rinzler, author of Estrogen and Breast Cancer (see Network News Jan/Feb 1994). Carol spoke not only about the evidence linking estrogen to breast cancer, but also about the medical community's unusually high degree of resistance to acknowledging the connection. Carol is a medical writer who has written over a dozen books. In her words, she's never written a bestseller, but no publisher has ever refused to work with her twice. Estrogen and Breast Cancer was originally published in 1993 and reissued in paperback in 1996. It received very little attention from the mainstream media, even though the book was well-documented and included an introduction by Graham A. Colditz, a prinicipal researcher at the long running Nurses Health Study. In retrospect, Carol attributes this lack of attention to her book to a larger phenomenon of looking at estrogen through rose-colored glasses.
Estrogen was first shown to be associated with breast cancer in women almost exactly 100 years ago when it was reported that tumor growth could be slowed by removing the ovaries of women with breast cancer. In the first half of this century, laboratory studies repeatedly demonstrated that estrogen increased the occurrence of breast, endometrial and ovarian cancer in animals. But at the same time, physicians began to prescribe estrogen to women as a cure for a variety of ills, ignoring the suggestive evidence of harm. The medical enthusiasm for estrogen reached its first apogee in the era of 'Feminine Forever', written by an industry-supported physician who recommended estrogen for breast "development", teenage acne, contraception, and lactation suppression as well as menopause. While proponents of long-term use of ERT now claim that their recommendations are based on science, too many ignore or dismiss the risk of breast cancer associated with estrogen use. Carol noted that while all of the ERT/breast cancer studies are observational (that is, women were not randomized to either ERT/HRT or a placebo) and thus cannot be considered completely conclusive, it is striking that the studies which have found an association between estrogen and breast cancer consistently find an increased risk of about 30-40%.

ERT for Osteoporosis: Necessary for Whom?
Nancy Worcester's talk about osteoporosis and ERT emphasized the issues or over-medication and over-prescribing often raised by health feminists. The mass-marketing of products (particularly ERT) to "prevent" osteoporosis has deliberately played on women's fears of aging and disability: menopause itself gets associated with our fear of dying from broken bones and ERT is simplistically offered as "the answer".
In contrast, Worcester urged that each stage of this continuum needs to be examined and challenged: menopause-lower estrogen-osteoporosis-fractures-death.
For example, the pattern of starting ERT during the peri-menopause to prevent the stage of faster bone loss and continuing it for at least 10 years to delay bone loss is exactly the pattern we know to be most associated with increased breast cancer. We know that weight bearing exercise and a good diet (which contains sufficient vitamins and minerals and minimizes calcium wasters) can play important roles in preventing osteoporosis (or making it appropriate to give lower doses of ERT) and that the very definition of osteoporosis (which compares the density of bone of older women to young adults) must be questioned. The fact that low bone density does not predict fractures while others such as advanced age, poor muscle strength, use of certain medications (tranquilizers, barbiturates, thyroid therapy and other ) and impaired vision are actually stronger predictors* for hip fractures than bone density means that more attention needs to be paid to other fracture prevention strategies.
Nancy also questioned who gets to make decisions about the use of ERT. Nancy's students of color have helped her recognize that while it may be appropriate to critique the over-prescription of ERT to white women, many women of color are not even being given the opportunity to choose whether or not to take ERT. With very few exceptions, osteoporosis is currently presented as a white woman's disease. (Although osteoporosis is much more common in women than men, osteoporosis also is a big problem for men in this country compared to men in other parts of the world.) Women of color, (especially African-American women) are usually not depicted in osteoporosis educational materials; statistics are often available only for white women, and osteoporosis studies may not include women of color and give inappropriate explanations such as "Black women are excluded from this study because of their lower risk of hip fracture." However, research conducted before osteoporosis was a high profile, high profit disease documented that the risk of osteoporosis increased with age in exactly the same manner for African American and white women but that African American women had stronger bones to start with and thus ended up with lower risks. The fact that mid-life and older health issues for African American women get so little attention is particularly problematic considering that mortality rate from hip fractures is higher in African American than white women.

*"Osteoporosis: Common Test Can't Predict Hip Fractures" in HEALTH FACTS, Vol XXI, No 206, July, 1996, p 1, 4-5.




The article below was published in the Network News (Sept/Oct 1997), a publication from the National Women's Health Network. (With permission)

ERT: If It's So Great, Why Aren't We All On It? Part II

by Jane Sprague Zones and Susan Rennie

This article includes excerpts from presentations on heart disease and Alzheimer's which were part of a panel discussion of ERT organized by the Network. Part I was published in Network News Jan/Feb 1997.

Will ERT save our minds?
Headlines in recent months have proclaimed "The Brainiest Reason to Consider Estrogen" or "Estrogen Aids Brain." Although most menopausal and post-menopausal women have resisted the nearly universal urging of the medical community to start taking estrogen replacement therapy (ERT) in middle age, a new and seductive benefit - that ERT delays or lowers the risk of memory loss - has increased its allure among women who have previously considered ERTs risks and benefits and decided against its use. We know we can take active steps to reduce our chances of developing osteoporosis and heart disease by diet, exercise, and other means, but no one seems to know when and why some people lose their memory and others do not.

Memory and Dementia
Recently, estrogen "deficiency" has been associated with memory loss, and dementia (especially the type of dementia known as Alzheimer's Disease (AD). Biological theories about estrogen's effects on the brain include increasing blood flow and nerve cell growth. Few studies have considered the effect of progesterone, which may counteract estrogen's action in the brain. Research on the relationship between ERT and cognitive functioning (including AD), reports inconsistent findings. A research team at the University of Washington found no differences in ERT use in a study of 107 women with AD and 120 age-matched, randomly selected female controls from a managed care organization. However, they did find that while 61% of controls had more than a high school education, only 35% of the AD cases were in the higher education category.
On the other hand, Annlia Paganini-Hill and her colleagues, who conduct continuing studies at Leisure World, an upper middle class retirement community in Southern California, compared 138 women who had died of AD and other dementias with four times as many age-match female controls who had died of other causes. They found that their risk of dementia (including AD) for ERT users was only about 65% of those who had never used ERT. Interestingly, however, there was a much higher rate of ERT use in 33 cases whose death certificates indicated they died of senility.
A more recent study which found a benefit for estrogen users was reported last year in The Lancet. A group of researchers at Columbia University studied 1124 elderly women initially free of AD taking part in a longitudinal study of aging and health. In their initial survey, subjects reported on their use of estrogen and age at menopause. They were followed up 1 to 5 years later. Those who developed AD were an average of five years older than
those who did not, and had an average of three fewer years of education. Duration of ERT use was related to a lower risk of developing AD.

