Recently deceased activist and cofounder of the National Women's Health Network, Seaman (The Greatest Experiment Ever Performed on Women) reported on women's health for more than three decades. Here, she and associate Eldridge articulate the myths, controversies, statistics, economics and prevailing protocols that feed continued confusion about what, they argue, is an overmedicalized but profoundly natural experience. With the abrupt end in July 2002 of one segment of the hormonal trial of the Women's Health Initiative (begun in 1992), the authors state, many women, formerly led to view hormone therapy as a cure-all for a multitude of symptoms and conditions (hot flashes, cardiovascular disease, osteoporosis and memory loss, for example), began looking critically at recommended tests, surgical procedures and drugs. Seaman touches on nearly every aspect of women's health (nutrition, exercise, sleep, stress relief, vitamins and herbs, aging, appearance, etc.) as she helps readers frame key questions, evaluate research studies, consider treatment options and move gracefully through menopause and the years leading up to and following it. This volume sheds an invaluable light on a long-cloudy subject. (July)Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.
The No-Nonsense Guide to Menopauseby Barbara Seaman
For nearly as long as women have been around, they have been going through menopause. It is a bodily process as old as human birth, death, and of course, menstruation. Like many normal biological events, menopause was gradually medicalized, and with the rise of pharmaceutical medicine, women and their doctors were convinced that it was an "estrogen deficiency disease" that could be treated by supplementing the body's declining estrogen levels with hormones. By 2002 hormone treatment had been on the market for more than fifty years when doctors and women alike were shocked by the results of a massive clinical trial, the Women's Health Initiative: women taking hormones had more heart attacks, breast cancer, strokes, pulmonary embolisms, and blood clots than women who did not, and patients were left scrambling to find new and sometimes difficult answers to their menopause and midlife health questions.
In The No-Nonsense Guide to Menopause, Barbara Seaman, a legendary figure in the women's health movement, and Laura Eldridge have written a comprehensive, easy-to-use resource that will give you all the information you need to make smart and informed decisions that will put you in control during this time of transition -- medically, psychologically, sexually, and even financially.
With the latest research on everything from hormone replacement therapy to skin creams to preventing osteoporosis, The No-Nonsense Guide to Menopause is the definitive manual on this important subject. You'll find out which changes are expected and natural and which can be a cause for concern; how hormonal shifts can affect your heart, your sex life, and your mood; and what you can do to address these issues. Whether the authors are discussing the risk factors for heart disease, the benefits of lifting weights, or if you should consider a hysterectomy, they offer unbiased, straightforward information and advice with a signature blend of wisdom and sensitivity.
Perhaps most important, you'll learn how to evaluate what you read in magazines, hear on the news, and are told by your doctor, so you can distinguish between solid facts and dubious claims. By learning how to read and evaluate scientific studies and becoming familiar with what goes on behind the scenes in research labs, at doctors' offices, and at pharmaceutical companies, you will be able to become your own advocate. The next time you go to the doctor's office, you will know how to make the most of your visit and leave feeling confident, informed, and in command. There is no one way to experience menopause and no single way to handle the challenges it can present, but as a no-nonsense patient, you will have the tools you need to make decisions that are right for you.
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Read an Excerpt
Arm in arm, the women walked toward the doors of the Natcher Auditorium at the National Institutes of Health. It was the end of February 2006. Dressed in brightly colored coats to keep out the late-winter chill, they entered the conference center and were handed rose boutonnieres to distinguish them from the fleets of doctors, scientists, and journalists who were also slowly making their way to their seats.
The occasion was a two-day summit to discuss the results of the Women's Health Initiative (WHI), a massive clinical trial that had studied possible preventative approaches to problems that plague aging women -- primarily heart disease, osteoporotic fracture, and breast and colorectal cancer. When we call the trial massive, we mean in scope, duration, and expense. Started in 1991 and involving 161,808 participants, the WHI cost millions of government dollars and spanned fifteen years.
