Are You In Control – Or Are They?
You may have started this book thinking that you were in thrall to your hormones. In some ways, you are. Melatonin, the slave of the clock, orders the timetabling of your internal day, synchronizing your life with that of the sun and the seasons. Oestrogen and progesterone, with their rhythmical and relentless ebb and flow, order your cycle and so ordain the fluctuations of your emotions, as well, of course, as the thickness of your womb lining and your readiness for pregnancy each month. The quiet and steady release of growth hormone turns babies into toddlers, into children, into teenagers, and into fully functioning, more or less mature adults.
Actually, the answer must be clear. You are in control. For what hormones do is to reflect the brain’s – your – responses to change, both those you consciously initiate and those you don’t. So if you were to be kept in constant light, or if you were to fall ill and not eat or, as a child, you were deprived of sleep, then your hormones would reflect that circumstance, as the brain – you – decided on a response and sent out the appropriate hormones. This might result in a disruption in your daily rhythms, a cessation of your periods or even a slowing of growth. Equally, your hormones are sent out in response to you tucking away a Christmas dinner, or bungee jumping or meeting the lust of your life.
You manipulate your hormones every day. You exercise, you sleep, you eat. Every mouthful of food you eat contains some sort of hormone-altering substance, whether it be phytoestrogens which dock at your oestrogen receptors and initiate acitivity at a cellular level, as oestrogen would do, or candyfloss on the beach providing a rush of sugar which gets insulin levels soaring.
So, hormones are truly your slaves, albeit extraordinarily powerful slaves. In this book, we’ve encountered hormones as the cause of trade wars, and hormones as the engine of cultural change.
Life-Changing Hormones – The pill and HRT
the pill, that little double-hormoned package, is the most obvious example. In the 1960s it seemed liberating and allowed women to escape from the drudgery of constant pregnancy with a method of contraception that was in their hands. Today, we wonder if we have misplaced that freedom somewhere, as women are now often expected by men to be responsible for contraception, which, if you ask me, is liberating them not us. Equally, because of the rise and rise of sexually transmitted diseases, we are now suggesting to our young people that the pill is not enough – a barrier method of contraception is also essential. the pill’s much-vaunted freedom has been bought at a price, for it has allowed people to have sex literally without consequence, ushering in an era of greatly relaxed attitudes to sex. These have paved the way for our current sexual live-and-let-live mores. This is what we wanted, but did we ever realize that it would involve thousands of teenage pregnancies every year?
Perhaps, however, the pill has allowed us to return to primate-like behaviour. Our closest cousins, chimps and bonobos, are extremely promiscuous. the pill allows us to emulate their behaviour, without the consequences, despite the brain’s attempts to corral us to ‘the one’ with shots of bonding oxytocin.
Hormone replacement therapy for menopausal women ushered in another revolution. Women were no longer consigned to the scrap heap at forty, considered old in our mothers’ day. With juiciness preserved by HRT, they showed that there was no deterioration in thought processes between a woman of thirty-five and one of fifty-five and both could be fabulous. They went out, they took no prisoners and they took exercise, watched their diets, looked after themselves. It was all part of the HRT experience and, I suspect, part of the reason for much of the beneficial effect first seen with HRT. For women that took it, HRT allowed them to reclaim their middle years and count them as an extension of youth. And, significantly, it pulled all women in that age bracket into its youthful embrace, even those who did not take HRT, shifting perceptions so that sixty became the new fifty. Without HRT, it is possible that this decade-warping effect would never have happened, and certainly, if it had happened, that it would have arrived far later.
Some people say that humans have outgrown their hormones, particularly their stress hormones, which were originally tailor-made for a caveman lifestyle of hunting and being hunted. Surely, having a stress hormone response to someone cutting you up on the motorway is over the top? Actually, I don’t agree. We have evolved to survive and to ensure that the human race survives and who knows what we face tomorrow? Our hormones are still fit for purpose.