Problems with current research
The failure to control for socio-economic status (SES) in the conduct of this research is its greatest shortcoming. Lower SES is associated with higher rates of AD. It is also associated with lower prescriptions for ERT. ERT is a daily or almost daily drug which women are being encouraged to take for several decades of life at and after menopause, costing thousands of dollars per woman over her lifetime. To the extent that researchers do not control for social status in their studies, they may be observing a false relationship between ERT and AD, in that those who were more likely to get AD anyway were also those least likely to use ERT because of access and expense. It is possible that environmental or other factors related to social class may be at play in the development of AD.
Age is a similar confounding factor. People are more likely to develop AD as they grown older, and older women are less likely to take ER than middle-aged women.
Research in this field is heavily subsidized by grants from pharmaceutical companies with vested interest in hormones sales. Paganini-Hill's research, for example, which lends the strongest published support to the connection between ERT and lowered risk for dementia, is sponsored in part by Wyeth-Ayerst, makers of Premarin, the most commonly used estrogen product at Leisure World (the research site), and the top selling prescription drug in the U.S. And the new Women's Health Initiative satellite study on ERT/HRT and Alzheimer's is completely funded by Wyeth-Ayerst.

Alternative Explanations
Environmental and social factors need to be explored as they affect the development of AD, dementia, and cognitive functioning. A September 1996 study reported that the risk of AD is nearly twice as high for men of Japanese heritage in Hawaii compared to Japanese men living in Japan. The risk of Japanese in Hawaii approached the prevalence of Americans of European ancestry. And a group of French Canadian researchers found a significant excess of AD cases in those born in a rural area compared with an urban-born population.
We need to examine the effects of ageism upon cognitive function. Levy and Langer studied short-term memory and attitudes toward aging in older (50-90) and younger (15-30) people from mainland China, deaf Americans, and hearing Americans. Memory loss was greatest in the older Americans with hearing impairment. Among the mainland Chinese, the elders performed very similarly to the young adults. For all of the older groups, performance on short-term memory tests was directly related to attitudes toward aging. The authors surmise that the ways we buy into the expectation of loss of functioning with with age are possibly self-fulfilling.

Conclusion
Sandra Coney, author of The Menopause Industry, argues that the attention on improved benefits of ERT is part of the rehabilitation of ERT, which suffered sales losses in the 1970s when it was found to increase cancer risk. Finding that ERT prevents Alzheimer's disease would expand the market for this very lucrative product. The ERT-AD connection is also an extension of a 30-year effort to focus attention on AD that has been conducted by NIH scientists in conjunction with a consumer movement largely created and choreographed by these scientists. What we are witnessing now is a redefinition of Alzheimer's Disease as a female disorder, when in fact there is no convincing evidence that women are more likely to develop AD than men. In a fashion similar to osteoporosis, women's fears about risk have been heightened by exaggerated claims of incidence which increase demand for potential remedies.
The research is not conclusive on the relationship between ERT and mental function. What research exists is very much influenced by profit motives. We may need to wait for the conclusion of the Women' Health Initiative - and hope that its independent oversight committed does its job! - to get more valid outcomes. Finally, it is possible that environmental and cultural factors play important roles in our cognitive functioning as we age, and more attention should be paid to these factors.

ERT, heart disease, and non-compliance
Many women who talk to their clinicians about ERT or HRT are told that the most important reason to take hormone "replacement" therapy is the prevention of heart disease. Heart disease, the leading cause of death for American women of all racial and ethnic groups, is responsible for over thirty percent of all deaths. The majority of studies of ERT and heart disease have shown a substantial reduction in risk. And yet, the majority of postmenopausal women are not on long-term hormone therapy. The apparent contradiction has led to tremendous frustration on the part of some physicians who believe that ERT/HRT is a good preventive medicine. These physicians often talk and write about ways to deal with what they consider to be the problem of non-compliance: a phrase more typically used to describe patients who cannot or will no follow instructions for adequate treatment of a medical problem.
It is important to take another look at "non-compliance," first by carefully reviewing the evidence on ERT/HRT and heart disease. There is no evidence from large, long-term randomized studies that estrogen prevents heart disease. The evidence doesn't exist because the studies addressing this aren't finished - in fact they only started a few years ago. After years of pressure by the Network, the federal government finally started the Women's Health Initiative in 1993 which will eventually enroll 25,000 women in a 9 year study of ERT vs HRT vs. placebo. This lack of information from randomized controlled trials is very important because it is the standard to which treatments are usually held before being considered effective. All cholesterol-lowering drugs have gone through randomized trials before approval, and even aspirin, which is available over-the-counter, was tested in a lengthy randomized trial to determine whether or not it could prevent heart attacks. It is true that there are several observational trials which have found 30-50% less heart disease in women who use ERT, but these trials aren't able to control for other differences between users and non-users, and there is good reason to think that to some extent, rather than ERT preventing heart disease, women who are less likely to develop heart disease are more likely to choose ERT. We need to question why physicians who looked for evidence from randomized trails before they recommended heart disease prevention drugs to men were willing to accept a lower standard of proof for estrogen and heart disease in women.
Many physicians downplay the risk of breast cancer, often talking about it only in terms of women's "fear" of breast cancer as if that fear were completely irrational. Actually, the evidence linking estrogen to breast cancer is consistent - the more estrogen a woman is exposed to, the more likely she is to develop breast cancer. Estrogen probably doesn't cause cancer, but seems to act as a promoter. While studies which compare women who have never used ERT to women who ever used ERT often find no increased risk of breast cancer, studies which look at long-term and current use consistently find an increased risk of about 30%. The level of evidence for ERT and breast cancer is about the same as the evidence for ERT and heart disease - probable, but not completely proven, and the strength of the effect can't be pinned down until randomized trials are completed.
Some physicians try to address women's concerns about ERT and breast cancer not by downplaying the risk but by trying to persuade women that it is worth trading an increased risk of breast cancer for a decreased risk of heart disease, because heart disease is so much more common. Some physicians ignore a statistic that women seem to know - although breast cancer may be less likely to kill you than heart disease, when it does, it robs women of many more years than heart disease. Women who die of heart disease lose an average of eight years of life. Women who die of breast cancer lose 19 years. Another way of putting that same statistic is that, at least according to the experience of women in the Nurses Health Study, up to age 71, there are three times as many cases of breast cancer as heart attacks.
Women are faced with trying to balance probably risks which occur at a younger age versus probably benefits which occur at an older age. Many women, reasonably enough, chose to forgo ERT and use health-enhancing heart disease prevention strategies such as exercise and changes in their diet. Is this non-compliance or a positive, non-pharmaceutical approach to aging healthfully?

A longer version of Jane Zones' article on ERT & Alzheimers is available from the Network Clearinghouse, as are "Taking Hormones and Women's Health ($8.00) and packets on Menopause, ERT/HRT and Alternative Treatments ($6.00 each). (202) 628-7814. The National Women's Health Network is one of the few women's health organizations that do not take money from pharmaceutical companies.

Note: Since this article was published, there has been a randomized clinical trial on hormones and heart disease in women who already had confirmed heart disease: the HERS trial. Unlike the observational studies showing a beneficial effect for hormone users, the results from HERS showed no benefit.