The clusters of middle-aged women proudly sporting the flowers on their lapels were members of that 161,808-strong sisterhood. Although they looked like any other people their age, these women had accomplished an incredible feat. Though they might not have understood it at the time they signed up to take hormone replacement therapy, make changes in their diet, and commit to decades of calcium and vitamin D capsules, these women had transformed the way that women in North America, Europe, and indeed much of the world experience menopause. For at least a century, the transition from fertility to menopause had been medicalized and treated as a disease. For over five decades, hormone treatment (HT) drugs were assumed to be the first line of defense for all women against this presumed illness. The WHI confirmed what some daring scientists and women's health advocates had been saying for years: hormones weren't the answer, and beyond that, menopause itself was a natural process that wasn't necessarily in need of any medical intervention.
None of this would have been possible without the trial participants and the generations of women who have experienced and talked about menopause in spite of prevailing medical opinions, drug fads, and dangerous social taboos. This conference, as organizer Marcia Stefanik made explicit in her opening remarks, was to honor their contribution.
Although it was a scientific meeting, the atmosphere at the NIH was closer to a school reunion. Images of the quilts created by WHI participants flashed on the main screen between presentations heavy with charts, figures, and seemingly endless statistical analyses. On panels, WHI subjects sat side by side with experts, doctors, and scientists. The message could not have been more clear: after decades of women being told what to do about their menopause by doctors, scientists, and drugmakers, at last the voices of women themselves were being heard.
As we -- Barbara and Laura, the authors of this book -- watched the results of the WHI unfold between 2001 and 2003, we couldn't help but wonder how we had arrived at a cultural point where we needed to be reminded that menopause was part of a woman's natural life cycle. We were amazed by the shock women experienced as the WHI was publicized and were impressed by their desire to understand the seismic shifts in menopause medicine. There were so many questions that needed answers, and we wanted to give menopausal women an easy-to-read but thorough, honest but optimistic way to understand how "the change" has, well, changed.
Things That Were, Things That Might Have Been
As long as women have been around, they have been going through menopause. It is a bodily process that is as old as human birth, death, and, of course, menstruation. There is a cultural myth that before the twentieth century, women didn't live long enough to experience menopause in significant numbers. Such a claim is simply not born out by the facts; a visit to any cemetery thick with graves from centuries past reveals the fallacy of a history without old women. Anthropologist Margaret Lock debunks the widely held idea that "the existence of women over fifty years of age is a recent phenomenon," explaining that statistics that put mean life expectancy before the twentieth century at forty-nine years of age is a mean; that is, all the people who died in infancy and as young adults are averaged in with those who lived to ripe old ages. For example: there are three people, one who dies at the age of one, one who dies at seventy-five, and one who dies at one hundred. The mean age, or average age, is fifty-eight years old. Even though two of the three people in this group live to be senior citizens, the average age is still one that falls in midlife.
It is exceedingly difficult to recover a history of menopause before the twentieth century. While it is likely that women were talking privately with each other about their experiences, written records are few and far between. This, in combination with the fact that humans are one of the few species to experience a long postreproductive life, has contributed to the idea that menopause is "strange" or even "unnatural."
In pre-nineteenth-century thinking, this included the idea that when a woman ceased to menstruate, the blood that would formerly have left her body in a monthly bleed had nowhere to go and would fester and eventually poison her. Like many normal biological processes, such as birth, menopause was gradually medicalized in the nineteenth and twentieth centuries when mostly male doctors, uncomfortable with the differences of female bodies and their processes, were quick to pathologize every gynecological event. Charles Reed, the president of the American Medical Association in 1901 and 1902, wrote that menopause was a "mental condition." In the twentieth century, with the rise of pharmaceutical medicine, smart women and smart doctors were convinced that the Change was an "estrogen deficiency disease" that could be treated by supplementing the body's declining estrogen with hormones from chemical and other biological sources. Generations of women matured assuming that "a choice about estrogen" was an inevitable part of getting older.
Of course menopause was already being treated with drugs long before the synthesis of oral estrogens. A European medical book dating from the Renaissance advised women having problems with menopause to combine "a decoction of myrrh and apples" with taking a walk. A more modern approach to "treatment" was pioneered by Merck, a drug company that still exists today but was founded in 1668 as an apothecary in Darmstadt, Germany. By the late nineteenth century, Merck suggested medicating women with, among other things, wine, cannabis, opium, and a product made out of the powdered ovaries of cows called Ovariin. It's hard to say what biological effect Ovariin would have had, but the effect of the opium and cannabis can be more easily imagined.
