The History of Medicine as told through the use of Hormone Replacement Therapy

Physicians, partly because of their general “character” and partly for the patient’s sake, want to sound confident and certain about whatever their recommendations might be. No patient really wants to hear their physician talk about their recommended Treatment “A” with anything but certainty and extensive knowledge. How many times have you heard someone talk about their physician and say “He’s the best in town” or “She’s got the finest reputation and graduated tops in her class” or “My doctor is the best doctor in the world!” There is also the problem of litigation—if a treatment goes badly, what doctor wants to be reminded on the witness stand that they couldn’t answer a question or were uncertain if this was the right treatment for the patient?

So, as a result, most doctors make their recommendations sounding as if they are absolutely certain this treatment will be darn near a miracle cure! Most also are likely trying their hardest to keep pace with ever increasing mountains of new research and information on various conditions, new approaches to various conditions, cutting edge technology, new drugs on the market and thousands of other bits of information. It is definitely a daunting task, and often, it is much easier just to take what the “experts” have said—their “clinical pearls” or what they learned in medical school as “gospel” and they have neither the time, nor the energy nor maybe even the wisdom and independent mind to think it through on their own.

Published clinical guidelines, while definitely useful and even necessary, do not encourage physicians to think on their own—the time limitations, the feeling that we must “reduce risk” for patients, the lack of long-term studies and the minimization of adverse side effects all worked together to keep most physicians then and now in lockstep. Again, not many physicians would want to risk their careers, their livelihoods and their reputation by thinking too far outside the conventional box.

The history of medicine is filled with stories about how conventional thinking can be wrong and can actually cause harm, and the use of artificial hormones to replace the natural hormones during menopause is one such story.

For millennia, menopause was considered a natural transition—women past the menopause were considered the wise elders, the wise women or crones of their community. They were the grandmothers teaching the children, giving advice, the keepers of the community history—and quite possibly living a much freer life knowing they could no longer get pregnant.

With the advent of modern medical science in the early 20th century, both childbirth and menopause became medicalized. 1 Childbirth was suddenly dangerous, could not be responsibly done at home, delivery had to be done in an operating room and the number of cesarean sections increased dramatically.

Menopause, particularly during the 1960’s was characterized as a medical condition—an “estrogen deficiency” due to “ovarian failure”. Countless women going through the menopausal transition were confidently placed on estrogen. If they still had their uterus (another topic for another time), women were often put on both estrogen and progestin (a synthetic progesterone) to replace and fix the “deficiency” and to treat menopausal symptoms. That was the standard of care at the time and few physicians questioned it. The “experts” also said that it would decrease the risk of heart disease, cancer and more recently, the risk of osteoporosis.

Women’s health advocates at the time and throughout the rest of the 20th century emphasized the potential risks of estrogen replacement therapy by reminding medicine of the Diethylstilbestrol (DES) disaster, by advocating for full patient education and by questioning the validity of the clinical trials performed. One of the major concerns was that there were no long-term studies concerning the effects of estrogen replacement therapy—and many women continued taking estrogen well into their 70s and 80’s!

In 2002, the world of hormone replacement therapy was shattered by the news of the results of the Women’s Health Initiative. This study was begun in 1991 to study “the most common causes of death, disability and impaired quality of life in postmenopausal women. The WHI addressed cardiovascular disease, cancer, and osteoporosis.” 2 Why was the world of hormone replacement therapy shattered? Well, because the study found that estrogen plus progestin increased the risk of stroke. Two years later, the NIH asked women in the WHI study who were taking estrogen alone to stop taking the estrogen because they also had an increased risk of stroke.

Overall, the WHI study found that hormone therapy increased the risk of stroke, had little or no effect on the risk of heart disease and that estrogen + progestin increased the risk of breast cancer.

One of the issues with these therapies was the use of either conjugated estrogens (which are essentially estrogens derived from the urine of a pregnant mare…as in PREgnantMar(e)in, or Premarin) and progestins, chemically synthesized molecular “mimics” of progesterone—except maybe they aren’t really such good mimics…bioidentical hormones are different and have been used successfully, and with few adverse effects in Europe for decades.

Watch for our next article on bio-identical hormone replacement therapy.

Notes:

  1. Krieger N, Lowy I, Aronowitz R, Bigby J. Hormone Replacement Therapy, Cancer, Controversies, and Women’s Health: Historical, Epidemiological, Biological, Clinical, and Advocacy Perspectives Journal of Epidemiology and Community Health 2005;59:740-8.
  2. Background and Overview. (Accessed at https://www.nhlbi.nih.gov/whi/background.htm.)

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