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The following article appeared in the Millennium Issue of "Off Our Backs", January, 2000 (Notes and references have been added.):

There is a long legacy of attributing ill health and even characteristics considered undesirable for women to our reproductive organs and hormones. The term “hysterical” originally came from the belief that behavior considered inappropriate for a woman was somehow due her uterus, and many women in the 19th century had hysterectomies in attempts to treat a wide variety of problems. The removal of both ovaries was considered an acceptable treatment for nymphomania and other behaviors thought to be undesirable for women. In fact, a woman's natural state was considered innately flawed and rest cures were advised. (1) The vast majority of physicians were men. The small percentage of women who did enter medical schools were taught male perspectives of health and illness.

Medical researchers defined men as the norm for humans. Studies on women were limited to the ways we differed from them: our reproductive organs and hormones. Pregnancy and childbirth were medicalized. Conditions which occurred in both sexes were studied almost exclusively in men. Heart disease, especially, was considered a "man's disease" and it was rare for women to be included in heart disease research. For those women who did develop heart disease, it was assumed that the results of male-only studies could be extrapolated to them. (2) Information on medical research and treatment was seldom shared with us. We were simply told to seek medical advice and be compliant.

In the early '60's, when I had my babies, I knew that something was terribly wrong with the way I and other women were treated during and after the birthing process, but I had no voice. We were shaved, given enemas, heavily medicated, and it was not uncommon for our water bags to be broken and our labors induced. We were separated from those who could comfort us (at that time, our partners were not allowed in the delivery room), our arms were tied down, our legs placed in stirrups, and our perineums cut. After we gave birth, our newborns were taken from us; we were not allowed even to touch them for the first 12-24 hours. We were taught that, without medical intervention, the natural process of birth could jeopardize our health and harm our newborns. (3)

The more things change ...

Then just about 30 years ago, women began to organize. Due to the demands from women in the childbirth movement, some changes were initiated. Women were no longer shaved, nor were their arms tied down. Our partners (and later other members of our families) were allowed to be with us while we gave birth, and policies which hindered breast feeding were changed. (4)

The Boston Women's Health Collective provided us with accurate information about our bodies in an easily accessible and respectful way. They encouraged us to question our doctors rather than meekly accept what we were told. We began to realize that we had the right to make choices about our bodies and the care we received. The title of their best selling book changed over the years, expressing the Collective's evolving perspective. It is now titled The New Our Bodies, Ourselves and continues to be widely read. Policies in hospitals and at doctors' offices were changed to incorporate the demands of women. (5)

The Federation of Feminist Women's Health Centers opened up health clinics staffed by lay women with a focus on self-help. They urged us to examine our own bodies including our cervixes. Prevention was emphasized rather than treatment of disease. Their major goal was to help us reduce our dependency on medical professionals. Their book, A New View of a Women's Body, is still considered revolutionary. (6)

In 1972, due to the efforts of many women, Title IX, the law which made sex discrimination in education illegal, was passed. Women began entering medical, law, and graduate schools in large numbers, and some were eager to make changes within the system. They joined women outside the system and, working together, many more successes were achieved.

The definition of male as the norm for humans was challenged. A major investigation was launched and gender biases were uncovered. Use of federal funds for medical research in which women were excluded or grossly underrepresented was documented. As a result of this investigation, policies were changed. The National Institutes of Health mandated equitable distribution of research funds for women and minority men in all of its sponsored clinical research. (7)

Today, almost half of medical school admissions are women and a higher percentage of women are becoming gynecologists than men. Medical research has greatly increased for women and more attention is paid to prevention. It is no longer assumed that the results of male-only studies can be extrapolated to women. The demands of the women's health movement for inclusion in medical research and for more information, more choices, and more control of our health seemed finally to be moving toward reality.

... the more they stay the same.

The long legacy of attributing ill health to our reproductive organs and hormones remains. As a midlife woman, I am experiencing some of the same kinds of frustrations that I did as a woman giving birth. Once again, I find myself regarded by the medical profession as a patient in need of treatment. I have been encouraged to view the end of my reproductive years as a negative change that, if left untreated, will jeopardize my health. (8)

Heart disease is now considered a "woman's disease", supposedly due to our "failed" ovaries. (9) "Estrogen deficiency" has become the most investigated risk factor for women for heart disease, osteoporosis, and now, Alzheimer's disease. As midlife women, we are urged to take hormones to reduce our risks and help us live longer. Since midlife men are not seen as governed by their hormones, they are encouraged to make lifestyle changes to reduce their risks. (10)

Women's health clinics have opened up in many parts of the country, but rather than being staffed by lay women, they are staffed by women gynecologists, internists, and nurses, most of whom have accepted the deficiency notion of menopause. We are encouraged to submit to a wide variety of tests to monitor our bodies for beginning signs of disease and deterioration due to our so-called deficient status. The emphasis on prevention, rather than decreasing our dependency on medical professionals, has increased it. Women's health has become big business. (11)

There is no lack of information or advice on menopause. We are informed of our so-called deficiencies in newspapers and women's magazines, on television and radio, in prestigious medical journals, and, of course at our doctors' offices. Special seminars have been set up especially for women in hospitals and community centers to remind us of our deficiencies and our need for treatment. (12)

We now have a dizzying array of choices to treat our so-called deficiencies: pills, patches, creams, vaginal rings or suppositories of estrogen, progestins, and even testosterone. And if we don't like these hormones, new ones are being designed just for us. The selective estrogen receptor modulators (the SERMs) act like an estrogen in some of our body parts and like an anti-estrogen in others. (13) All we have to do to "take control" of our health and retain our youth is to choose how we want our "deficiencies" treated. Of course, we are told we can choose not to take hormones and end up asexual, crippled, diseased, demented, dead, or simply old. It is easy to see why the current discourse on menopause has been referred to as a form of cultural terrorism. (14)

Once again, our bodies are seen as innately flawed. The notion of innate flaws has historically been used to justify inequality between the sexes and among racial/ethnic groups. (15) While our demands for inclusion of women in medical research have been met, the research has primarily been used to reinforce the notion of our innate flaws, our need for medical intervention - and to justify inequality. The information we seek is steeped in gender and cultural biases, much of it based on research funded by pharmaceutical companies. (16) Research both within and across nations that does not support the deficiency notion of menopause is ignored. The fact that many studies show a health-enhancing diet and increased exercise are both more efficacious and associated with far less risk than taking hormones is being withheld from us. (17) Environmental and socioeconomic determinants of health are typically ignored. (18) The adverse effects of hormones, especially the increased risk of breast cancer, are trivialized. (19)

Choice, a concept so important to the women's health movement, has become an illusion. Large numbers of healthy midlife and older women, feminists included, believing their ovaries have failed them, are "choosing" to take long-term hormones in order not to jeopardize their health. The women's health movement has been co-opted!