When Premarin, a pill made from the urine of pregnant horses, was accepted by the Food and Drug Administration (FDA) for the treatment of menopause in May 1942, it was approved primarily to treat hot flashes and vaginal dryness and atrophy. From the beginning, HT was prescribed for a host of other things. (When a drug is prescribed to deal with an ailment that the FDA hasn't approved it to treat, this prescribing is called "off label" use.) For example, for years women were told to take HT to protect their hearts, despite the fact that the drug was never conclusively shown to do that.
By 1990, HT had been on the market for forty-eight years but there had still never been serious clinical trials to demonstrate its effect on the heart, as well as other symptoms it was being used to treat. Despite this, Wyeth-Ayerst Laboratories (now Wyeth Pharmaceuticals), the makers of Premarin, attempted to get the drug officially approved for the prevention of heart disease, hoping to expand its already lucrative market. The FDA refused. Taking the advice of the National Women's Health Network, a grassroots group that eschews pharmaceutical funding and functions as an advocate for women's health rights, the FDA called for the creation of the WHI, a massive randomized double-blind clinical trial set to last for more than a decade and a half. Almost everyone was convinced that trial would affirm what everyone already knew: HT was a wonder drug for "women of a certain age" that should perhaps, as one doctor suggested, be put in the drinking water alongside fluoride.
When the Prempro (premarin and progestin) arm of the trial came to a screeching halt in 2002, doctors and patients alike were shocked by the reasons. Women taking hormones had more heart attacks, more breast cancer, more strokes, more pulmonary embolisms, and more blood clots than women taking sugar pills. The reigning paradigm of menopause management for over fifty years had fallen like a collapsing bridge, and legions of women and their doctors were left to scramble for solid ground and make sense of this brave new world.
A Word about Words
Recently, those in the know have started to use different names for hormone drugs known for decades as "HRT" and "ERT." Now experts will refer to "HT" and "ET," but they are talking about the same medications. "ERT," the grandmother of them all, stood for "estrogen replacement therapy." When progestin and testosterone were added for safety, the term HRT or hormone replacement therapy was added. These terms reflected the attitudes of the time. Doctors believed that women needed estrogen and were therefore "replacing" something the body had lost. Since the WHI, doctors have reminded themselves and their patients that it's normal for estrogen and progesterone levels to fall. Because of this, folks have started calling these drugs "ET," or estrogen treatment, and "HT," or hormone treatment. These terms convey the current beliefs that estrogen is an outside chemical being used in the body to help treat a certain problem, such as hot flashing, not to to "replace" something natural.
Menopause: What's in a Name?
The "menopause," the "climacteric," the "change," the "pause," entering middle age, becoming "a certain age," becoming a "crone," going through "that time," suffering "ovarian failure," becoming "estrogen deficient": over the years we have come up with countless ways to talk about, euphemize, characterize, and medicalize this part of women's lives. While each "way of seeing" menopause tells us something about the point in time or attitudes of the people who came up with it, the multiplicity of terms makes it very difficult to pin down exactly what we are talking about.
Technically, menopause is the "permanent cessation of menstruation resulting from the loss of ovarian follicular activity."
As women age, periods gradually cease due to the end of ovulation. This means that the cells that make eggs run out, and reproduction by natural, nonmedical means becomes impossible. Menopause is determined only in retrospect. A woman has officially gone through the process when a full year has passed since her last period. Dr. Sherry Sherman points out that the word menopause "corresponds to a single point in time," that is, the date immediately following the last period. Yet when we use the word menopause in conversation, we are most likely talking about a long process, not a discrete moment.
Premenopause is technically the entire time between menarche (which is your first menstrual bleed and is pronounced, appropriately enough, like "anarchy") to the final menstrual period. Perimenopause is the time before the final bleed when the reproductive cycles are winding up and slowing down. During perimenopause, bleeding begins to become irregular, and other possible symptoms that can accompany menopause, like hot flashes, start to show up. Dr. Sherman and others admit that "an adequate independent biological marker for the event doesn't exist."
