This past weekend, the International Menopause Society (IMS) issued a public statement calling on the National Institutes of Health (NIH) to revise current recommendations on use of hormone replacement therapy (HRT). In this statement, the IMS stated that it believed that the “NIH has been guilty of unbalanced reporting in failing to inform women of the latest information,” adding that it “calls on the WHI (Women’s Health Initiative) and the NIH to revise its advice to reflect current consensus — not just the initial WHI results.” IMS President Dr. Tobie de Villiers said “Of course there are differences between what the WHI thinks and what the menopause community thinks, but I think that it’s fair to say that in many ways the WHI has moved more towards our position over the last 10 years. In spite of this, they have not been particularly even-handed in presenting results. For example, the main NIH patient brochure on HRT has not been updated in the last 7 years, in spite of a wealth of new information…the least that they can do is agree that HRT is a good option for symptom relief for most women going through the menopause.”
If you’ve been following the news or this blog closely for the past four years, evolving analyses of WHI data don’t entirely support this last statement. Moreover, several organizations, including the US Preventive Task Force, the US Food & Drug Administration, the American Association for Cancer Research and the Canadian Cancer Society have issued warnings about of combination HRT or estrogen alone with regards to timing and duration of use. And, two years ago, I quoted lead study investigator for the Canadian Cancer Society — Dr. Prithwish De, who said that “The Canadian Cancer Society’s ongoing review of the evidence on HRT and breast cancer since 2003 led us to our current position and the research study findings reaffirm this position. The Society recommends that women avoid taking HRT for any reason other than to relieve severe menopausal symptoms that have not responded to other treatment. We understand that each woman’s experience with menopause is unique. If, after consulting with their healthcare professional, a woman decides to take HRT, it should be the lowest effective dose for the shortest time possible.” Notably, like the IMS, the North American Menopause Society’s recommendations also tend to minimize certain noted risks.
So, why the disconnect?
Is it at all possible that menopause has been overpoliticized, medicalized and poorly characterized, a “phenomenon not so much hijacked by medicine as gradually occupied, [with] authorities throughout the ages grimly trying and failing to define their subject?”1
In a recent editorial in Menopause journal, several authors express concern that the North American Menopause 2012 recommendations on use of HRT do not include caveats with regards to prevention of coronary heart disease (CHD) or stroke and also ignore data suggesting that longer-term use of estrogen-alone may not be safe. Noting that “long term observational data are especially unreliable for CHD (as they reflect the experience of women who were not susceptible to early risk), they add that 1) lifestyle choices have the ability to influence the likelihood of developing heart disease and 2), that generalizations as to ongoing lower risk rates should HRT not be used for longer periods cannot be assumed. They also point out that the NAMS statement blatantly understimates stroke risk on younger women who choose hormone therapy. These concerns are largely echoed by Jacques Rossouw, M.D., National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Chief, Women’s Health Initiative Branch, who sent me an email statement when I asked for a comment. He writes:
“WHI has made substantial contributions to our understanding of the effects of hormone therapy, providing women and their physicians with much better information on which to base an informed decision about the use of hormone therapy. In women close to menopause, the risks of short-term use of hormone therapy for treatment of hot flashes and night sweats are small, and WHI investigators have supported short-term use, provided that patients are fully informed of the risks and benefits. The main objective of the WHI was to address whether hormone therapy should be used to prevent cardiovascular disease in postmenopausal women ages 50 to79, and the data on this are overwhelming. The risk of coronary heart disease is particularly increased in older women, especially among older women with hot flashes and night sweats. Therefore, hormone therapy should not be used in older women to prevent coronary heart disease or even to relieve vasomotor symptoms (hot flashes and night sweats). Even in younger women, long-term hormone therapy is unwise because of the likely increasing risk of breast cancer over time, and uncertainty about long-term cardiovascular effects. The hormone prescriptions for older women have decreased more markedly than in younger women, and this seems an appropriate response to the data. It is not possible to evaluate whether hormone prescriptions to younger women are at an appropriate level.”