(1) Classic books for a history of medical care of women are: Barbara Ehrenreich and Deirdre English, For Her Own Good: 150 Years of the Experts' Advice to women. (New York: Anchor, 1978), and Barker-Benfield GJ, The horrors of the half-known life. (New York: Harper Colophon books, 1976). Also see Gena Corea,The Hidden Malpractice: How American Medicine Mistreats Women. (updated ed, New York: Harper Colophon Books, 1985), and L. Doyal,What makes women sick: Gender and the Political Economy of Health. (Rutgers University Press. New Brunswick, New Jersey. 1995). The Yellow Wallpaper is a fictionalized account of Charlotte Perkins Gilman's own experience with the "rest cure".

(2) Examples of large studies on heart disease which excluded women: the Multiple Risk Factor Intervention Trial (MRFIT) which included 316,099 white men in the observational study (JAMA 1982; 248: 1465-77)) and 12,866 in the randomized clinical trial (Arch Intern Med 1992; 152: 56-64). The Physicians Health Study (popularly referred to as the "Aspirin Study") included 22,071 men, almost all white (N Engl J Med 1989; 321: 129-35), and the Seven Countries Study which included 12,467 men (JAMA 1995; 274: 131-136). See Rebecca Dresser, Wanted: Single, White Male for Research. (Hastings Center Rep. Jan/Feb 1992; 24-29) for a critique of this.

(3) Joseph Lee is considered the infamous father of medicalized childbirth in the United States. He advocated the routine use of heavy sedation, episiotomy, forceps delivery, and manual removal of the placenta. Most of these interventions became the standard of practice in the early 1920s. For good histories of the medicalization of childbrith see: Judith Walzer Leavitt, Brought to Bed: Childbearing in America 1750-1950. New York, 1986. Also Richard Wertz and Dorothy Wertz. Lying-In: A History of Childbirth in America. rev. ed. New Haven: 1989. A series entitled "Cruelty on the Maternity Wards" which gave the experiences of childbirth from women's points of view was published in 1958, in the Ladies Home Journal.

(4) Seven women met in 1956 with the aim of supporting others who chose to breastfeed. They formed the La Leche League, one of the first major groups to challenge the authority of medical professionals. It took about 20 years for doctors to catch on. One of the leaders wittily stated, "A fanatic is a breastfeeding mother who for twenty years and against great odds has been doing and believing what physicians have only now discovered is a scientific truth." (The Womanly Art of Breastfeeding, 4th edition, p xvi) See also Margot Edwards and Mary Waldorf, Reclaiming Birth: History and heroines of American childbirth reform. See pp 4-5 for information on Joseph Lee. Anything by Sheila Kitzinger. She's great!

(5) Actually the title of the latest book is Our Bodies, Ourselves for the New Century, 1998. Sorry about that. This book has a good history of women's health as well as up-to-date information on women's health concerns. A good book with great articles on political aspects is Women's Health: Readings on social, economic, and political issues, 3rd edition by Nancy Worcester and Mariamme Whatley, Kendall/ Hunt. Dubuque. 2000.

(6) This book has amazing actual photographs of vulvas and cervixes taken by Suzann Gage. These are far, far better than can be found in any medical textbook. It also includes a section on menstrual extraction, a simple, very early abortion procedure developed by the Los Angeles group to be used by lay women. A great book like this, unfortunately, is difficult to find and some women told me that they could not get it through the new mega bookstores. Check with your local independent bookstore. I ordered several for my friends and students through Women & Children First in Chicago (773-769-9299). It was first published by Simon and Schuster in 1981 but it is now printed by the Feminist Health Press. Its ISBN is 0-9629945-0-2.

(7) The report of the Council on Ethical and Judicial Affairs, in which gender disparities in clinical decision making were found was published in JAMA, July 24/31, 1991. Some of the recommendations of this report included: research into the possible causes of gender disparities, greater awareness of sociocultural influences on medical decision making, and "... increasing the number of female physicians in leadership roles and other positions of authority in teaching, research, and the practice of medicine".

(8) In the latest edition of Mishell's textbook of infertilty, contraception and reproduction. (Ed) Rogerio Lobo, 1997, the chapter on menopause was moved from normal to abnormal endocrinology. In the Br Med J. 1996; 313: 351-2, Philip Toozs-Hobson and Linda Cardozo write: "Some women believe that menopause is a natural event and that taking medication (hormones) should be avoided. These women are wrong: oestrogen deficiency is the unnatural state." Saul Lerner uses an immunization analogy to explain his position and argues: "So I am putting my patients on hormones not because I consider the women as having an illness, but rather because I hope to prevent future problems." (Annals NY Acad Science 1990; 592: 192) For critiques of the medicalization of menopause, see: R Klein and L Dumble, Disempowering midlife women: The science and politics of hormone replacement therapy (HRT), Women's Studies International Forum 1994; 327-43. Kathleen MacPherson. "Osteoporosis: The new flaw in woman or in science?' Health Values. 1987; 11: 57-61, and Ingar Palmlund, The social construction of menopause as risk. Journal of Psychosomatic Obstetrics and Gynaecology 1997; 18, Issue 2.

(9) There are actually no studies showing any connection whatsoever between endogenous estrogen levels and heart disease. In fact, published research which has directly investigated this relationship shows no correlation. See Brit Med J. 1995; 311: 1193-96 for an example of one of these studies. Contact me if you need more.

(10) Cardiovascular research: Estrogen key player in heart disease among women. (Science 1995; 269: 771-73) Also in the Harvard Guide to Women's health. Harvard University Press, Cambridge 1996. "New evidence that physical changes after menopause significantly increase a woman's risk of developing debilitating, life-threatening, and costly diseases, particularly heart disease and bone fractures from osteoporosis, has put menopause in a whole new light." It was disappointing for me to read in a book written by the American Medical Women's Association, Women's Complete Healthbook, 1995. uncritical support for the purported menopause-heart disease link.

(11) For an interesting article on the differences between the grass-roots women's health movement and the newer professional women's health groups see (J American Medical Women's Assoc 1/30/98).

In 1996, the U.S. Preventive Services Task Force indicated that osteoporosis screening has insufficient evidence of effectiveness for recommendation. In 1998, the National Osteoporoisis Foundation guidelines state that women 65 years and older who are willing to consider treatment for osteoporosis should have a measurement of bone density to determine whether they would benefit from treatment. Yet, physicians, especially obstetricians, are encouraging women around the time of menopause to be tested for osteoporosis. In a randomized trial of women within three years of their menopause, it was found that a bone mineral density test tripled the likelihood that an estrogen prescription would be filled regardless of the result of the test, compared to women not tested. (Obstet Gynecol 1997; 89: 321-5) The authors concluded that bone density tests "can be a valuable tool in encouraging the use of HRT in those women who are undecided about therapy." This study, as are many of the studies supporting the use of hormones, was funded by a grant from a pharmaceutical company.