When we talk about menopause in this book, unless we specify that we are using the clinical definition, that "single point in time," we are talking about the whole transition. We want to encourage women to think about the entire process as a unified experience. We want to broaden the discussion and ask how this particular transition relates to the ones that came before it. In many ways, puberty and menopause are part of the same larger process. Most books assume that women won't think about menopause until they are about to go through it. We believe that as with puberty, understanding menopause is something that should begin long before the physical experience. The decisions that a young woman makes about her health can have huge repercussions later on. For example, taking calcium and getting proper exercise throughout youth can have a huge impact on bone quality in later years; and women who smoke seem to go through menopause earlier than nonsmokers and are more likely to have a host of complications.
What's the Big Idea?
The ancient Greeks, who wisely observed a similarity between the cycles of the moon and a woman's monthly menstruation, incorrectly believed that all women would bleed at the same time each month. While this seems silly to us, in many ways women are still dealing with the notion that we all experience reproductive changes in the same way at the same time. While it might be nice if this were true, nothing in life is this straightforward, particularly changes in the body. Women can begin the menopause transition as early as their mid to late thirties or as late as their upper fifties. It can happen quickly, in the course of a year or two, or take a decade to complete itself. This variability makes it hard to paint a picture of an "average" transition or to reassure women when so many different events and experiences can rightly be called "normal."
For these reasons, when it comes to asking questions like "Am I going through menopause?" there are no straightforward answers. And a question like "What do I do about menopause?" is even more complicated.
A lot of menopause books tell women that they should be excited about this time in their lives while happily reinforcing women's worst fears about the transition. Most menopause books start by assuming that women are going to have a hard time changing. We want to start by assuming that like the majority of women, you won't have anything more than the small discomforts that accompany any major biological endocrinological shift.
If you are a woman who is having a tough menopause -- and around 15 percent of us will -- we want to provide a comprehensive, easy-to-use resource that gives you the information you need to make smart health decisions. We want to help you become a no-nonsense patient. Self-education can be a challenge. In certain ways, the Internet and other modern information sources have made it much easier to learn about, well, anything. You can get access to journals, Web sites, and online communities of women discussing the very challenges you might be facing. On the other hand, it is harder than ever to judge the quality of the information you are receiving. It seems as though every day there is a new medical breakthrough blasting its way across the evening news and the banners of Web sites.
We want to help you feel confident in evaluating different information sources (including this book!). We'll show you how to read and understand different scientific studies and assess the information you see in the media and hear from friends. We'll look at Web sites and menopause groups and show you how to tell if a group is funded by a drug company or other source that might compromise or bias the information it is presenting. Most basically, we'll talk about doctors and how to have a confident, mutually beneficial conversation with your health care professional. In the old days, doctors would tell their female patients exactly what to do, and if the patient expressed concern or objection, she was told not to worry her pretty head about it. More and more, physicians and internists are looking to their patients to be informed and ask smart questions about their health.
Finally, we want to take a hard, honest look at what we know and what we don't know about menopause. We will look at the different "symptoms" women experience that, rightly or wrongly, have become associated with it. There is no reason for anyone to suffer discomfort unnecessarily, and we'll look at all the possible treatment options available and ask some tough questions about what we really know about each problem. For many years, doctors thought the answer was simple: hormones. Since the findings of the WHI, this is clearly no longer a responsible or comprehensive response to the menopause experience. We'll look thoroughly at HT and ask what we know of its benefits and risks. As estrogen falls under greater scrutiny, alternatives such as natural medicines gain in popularity. The same kinds of questions need to be asked about their safety. Other pharmaceuticals such as bisphosphonates, statins, and antidepressants have been all too ready to fill the void left by HT. What lessons have we learned from HT that can be applied to other potentially helpful, potentially harmful pills?
Women have emerged from the collapse of HT with a new skepticism about menopause advice and treatments. This new menopausal woman -- the no-nonsense woman -- is who Germaine Greer has triumphantly termed "noncompliant." She realizes the importance of self-education and the value of consistently challenging received medical wisdom, refusing to take a drug until sufficient studies on it are available. She gets mad when important news about a drug's medical risks are shuffled to the back pages of the newspaper while claims of its benefits are ballyhooed on the front page.