We’re drowning in politics, medicine and industry. And it’s difficult to discern truth from fiction, data from data, risk from benefit. Ongoing analyses will eventually reveal what’s what. Meanwhile, read the library of HRT posts on Flashfree. Talk to your physician. Avoid hasty decisions. And consider alternatives. If the medical community can’t agree, perhaps it’s time to put down the gauntlet and wait out the firestorm.
1. Louise Foxcroft, Hot Flushes, Cold Science. A history of the modern menopause. London: Granta Press. 2009.
For some time now, I have been writing about the medicalization of menopause and about the Menopause Industrial Complex and its implication for how the life transition is currently managed, understood and communicated. And if you are a regular reader of this blog, you know that I find it appalling how society has managed to change how we perceive a biologically natural transition from a positive to a negative. Consequently, I was intrigued when I stumbled across a research article in BioMedCentral Medical Education journal discussing the role of medical education in driving how future clinicians view a constellation of symptoms as the norm (or not) and how they subsequently label them as a result.
Not surprisingly, how something is labeled drives practitioner atttiudes towards management and treatment.
Writing in the journal, the study’s co-authors say that “The labelling of a condition as a “disease” has important implications…failing to label a condition as a disease may mean effective treatment is not prescribed, labeling a non-condition as a disease may result in unnecessary treatment.” Moreover, they point out that data have shown that such labelling leads to greater numbers of prescriptions. And, that labeling a spectrum of symptoms incorrectly may promote anxiety about prognosis and overtreatment.
Fortunately, in this study of 190 medical students, approximately 80% concurred that menopause was a “non-disease.” And yet, one has to wonder that if a cohort of licensed practitioners were surveyed, the results would be the same?
Despite the fact that the rates of prescriptions for hormone replacement therapy have significantly declined, the historical construct of the menopause has long been associated with loss, decline and decay, something is abhorred and shunned in society. In response, marketers and the media have perpetuated and pathologized what author Louise Foxcroft (in her book, ‘Hot Flushes, Cold Science’) refers to as “one more feature in a woman’s linear life history, an inevitable and natural phenomenon, one more thing to negotiate and nowhere near as astonishing or potentially problematic as pregnancy.”
It is all in how you/we view it. And how our practitioners view and label it.
If you are encouraged by the future of medicine, let’s take a look at the ‘now.’
Cynical as I may be about society’s vision of the aging woman, I was further dismayed when my friend and esteemed colleague, Ivan Oransky forwarded an article outlining a small study of residents that participated in a menopause clinic rotation. Within this rotation, the residents had an opportunity review each case after menopausal women were seen and additionally, were offered after-hour lectures to enhance their knowledge and education.
Overall, the findings demonstrated that it was the clinical contact with the women and not sporadic instruction, that significantly impacted residents’ ability to thoroughly understand issues relating to menopause and women’s health (this was evidenced by mean improvements in menopause test scores by 13%). And yet, as the study authors point out, most resident education is currently based on didactics and not face-to-face contact. This implies that these results, however favourable, may not be applicable to the real world.
Another overlooked challenge in this particular case is the adjunctive educational opportunities offered to the resident physicians. In addition to colleague-directed knowledge or realtime clinical experience, they were provided with an opportunity to purchase educational materials about menopause produced by Red Hot Mama’s. Herein lies the rub: Red Hot Mama’s, one of the oldest organizations for menopause, receives funding from Norogyne Pharmaceuticals and advertises Vivelle-Dot hormone replacement on its home page. You may recall that the organization even teamed up with Norogyne Pharma to pimp Vivelle up on a roof; you can find the post here.
The take-home message of these two studies is very clear: currently, medical students appear to be ‘in the know’ about menopause, at least in so far as how it should be classified. This divergent path has the potential to ultimately influence how menopause is viewed and managed in Western society. Moreover, there appears to be a realization that in certain situations real time clinical contact may supercede or significantly enhance didactic education. However, this education may be less valuable if it is driven by commercial interests. What concerns me most is that by the time these practitioners of the future get out into the real clinical world, they may possibly drink the the Kool-Aid or at least, taste it.