A woman who has not had her uterus removed (in the US, about 1/3 of women have) is encouraged to undergo endometrial biopies to monitor the effects of estrogen on the lining of the uterus (the endometrium). Although adding a progestin greatly reduces this negative effect of estrogen, the risk is still generally higher than for women who do not use hormones. For example, women who take a progestin for less than 10 days each month or for those who have taken progestin for 5 or more years (even if they took progestin for more than 10 days a month) have more than double the risk of endometrial cancer compared to hormone non-users. (Lancet 1997; 349: 458-61)

(12) A strategy of Yecies Associates, the marketing firm for Premarin, is to target "large corporations with mixed gender emphasis, alumni associations, and women's organizations." (Menopause: Taking the cures or curing the takes? in Mother Time, p156) Not only are the majority of studies on menopause funded by the pharmaceutical companies, many of the seminars for physicians and the supplements in the major gynecology journals are as well. Ads for hormones are used to support women's magazines and professionals journals and therein lies a serious conflict of interest. During the period whenMs magazine accepted advertising revenue, they did not publish anti-smoking articles, even though lung cancer had become the #1 cause of cancer death in women in 1987 and remains so today. Now that they have an ad-free format, they are without constraint to publish what they think is best for women. In addition, the authors of articles about menopause and hormones in women's magazines get most of their information from medical professionals who support the medicalized view of menopause. Also see Sandra Coney. The menopause industry: How the medical establishment exploits women.. Penguin Books. 1991.

(13) Premarin is the leading estrogen prescribed in the U.S. Some women feel well on Premarin but there are many who do not. For women who cannot (or will not) tolerate its side effects and its long term adverse effects, other preparations are prescribed. Testosterone is mainly added to increase libido. According to a recent study by the Pharmaceutical Research and Manufactures of America, 372 new medicines are being developed to "treat" menopause. (cited in Generations Sp 98) For an article in which the selective estrogen receptor modulators, the SERMS, are being referred to as a possible panacea for women see Am J Obstet Gynecol 1999; 180: 763-70.

(14) Margaret Morganroth Gullette is the first person I know who used the term "cultural terroism" to describe the discourse on menopause. It can be found in the chapter of her book, Declining to Decline, entitled "Menopause as magic marker." p108, 1997. See also Nancy Worcester and Mariamme Whatley. The selling of HRT: Playing on the fear factor. Feminist Review 1992; 41: 1-26.

(15) Stephen J. Gould's classic,The Mismeasure of Man, was recently updated. WW Norton, 1996. Carol Tavris, The Mismeasure of Woman. Simon & Schuster, New York, 1992. Both are great books.

(16) Ingar Palmlund. The marketing of estrogens for menopausal and postmenopausal women. J Psychosom Obstet Gynecol 1997; 18: 158-164.
Dukes MNG. The menopause and the pharmaceutical industry. J Psychosom Obstet Gynecol 1997; 18: 181-188.

(17) For heart disease - There are plenty of studies showing regular moderate exercise (N Engl J Med 8/26,/99) eating a Mediterranean diet (JAMA 7/12/95), adding soy products to your diet (Int J Gynaeol Obstet 1999; 67: 39-40) and taking Vitamin B6 and Folate supplements (JAMA 2/3/98) can lower the risks of heart disease. Also the statins, a new group of cholesterol lowering drugs, have shown to be effective as a heart disease prevention strategy in women (and men) with high choleterol levels. It is important to know that the studies on estrogen have not been rigorous enough to show that it actually causes a reduction in heart disease. (See HERS for a discussion of this.) This is why estrogen has never been approved by the FDA for heart disease prevention and therefore it cannot claim to do so in any advertisements. It is only because of the power of marketing techniques that most people, including medical professionals, are not aware of this. In contrast, foods containing soluble fiber such as oatmeal and soy products have been approved by the FDA as heart disease prevention strategies, as have the statins, and therefore they are allowed to be advertised as such. The American Heart Association and the College of Cardiology no longer recommend estrogen as a first line heart disease prevention strategy. (Circulation 1999; 99: 2480-84)

Osteoprosis - Again, there are plenty of studies showing regular moderate exercise (Epidemiology 1991; 2: 16-25), eating bone-enhancing foods, adding soy products to your diet, and taking calcium and a Vitamin D supplement (if your diet is low in these nutrients) all help to reduce risk of osteoporosis. While estrogen has been approved by the FDA as an osteoporosis prevention strategy, this does not mean that it is best way to reduce one's risk. In fact a major study comparing all methods found that calcium and vitamin D were both more efficacious and cost-effective than hormone use and therefore should be the first choice for women at risk for osteoporosis. (American Family Physicians 1999; 60: 194-202). In addition, bone tissue becomes less sensitive to estrogen with time. In a major study of women 75 years and older, there was little difference in bone density in long-term estrogen users compared to non users (N Engl J Med 1993; 1192-93). In the US, the median age of hip fractures is 80. If bone mineral density is the major factor in hip fracture risk, long term estrogen would be of little help to women at the age when they are at greatest risk. See also Healthful living

(18) Samuel Epstein is a good source of information on environmenatal causes of cancer. The Politics of Cancer Revisited, East Ridge Press, 1998.

A major study found that after controlling for smoking, drinking, diet, and exercise, the death rate for the US poor, those with incomes less than $10,000 a year, were more than twice that of those with incomes of $30,000 or more. (N Engl J Med 1993; 329: 103-9) Women 65 years of age and older are almost twice as likely to live in poverty than men. Moreover, the interaction between race and sex amplifies these disparities. Black women are more than 5 times more likely to live in poverty than white men. (Poverty in the United States: 1997. Current population reports; Series P60-201. GPO 1998); Nancy Krieger and colleagues article on racism, sexism, and social class (Am Journal of Prev Med 1993; 9 (6 Suppl) 82-122).

(19) Susan Love, the well-known breast cancer specialist wrote that the research she did for her book (Dr. Susan Love's hormone book: Making informed choices about menopause. New York: Random House 1997) has strengthened her decision not to take hormones. Also see: Relationship between estrogen levels, use of hormone replacement therapy, and breast cancer. J Natl Cancer Inst 1998; 90: 814-23.

If there are any more references you need or if you youself have references that you feel would benefit women who are reclaiming menopause, please contact me by e-mail at women@inorm.org

I presented this paper at the 128th annual meeting of the American Public Health Association. (Boston, MA, November 14, 2000). It is part of a much larger paper (with the same title) that was published in the International Journal of Health Sciences. It can be downloaded here.

Medicalization refers to changing a process or a condition considered normal into one requiring medical intervention. Midlife and older women are being told that the normal process of menopause is actually a hormone deficiency condition requiring replacement hormones to maintain health and increase longevity. This deficiency notion originated primarily in the United States as has much of the research supporting it, and is being actively promoted in many countries throughout the world.

The three major diseases that are being linked with the lower estrogen levels of midlife and older women are heart disease, osteoporosis and, most recently, Alzheimer's disease. Primary prevention of these diseases is the rationale used for urging healthy women to take long term hormones (1). Although there have been many challenges to these links and warnings against the widespread use of hormones (2), these challenges and warnings have either been ignored or trivialized.