It is for this new reader that we are writing this book.
The Women's Health Initiative: A Brief Timeline
- 1991: The Women's Health Initiative is mandated by Congress.
- October 1992: The Trial begins operations; it is really several small trials under the umbrella of a larger one. The WHI seeks to look at the roles of various lifestyle factors in the health of aging women. It will last fifteen years and involve 161,808 postmenopausal women. Here is a brief summary of the design.
- It had two main components -- the clinical trial and the observational trial. The clinical trial was a randomized, controlled study that included 68,132 women between the ages of fifty and seventy-nine. The observational study included 93,676 women in the same age range, many of whom either didn't want to participate in the clinical trial or were ineligible to do so. (For more information on the differences between clinical and observation studies, see the Afterword.)
- There are three major wings of the study: the Hormone Trial, the Dietary Modification Trial, and the Calcium/Vitamin D Supplementation Trial. All three wings have both clinical and observational parts.
- The Hormone Trial has two arms: the Estrogen Only section that studied women taking Premarin alone, and the Estrogen Plus Progestin section that studied women taking Premarin plus progestin (Prempro). For the most part, the women in the Estrogen Only section had hysterectomies and the women in the Estrogen Plus Progestin section had intact uteri. Originally, there was a small group of women with intact uteri taking Premarin alone, but this ended in 1995 because of concerns about endometrial cancer. Both arms of this trial examined the effects of hormones on heart disease and osteoporosis. The clinical hormone trials contained 27,347 women, and although it received the most media attention, it had the fewest par- ticipants.
- The Dietary Modification Trial: the largest of the clinical trials with 48,835 women participating, this section of the WHI sought to evaluate the role of a low-fat diet in preventing chronic illnesses like heart disease and breast and colon cancer.
- The Calcium/Vitamin D Trial included 36,282 women and looked at the effect of calcium and vitamin D supplementation on fracture risk and colon cancer. It actually began two years after participants had joined one or both of the other trials.
- December 1993: First Clinical Trial participants are randomized (from the Hormone and Dietary Modification trials).
- September 1994: Observational Study begins.
- 1995: First Calcium/Vitamin D participants randomized.
- 1995: After the results of the Postmenopausal Estrogen/Progestin Interventions Trial (PEPI) emphasize the dangers of taking estrogen alone with an intact uterus -- particularly of endometrial growths and even endometrial cancer -- the unhysterectomized women in the Estrogen Only Trial are reassigned to the Estrogen Plus Progestin Trial.
- April 2000 and May 2001: Participants in the Estrogen and Estrogen Plus Progestin trials receive letters informing them of unexpected findings, particularly more heart attacks, strokes, and blood clots in the legs and lungs. The findings receive media attention.
- July 2002: Because of increased heart attacks, strokes, and blood clots, as well as higher breast cancer rates, the Estrogen Plus Progestin Trial is halted early. A media firestorm erupts and women everywhere are left wondering how to move forward.
- March 2004: The Estrogen Only study is stopped, again because it is decided that the risks of ET outweigh the benefits for participants.
- March 31, 2005: All components of the WHI end. This coincides with a National Institutes State-of-the-Science conference on the Management of Menopause Symptoms that concludes that menopause is a natural part of life and "not a disease state."
- April 2005: The Extension Study, which will follow willing participants for an additional five years, begins.
- February 2006: The WHI Legacy conference officially summarizes and synthesizes the various findings of the entire study.
Meet the Author
Barbara Seaman was a leader in the women's health movement. An alumna of Oberlin College, she was a Sloan/Rockefeller Advanced Science Writing Fellow at the Columbia Journalism School. She was a cofounder of the National Women's Health Network and a contributing editor to Ms. Magazine. Her previous books include The Doctor's Case Against the Pill, Free and Female, Women and the Crisis in Sex Hormones, Lovely Me: The Life of Jacqueline Susann, The Greatest Experiment Ever Performed on Women: Exploding the Estrogen Myth, and For Women Only! Your Guide to Health Empowerment.
Laura Eldridge is Barbara Seaman's longtime associate. Eldridge grew up in New York and Salt Lake City and attended Barnard College.
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