washingtonpost.com  > Opinion > Columnists > Marjorie Williams

Minimizing Menopause

By Marjorie Williams
Wednesday, November 20, 2002; Page A25

It's hardly the first time science has suffered some distortion on its way to the front page. But the past four months of reporting on the Perils of Prempro -- the findings of a major federal study of hormone replacement therapy, or HRT -- offer the most glaring recent example. Through a combination of misplaced delicacy and simple sexism, the mainstream media have done American women a serious disservice.

To recap, briefly: The massive Women's Health Initiative study was halted in July, three years early, when researchers concluded that the most widely prescribed combination of estrogen and progestin had elevated the rates of breast cancer, heart disease and stroke in the women being studied. The risks, while small, were very clear: an increase of seven or eight instances, per 10,000 women per year, of breast cancer, stroke and non-fatal heart attacks.

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This was legitimately seen as big news, at a time when an estimated 14 million American women use some form of estrogen therapy. I don't quarrel with the study's firm conclusion that doctors have erred when they have promoted HRT as a risk-free preventive for such conditions as osteoporosis and heart disease. But the study's sponsors were careful to say that their findings ended there; the research explicitly did not address the efficacy or benefits of hormone therapy as a treatment for some of the miseries that can surround menopause. For women using hormones for the short-term relief of these effects, said Jacques Roussow, acting director of the Women's Health Initiative, "the benefits are likely to outweigh the risks."

But you wouldn't know this from reading the lay coverage of the study, which, with rare exceptions, has muddled this distinction out of existence. This has been a failing of both emphasis and language. Many news reports say or imply that the risks were found to outweigh all the benefits. When they do acknowledge otherwise, it tends to be in a prim eighth- or 10th-paragraph disclaimer alluding vaguely to "the symptoms of menopause," and sometimes to hot flashes. Even articles purporting to explore this angle in depth have minimized -- to the point of de-legitimizing -- the possibility that hormone use remains a rational choice for women whose symptoms are severe.

This month, the New York Times threw the great weight of its front page behind the dubious premise that even gynecologists -- the doctors who deal most often with the problems of menopause -- are stampeding away from the use of HRT. And you've got to love this headline: "Doctors' New Tack on Hormone Pills: Maybe a Little Hot Flash Isn't So Bad." (Why, a gal would have to be crazy to take that stuff!) I can promise you the person who wrote that headline has never felt this distinctive crashing of the internal thermostat.

The very emphasis on hot flashes tends to make those "symptoms of menopause" sound like the dotty complaint of the neurasthenic few. In stressing this one symptom, these reports extend our culture's long-running determination to miniaturize the whole topic of menopause. In particular, they tiptoe around the subject of estrogen's huge impact on women's sexuality. An accurate account would have to acknowledge taboo subjects such as vaginal dryness and the vanishing of libido, as well as unpopular subjects such as urinary tract infections and such hard-to-summarize ones as depression and vitality and cognitive function. An honest portrait of estrogen's use would acknowledge that for some women, for some years, it makes the difference between having and not having a sex life.

Next time you read one of these stories, ask yourself why quality of life -- a concept revered in all other quarters of American culture -- is treated so dismissively there. The truth is that we undertake health risks all the time when perspective tells us that other things weigh more in the balance. If the only thing that mattered were the presence of risk, we would all bear our children before the age of 20; waiting until after 30 nearly doubles a woman's lifetime risk of breast cancer. ("Doctors' New Tack on Early Childbearing: Maybe a Little Teen Pregnancy Isn't So Bad.")

In some ways, I should acknowledge, I may be a poor apostle for this argument. I came to an early and harsh menopause as a side effect of chemotherapy. It is possible that my history -- including my experience of Prempro as something akin to a miracle drug -- falls toward an extreme of the spectrum. And I can't claim to be making the same assessment of risk and benefit that I am trying to dignify, here, for other women: When you already have a form of invasive cancer, getting breast cancer in five years is not at the top of your worry list.

But perhaps a woman in my position is the exception who proves the rule. I must tell you it's an illusion that you can bargain away all risk of serious illness. I can also tell you that there's something worse than getting sick. The worst thing, the one most worth regretting, would be to surrender to fear the best possibilities of the life you have.


© 2002 The Washington Post Company