The adverse consequences of constructing menopause as a deficiency condition on the health and well-being of midlife and older women are enormous. Rather than addressing these adverse consequences, however, the emphasis in the medical literature continues to be on the unsubstantiated adverse consequences of the menopause itself. I have identified six major consequences of medicalizing menopause.

1. Medicalizing menopause has led to different and unequal approaches to disease prevention for women and men. Chronic diseases in men are generally attributed to genetic factors, a faulty life style, or simply the physiological processes associated with aging. Women, on the other hand, are being told that their "failed ovaries" put them at risk. These assumptions shape the research questions. For example, the HERS trial (Heart and Estrogen/progestin Replacement Study) (3) is said to be the female counterpart to MRFIT (Multiple Risk Factors Inventory Trial (4). Both are randomized clinical trials designed to study the effects of intervention on risk for heart disease. However, MRFIT, as the name implies, studied the effects of multiple risk factors such as smoking cessation, diet, and exercise in men while HERS only studied the effects of hormone use in women. So-called estrogen deficiency has, in fact, become the most investigated risk factor for women.

Yet, there is overwhelming evidence from studies across and within nations that non-hormonal factors have a far greater impact on health and longevity on women than the purported efits of hormone use. Midlife U.S. white women have almost 7 times greater rate of heart disease mortality than Japanese women (5) and a more than 7 times greater risk of experiencing a hip fracture than Beijing women. African women have significantly lower rates of hip fractures than African American women, even allowing for the possibility of substantial under reporting (6). Yet, Japanese, Chinese, and African women have very low rates of hormone use while U.S. women have the highest rate in the world (7).

In the US, as well as in other countries, a health enhancing diet and adequate exercise have consistently been found to decrease the risk of chronic diseases such as heart disease and osteoporosis and improve the overall quality of life for both women and men. In fact, diet and exercise have been shown to be both more efficacious and with far less risk than estrogen use (8). In the on-going Nurses' Health Study, the longest and largest prospective study of women in the United States, women who adhered to low-risk patterns reduced their risk of heart disease by 82% (9). Yet proponents of medicalized menopause construct risk/benefit analyses which emphasize estrogen use and discount lifestyle factors (10). Different and unequal approaches to disease prevention harms women.

2. Medicalizing menopause allows for the widespread acceptance of hormone use as a prevention strategy with a lower standard of proof than other prevention strategies. Most drug interventions require proof of efficacy from large scale, long-term, randomized clinical trials (considered the "gold standard" in medical research) before they are widely used (11). There has been no such proof for hormone use. In fact, the first two trial measuring the effects of hormones on women with established heart disease, the HERS trial, and the Estrogen Replacement and Atherosclerosis trial showed no benefit. The preliminary results of the Hormone Replacement Therapy trial of the Women's Health Initiative was released April 4th 2000. This trial only included women without established heart disease. Surprisingly, these preliminary results showed that women who took hormones experienced a small but significant increased risk of heart disease (12). Yet hormones continue to be recommended for prevention.

For osteoporosis prevention, estrogen has not shown to be more efficacious than diet, dietary supplements, and exercise. And in women 75 and older, the group most likely to experience an osteoporotic fracture, long term hormones provided very little benefit (13). There have been no large scale randomized clinical trials showing that hormones reduce fractures in older women.

Prevention of Alzheimer's disease is seen as one more possible efit of estrogen use. Yet, the Nurses Health Study, the largest observational study to date examining the relationship of hormone use and heart disease, either current nor long-term hormone users, ages 70-78, performed better on an assortment of tests of reasoning and recall or on overall cognitive functioning than never users (14). The longest and largest randomized trial for secondary prevention also showed no benefit (15). There have yet been no results of randomized trials of hormone use for primary prevention of Alzheimer's disease.

Rather than not allowing wide spread use of a drug unless a randomized clinical trial shows a beneficial effect, as is the usual protocol, proponents of medicalized menopause continue to urge the widespread use of hormones for primary prevention even though the few randomized clinical trials examining the effects of hormones on disease prevention have showed no benefit. Allowing a lower standard of proof for hormone use than for other prevention strategies harms women.

3. Medicalizing menopause encourages healthy midlife and older women to accept an increased risk of breast cancer and other adverse effects in the hope that the use of hormones will decrease the risk of other diseases. Graham Colditz's review of the literature found evidence for a causal relationship between female hormones and breast cancer based on the following criteria: consistency, dose-response pattern, biological plausibility, temporality, strength of association, and coherence. In the Nurses Health Study, it was found that after 5 years, the risk of breast cancer increased 32% with the use of exogenous estrogen, and 41% with combined estrogen and progestin compared to never-users. For women in the 60-64 age group, the oldest age group studied, the increased risk was 71% for 5 or more years. The death rates for breast cancer, moreover, paralleled the incidents rates, countering the argument that the breast cancer which develops in hormone users is somehow less serious than cancer in non hormone users. A meta-analysis from 51 epidemiological studies which included 90% of published research world-wide, confirms the magnitude of the increased risk with long-term use (16).

here are studies which show little or no increase in breast cancer but they are primarily small scale, short term, or studies which compare women who used estrogen for an indeterminate time (ever-users), to women who never used estrogen. Short term studies, of course, cannot measure long term effects. Most women who have used estrogen, have done so only for the short term, typically less than one year and therefore the effects of long term use (more than 5 years) cannot be evaluated from these studies. Yet, these studies are used to argue that the evidence for a hormone-breast cancer link is inconclusive.

The overwhelming weight of the evidence supports an increased risk of breast cancer and this is the major risk included in virtually all risk-efit analyses. The assumption has been that for most women, the increased risk of breast cancer is worth the purported benefit of a reduction in heart disease. Yet, as noted above, the best available evidence is that hormones do not reduce heart disease. Other serious adverse effects of hormones include an increased risk of blood clotting, endometrial cancer, and gallbladder disease (17). If menopause was not seen as a deficiency condition, giving healthy midlife and older women drugs with such serious adverse effects would be as unacceptable as giving such drugs to healthy midlife and older men. Discounting serious adverse effects of hormone use harms women.

4. Medicalized menopause results in further medicalization of women's lives. The adverse effects of estrogen use are frequently countered with other drugs, also with adverse effects. For example, it is common practice to prescribe a progestin to a woman who has not had a hysterectomy to counter the increased risk of endometrial cancer from unopposed estrogen. Cyclical progestins typically bring on monthly bleeding and, as stated above, an even greater increase risk of breast cancer than with estrogen alone. Moreover, recent data suggest that progestins' protective effect on the endometrium diminishes in long term users since the relative risk of endometrial cancer more than doubles in women who take cyclical progestin with estrogen for longer than 5 years (17).

Women who take exogenous estrogen have lower androgen levels compared to age-matched women who do not take estrogen, creating a rationale for adding an androgen to the mix. Androgens, however, have been found to decrease HDL-C and increase LDL-C, reversing major purported efits of estrogen on the risk of heart disease. Additional adverse effects include virilization and hepatic toxicity. Increased medicalization harms women (18).