How do we approach this ironic paradigm that is being perpetuated and rewound, even by organizations organized to help the very women that they may ultimately be hurting?
Labels? It’s up to you. Menopause, is it a disease or not? And what are you going to do about it?
I have been writing about the medicalization of menopause for several years now. So I was intrigued when I stumbled across a review in the Journal of Aging Studies discussing how the social construct of menopause has shifted to “an increasingly more medicalized perspective that emphasizes the biological deficits of the aging female body.”
In this piece, researcher Rebecca Utz reports on qualitative interviews that she conducted with a small group of pairs of mothers and daughters, divided by generation and apparently, attitudes towards menopause. Medicalization, she writes, “is defined as the way in which the apparently scientific knowledge of medicine is applied to a range of behaviors that are not self-evidently biological or even medical, but over which medicine has control.” Therefore, in the case of menopause, our definition has shifted from something that a natural part of our development to an illness-based perspective “requiring medical intervention.”
Accordingly, when she interviewed both groups of women (mothers born during the 1920s and 1930s, and daughters born in early to mid-1950’s) she discovered that despite the commonality of physical symptoms, attitudes were significantly different:
- The older women did not perceive menopause as a problem or disease but rather, something that “just happened.” As such, it was not part of their narrative and most were uncomfortable discussing it, primarily because they considered it private and “inappropriate for public discourse” much like sexuality or emotional instability. And the steps taken to address it: Watch and wait for it to be over.
- The daughters, on the other hand, were likely to seek medical treatment as soon as symptoms appeared. This behavior is consistent with the premise that menopause has been increasingly medicalized. However, it wasn’t simply menopause that the younger women were fighting but on a larger level, aging. “In other words, menopause was just the beginning of a long, downhill battle that cannot possibly be won,” but can be controlled and self-managed. Moreover, these women’s fear was not necessarily entrenched in hot flashes and night sweats, but in what the start of menopause meant in terms of the delineation between youth and middle/old age and even “end of life as we know it,” a new older life stage that was unwelcome. The “cure” of course, were hormones and other pharmaceutically-derived interventions, which represented a way to “suspend old age” and control the physiological aspects of aging.
Not surprisingly, Utz also points to the ‘Menopause Industry:’ a “profit-seeking enterprise comprising pharmaceutical companies and perpetuated by the media intent on “turning 40 million baby boomer women into patients for life by defining menopause as an estrogen deficiency disease requiring significant medical intervention.” While the companies create the drugs, the media (whose increased attention attention to menopause, largely fueled by the wave of 1970s feminism and in part, funded by corporate interests) not only provide women with access to the information and resources that they seek but also contribute to perceptions of personal control among women who do not want to “sit back and let menopause just happen to them.” The result is that the Menopause Industry has not only developed products that these women crave that allows them to win their battle against old-age, but, continues to highlight the need for them.
Where does this leave us?
Although some women have fallen off the HRT wagon post-WHI study findings, others have remained. And even more expect the pharmaceutical industry to come up with something different to “quell the realities of their aging bodies.” Are we/they in for a surprise? Perhaps, because as Utz writes, aging is inevitable, even with quick fixes, and that at some point “the perceived autonomy and need for personal control may make [these women] more vulnerable or less prepared than their mothers to face the realities of old age.”
I’d like to offer another, more positive construct up for consideration:
Taking control doesn’t have to mean that the aging process is denied, stopped or obliterated, medicalized or industrialized. Rather, it means taking charge to feel better, more vibrant, healthier so that you/we/I can live the best life I can live while we are alive. For me personally, that doesn’t mean hormone replacement or botox or lipo; it means trying to make more healthier decisions, control or address my symptoms with evidence-based alternatives and accept the transition as a natural part of my journey. So, much like the mothers in this research, I consider this time an opportunity for shifting priorities and interests that open all sorts of possibilities. And like the daughters, I want to take the experience out of the closet and foster discussion and sharing. Ultimately, I’d like the see a more natural course driven by women themselves, as opposed to societal expectations and stigmatization of the aging process and as opposed to the Menopause Industrial Complex.