5. Constructing menopause as the major factor in women's health diverts attention away from other factors relating to health such as environmental factors, socioeconomic status, and violence against women. In one study, physicians policies and attitudes were examined. Among eight preventive services respondents were asked to rank, gynecologists ranked hormone therapy second only to mammography for women over 50. Smoking cessation was ranked 4th (19).

The importance of non-hormonal factors in the etiology of disease can be found in migration studies. For example, in a population-based case-control study of breast cancer in Chinese, Japanese and Filipino women who migrated to the United States, it was found that migrants who lived in the West for a decade or longer had a risk 80% higher than more recent migrants (20) Ethnic-specific incidence rates of breast cancer in the migrating population were clearly elevated above those in the countries of origin while rates of those born in the West approximated the US white rates.

Environmental factors which contribute to poor health are grossly understudied. The National Cancer Institute continues to focus on the molecular biology and genetic factors associated with breast cancer in spite of pressure from women' groups to focus on environmental determinants (21). It is very likely that lifestyle and environmental factors operate interactively to increase risk of disease.

Racism, sexism, and poverty clearly contribute to poor health. A recent US government study found that after controlling for smoking, drinking, diet, and exercise, the death rate for the US poor, those with incomes less than $10,000 a year were 2.8 times higher than those with incomes of $30,000 or more. Women 65 years of age and older are almost twice as likely to live in poverty than men. Moreover, the interaction between race and sex amplifies these disparities. Black women are more than 5 times more likely to live in poverty than white men. Recent decades have shown an increasing disparity in death rates according to socioeconomic status (22).

According to a comprehensive review of worldwide domestic violence studies, at least one in every three women has been beaten, coerced into sex, or otherwise abused in her lifetime. The somatic consequences of this violence is enormous but has only recently been recognized as a major health concern of women (23). Focusing on hormones and diverting attention away from the ill health and reduced quality of life caused by environmental factors, poverty, and gender violence harms women.

6. Medicalizing menopause almost certainly harms women psychologically and socially as well (24). If all women are considered to be estrogen deficient around midlife and require replacement hormones to maintain health, this is equivalent to saying that our bodies are flawed. The notion of innate flaws has historically been used to justify inequality between the sexes and among racial/ethic groups. The impact of medicalizing menopause on the collective well-being of all women has yet to be explored.

1. Just a few of the many books and articles urging women to take long term hormones. Note: The last two are recent text books:

Wilson, R.A., and Wilson, T.A. The fate of the nontreated postmenopausal woman: a plea for the maintenance of adequate estrogen from puberty to the grave. J. Am. Geriatr. Soc. 11: 347-362, 1963.

Rhoades, F.P. Minimizing the menopause. J. Am. Geriatr. Soc. 15: 346-354, 1967.

Utian, W.H. The fate of the untreated menopause. Obstet. Gynecol. Clin. North Am. 14: 1-14, 1987.

Toozs-Hobson, R. and Cardoza, L. Hormone replacement therapy for all? Universal prescription is desirable. Br. Med. J. 313: 350, 1996.

Shoupe, D., Brenner, P.F., Mishell, D.R. Menopause. Mishell's Textbook of Infertility, Contraception and Reproduction. edited by Rogerio Lobo, Blackwell Science, Malden, Maryland, USA, 1997.

Speroff, L., Glass, R.H., and Kase, N.G. Postmenopausal hormone therapy. Clinical Gynecologic Endocrinology and Infertility. Ed. 6, Lippincott, Williams & Wilkins, Maryland, USA, 1999.

2. Some challenges to medicalized menopause:

Kathleen MacPherson. Menopause as disease: The social construction of a metaphor. Advances in Nursing Science. 3: 95-113, 1981.

Nancy Worcester and Marianne Whatley, The selling of HRT: Playing on the fear factor. Feminist Review 41: 1-26, 1992,

Lynn Rosenberg, Hormone Replacement Therapy: the need for reconsideration. Am. J. Public Health 83: 1670-1673, 1993.

Jacque Rossouw, Estrogens for prevention of coronary heart disease. putting the breaks on the bandwagon. Circulation 94: 3355-3361, 1996.

Ingar Palmlund, I. The social construction of menopause at risk. J. Psychosom. Obstet. Gynaecol. 18: 87-94, 1997.

Rueda Martinez de Santos, J.R. Medicalization of menopause and public health. J. Psycosom. Obstet. Gynecol. 18: 173-180, 1997.

3. The HERS trial.

Hulley, S., et. al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. J.A.M.A. 280: 605-613, 1998.

4. MRFIT

Multiple risk factor intervention trial: Risk factor changes and mortality results. J.A.M.A. 248: 1465-1477, 1982.

5. World Health Organization gives mortality statistics for most diseases in most countries of the world.

World Health Organization, 1995, World Health Statistics Annual, Geneva, 1996.

6. Hip fracture rates in selected countries.

Xu, L., et al. Very low rates of hip fractures in Beijing, People's Republic of China. Am. J. Epidemiol. 144: 901-907, 1996.

Slemenda CW, Johnston CC. Epidemiology of osteoporosis. In Treatment of the Postmenopausal Woman: Basic and Clinical Aspects, edited by R.A. Lobo, Raven Press, Ltd., New York, 1994.

Falch, J.A., Meyer, H.E. Osteoporosis and fractures in Norway. Occurrence and risk fractures. [in Norwegian] Tidsskr. Nor. Laegeforen 118: 568-572, 1998

Kellie, S.E., and Brody, J.A. Sex-specific and race-specific hip fracture rates. Am. J. Public Health 80: 326-328, 1990.

Elffors. L., et al. The variable incidence of hip fractures in Southern Europe. The MEDOS study. Osteoporos. Int. 4:253-263, 1994.

7. Hormone use in selected countries.

Jolleys, J.V. A comparative study of prescribing of hormone replacement therapy in USA and Europe. Maturitas 23: 47-53, 1996.

Nagata, C., Matsushita, Y., and Shimizu, H. Prevalence of hormone replacement therapy and user's characteristics: A community survey in Japan. Maturitas 25: 201-207, 1996.

8. The many ways women can reduce risk of osteoporosis and heart disease.

Ilich, J.Z., Badenhop, N.E., and Matkovic, V. Primary prevention of osteoporosis: Pediatric approach to disease of the elderly. Women's Health Issues 6: 194-203, 1996.

Cummings, S.R., et al. Risk factors for hip fractures in white women. N. Engl. J. Med. 332: 767-773, 1995.

Dawson-Hughes, B., et al. Effects of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N. Engl. J. Med. 337; 670-676, 1997.

Coupland, C.A., et al. Habitual physical activity and bone mineral density in postmenopausal women in England. Int. J. Epidemiol. 28: 241-246, 1999.
101.

Ullom-Minnich, P. Prevention of osteoporosis and fractures. Am. Fam. Physician 60: 194-202, 1999.

Kass-Annese, B. Alternative therapies for menopause. Clin. Obstet. Gynecol. 43: 162-183, 2000.

Chiechi, L.M. Dietary phytoestrogens in the prevention of long-term postmenopausal diseases. Int. J. Gynaecol. Obstet. 67: 39-40, 1999.

Knopp, R.H., et al. Long-term blood cholesterol-lowering effects of a dietary fiber supplement. Am. J. Prev. Med. 17: 18-23, 1999.

Paradis, G., and Fodor, J.G. Diet and the prevention of cardiovascular diseases. Can. J. Cardiol. 15 Suppl G: 81G-8G, 1999.

Warner, J.G. Jr, et al. Long-term (5-year) changes in HDL cholesterol in cardiac rehabilitation patients. Do sex differences exist? Circulation 92: 773-777, 1995.

9. Nurses' Health studying showing a 82% lower risk of heart disease.

Stampfer M.J. , et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N. Engl. J. Med. 343: 16-22, 2000.

10. Risk/benefit analysis which focus on hormones and ignore lifestyle factors.

American College of Physicians. Guidelines for counseling postmenopausal women about preventive hormone therapy. Ann. Intern. Med. 117: 1038-1041, 1992.

Col, N.F., et al. Individualizing therapy to prevent long-term consequences of estrogen deficiency in postmenopausal women. Arch. Intern. Med. 159: 1458-1466, 1999.

Panico, S., et al. Large-scale hormone replacement therapy and life expectancy: Results from an international comparison among European and North American populations. Am. J. Public Health. 90: 1397-402, 2000.

11. Need to consider the "gold standard"

Goldman, L., and Tosteson, A.N.A. Uncertainty about postmenopausal estrogen: time for action, not debate. N. Engl. J. Med. 325: 800-801, 1991.

12. Discussion of the three recent studies showing hormones do not benefit women's risk of heart disease can be found on this site.

13. Studies showing hormones offer very little benefit to older women.

Felson, D.T., et al. The effect of postmenopausal estrogen therapy on bone density in elderly women. N. Engl. J. Med. 329: 1141-1146, 1993.

Paganini-Hill, A., et al. Exercise and other factors in the prevention of hip fracture: The Leisure World Study. Epidemiology 2: 16-25, 1991.

14. NHS showing no benefit of hormones on cognitive functioning.

Grodstein, F., et. al. Postmenopausal hormone therapy and cognitive function in healthy older women. J. Am. Geriatr. Soc. 48: 746-752, 2000.

15. Longest and largest randomized trial on Hormones and women with AD showing no benefit.

Mulnard, R.A., et al. Estrogen replacement therapy for treatment of mild to moderate Alzheimer's disease: A randomized controlled trial. Alzheimer's disease cooperative study. J.A.M.A. 283:1007-1015, 2000.

16. Studies showing an increase risk of breast cancer with hormone use.

Colditz, G.A. Relationship between estrogen levels, use of hormone replacement therapy, and breast cancer. J. Natl. Cancer Inst. 90: 814-823, 1998.

Colditz, G.A., et al. The use of estrogens and progestins and the risk of breast cancer in postmenopausal women. N. Engl. J. Med. 332: 1589-1593, 1995.

Collaborative Group on Hormonal Factor in Breast Cancer. Breast cancer and hormone replacement therapy: Collaborative reanalysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet 350: 1047-1059, 1997.

17. Increased risk of endometrial cancer

Beresford, S.A.A., et al. Risk of endometrial cancer in relation to use of oestrogen combined with cyclic progestagen therapy in postmenopausal women. Lancet 349: 458-461, 1997.

18. About adding androgens to the mix

Casson, P.R., et al. Effect of postmenopausal estrogen replacement on circulating androgens. Obstet. Gynecol. 90: 995-998, 1997.

LaRosa, J.C. Androgens and women's health: Genetic and epidemiologic aspects of lipid metabolism. Am. J. Med. 98: (Suppl 1A) 22S-26S, 1995.

Urman, B., Pride, S.M., and Yuen, B.H. Elevated serum testosterone, hirsutism, and virilism associated with combined androgen-estrogen hormone replacement therapy. Obstet. Gynecol. 77: 595-598, 1991.

Kaunitz, A.M. The role of androgens in menopausal hormone replacement. Endocrinol. Metab. Clin. of North Am. 26: 391-397, 1997.

Casson, P.R., and Carson, S.A. Androgen replacement therapy in women: Myths and realities. Int. J. Fertil. 41: 412-422, 1996.

19. Physicians' attitudes

Saver, BG, Fugate Woods N, Taylor TR, Stevens NG. Physician policies on the use of preventive hormone therapy. Am J Prev Med 13: 358-65, 1997.

20. Migration studies. Note. We need to ask medical researchers how U.S. and European women can have the same low rates of breast cancer as Asian women. Instead researchers are investigating what new drug we can take to help reduce our risk.

Ziegler, R.G., et al. Migration patterns and breast cancer risk in Asian-American women. J. Natl. Cancer Inst. 85: 1819-1827, 1993.

21. Pressure from women's groups. They want the money raised by the 40 cent breast cancer stamp to go to an environmental agency

Stamp Out Wasted Funding. Massachusetts Breast Cancer Coalition Newsletter, No. 20, Spring, 2000, p. 5.


22. Racism, sexism, and poverty contribute to poor health.

Krieger, N., et al. Racism, Sexism, and Social Class: Implications for Studies of Health, Disease, and Well-Being. Am. J. of Prev. Med. 9 (6 Suppl) 82-122, 1993.

Lantz, P.M., et al. Socioeconomic factors, health behaviors, and mortality: Results from a nationally representative prospective study of US adults. J.A.M.A. 279: 1703-1708, 1998.

Krieger, N., et al. Racism, Sexism, and Social Class: Implications for Studies of Health, Disease, and Well-Being. Am. J. of Prev. Med. 9 (6 Suppl) 82-122, 1993.

23. Domestic violence and relationship to health

John Hopkins Center for Communication Programs. Ending Violence Against Women. Volume XXVII, No. 4, December 1999. Ending Violence Against Women

Mouton, C.P., et al. The associations between health and domestic violence in older women: Results of a pilot study. J. Women's Health End. Based Med. 8: 1173-1179, 1999.

Koss, M.P., and Heslet, L. Somatic consequences of violence against women. Arch. Fam. Med. 1: 53-59, 1992.

24. Harms women psychologically and socially.

Klein, R. and Dumble, L. Disempowering midlife women: The science and politics of hormone replacement therapy (HRT). Women's Studies International Forum 17:327-343, 1994.

Callahan, J. Menopause: Taking the cures or curing the takes? In Mother Time: Women, Aging, and Ethics, edited by Margaret Urban Walker, Rowman & Littlefield Publishers, Lanham, Maryland, 1999.

Coney, S. The Menopause Industry: How the Medical Establishment Exploits Women. Hunter House, Alameda, California , 1994.