What about you?
What’s the lowdown on depression, midlife and women? And how does the menopause come into play?
I written previously that depression may affect as many as 20% to 40% of women during menopause. However, gender differences in depression evidently begin well before the menopause and women are 1.5 to 3 times likelier than men to report a lifetime history of depression. Moreover, these distinctions start as early as the teen years and continue until the mid 50s, which researchers say, corresponds to female reproductive. Hence, experts have connected waning and altered hormone levels to high rates of mood and anxiety disorders in women.
Is this hypothesis valid? And, where did it originate?
According to a review in the early online edition of the Journal of Affective Disorders, some research has suggested that premenstrual, post partum and menopausal mood disorders are linked and that women are especially vulnerable during certain time periods. This has led to a proposal that reproductive-related depression have its own classification, and that during midlife in particular, all women should be routinely screened for symptoms. Interestingly enough, however, it has also led some researchers to question if we are “overpathologizing the menopause?” Hallelujah! (If you want to read more on medicalizing the menopause, check out one of my favourite Flashfree posts.)
The key finding?
Although studies demonstrate that significant numbers of women in midlife report depressive symptoms, menopause is only one of a range of factors purported to lead to depression during this timeframe. Others include stress, family life, general health issues and a lack of exercise, as well as a history of some sort of anxiety disorder. What’s more is that how women perceived the effect of menopause on their physical health almost doubled the risk that they would first develop depression at the onset of menopause.
The researchers say that although women might score high on self-reported mood scores, these scales or instruments tend to exaggerate the rate of depression in women in midlife and menopause. They also note that if a score is only taken at one time point that is might indicate temporary distress rather than a long-term problem. They add that during menopause, certain symptoms, such as sleep disturbance and fatigue, may be easily confused with depression even though they have nothing to do with a mood disorder and everything to do with hormones.
The bottom line is that symptom overlap and environmental factors can confuse a diagnosis, and that depression is not necessarily more prevalent during menopause than during other periods in a woman’s life. Consequently, like many things, the studies that are out leave more questions than provide definitive answers. Hence, the call for all women to be screened for depression during menopause may be an example of extreme assumption and not based in true necessity.
Is it possible that depression is just the tipping point in the medicalization of menopause?
What do you think?Read More
[Used with permission. Thanks to egopicks.com and their seriously fine guitar picks! Rock n Roll!]
Your ‘tude may be affecting how you experience menopause as well as how frequently those flashes occur. What’s more, your environment may also play a role.
In a detailed review of 13 studies examining women’s attitudes before and during menopause, researchers discovered a few choice tidbits:
- Ya gotta live it to understand it. Apparently, younger women who are premenopausal have more negative attitudes towards menopause than women who are menopausal. In fact, data show that one’s mood state prior to starting menopause may actually affect one’s menopausal atttitudes and experiences.
- I’ve got all my sisters (and teachers) with me. Research shows that education and social support contribute greatly to having positive attitudes and experiences during the transition.
- Which came first? The chicken or the egg? Depression is apparently associated with having more negative attitudes about menopause although researchers haven’t quite figured out the causality, i.e. depression before symptoms or symptoms before depression. Regardless, it might bet helpful to tackle those blues and try to chase them away.
- It takes a village. The reviewed studies included women from North America, Europe, Asia and the middle east. They showed that cultural attitudes can significantly impact attitudes towards menopause. One of the most discouraging (and telling) findings was that the medicalization of menopause affected Caucasian women in particular, leading to a tendency towards negative attitudes. Say no more!
Overall, the key take-away point is that negative social attitudes + individual negative attitudes = worsening symptoms and poorer experiences. I believe that we can change this equation for the positive by supporting one another, working on changing our beliefs about menopause and what it is (and isn’t), taking steps to boost mood, whether they be exercise, herbs, antidepressants, or mind-body practices, and by unifying to stop the medicalization of menopause.
What do you say? You in? Got ‘tude?Read More