Where we do need to take care is in ensuring that a generation of children are not blighted by the consequences of their mothers’ poverty and despair. For despite everything the body does to attenuate the hormonal stress response in pregnancy, too much maternal stress will irrevocably reset the baby’s stress thermostat, condemning a child to a greatly increased hormonal stress response, and to all the consequences of ill-health and unhappiness that may follow.
PUBERTY
Hormones have not been kind to today’s teenagers. We have seen how the age of puberty has been falling, linked as it is to better nutrition and higher body fat content. Conditions of plenty have caused confusion, as reproductive hormones course through ten year olds, creating women’s bodies with the minds of little girls. Worse, puberty is a time when the brain makes adjustments to those centres controlling executive action, making teenagers particularly unsuited to coping with the adult decisions that they now need to make. In my view, we have to accept that girls with women’s bodies are the price of affluence, but we also need to find ways to protect young girls (and to an extent, young boys) from doing things that they will find hard to live with in later years, that push their bodies and brains beyond their maturity.
As for hormone determinsm – in particular that levels of testosterone decide the future direction of people’s lives – I am suspicious, yet recognize all the same what tesosterone does show us about teenagers – which is that keeping the wrong company can set behaviour, and turn a potential leader into a gang member with no future.
Uniquely Hormoned
We are all uniquely hormoned. What might be the right level for another person to operate at full function might be wrong for us. There are reference values – numbers which provide a guide as to the top and bottom of usual hormone levels – but these are crude. Moreover, blood levels of a hormone may not reflect what is going on with that hormone at a critical tissue level, which makes knowing how much to put back to restore health difficult. In these terms we are still groping for knowledge. This has implications for attempts at mass hormonization – sales of hormones intended for the benefit of the majority, which may be desperately unhelpful, or potentially even very harmful, to the few.
Hormones are now available to treat virtually all the hormone-deficient diseases. Nor are these hormones full of impurities as they were at first, when manufactured from vast pools of donated urine or from tons of sows’ ovaries. Most are produced using bioengineering in a pure, synthesized form or even as designer molecules, such as the new range of insulins. Nevertheless hormone administration is still relatively crude, with most people getting just too much or just too little, rather than providing a complete cure.
If J. F. Kennedy, who had Addison’s disease, the disease of the adrenal glands, had been born five years earlier, or had not come from a rich family able to afford the newly synthesized cortisone he needed, the course of history would have been altered. Nobody need die from Addison’s disease or insulin-dependent diabetes, or the other hormone insufficiency diseases these days but neither is the idea of an instant return to wellness through hormones a reality. Many patients complain of tiredness or other vague problems, reflecting the fact that replacement hormones are a poor substitute for the extraordinary responsiveness provided by the on-board, in-house variety.
Thus it is that aggressive treatment of over-productive thyroids leads to the reverse problem of hypothyroidism, and the use of hormones in assisted reproduction leads to multiple pregnancy. Some of these problems are now being overcome – for instance, the use of individualized and gradual ovulation induction can assure single pregnancies rather than the nightmare of sextuplets.
There are people – usually geneticists – who claim that in the future genetic testing will ensure better use of hormones, with dosing schedules tailored to the individual. Would that it were so simple. The genes causing many endocrine diseases are just a part of the story, since there is multiple interfering, not just from other interacting hormones, but more particularly from lifestyle choices, so that what you might expect to see from your gene testing is completely different from what you actually see in real life. Reports of genetic crystal-ball-gazing in endocrinology are currently not encouraging. What we will see is genetic testing to reveal disease susceptibility, with the result dictating which of several ‘designer’ hormone replacement drugs you might be given. For instance, if you were likely to develop osteroporosis, you might be given a selective oestrogen receptor modulator, that acted powerfully on bone but not on breast or womb.
The lessons of the past are that hormones are not magic bullets, with a precise action; rather they are scatterguns. For sure, they may be aimed at one hormone system in particular, but all that we now know should tell us that no hormone or set of hormones works in isolation. All are linked in a fantastically complex web and what you do to one will inevitably cause a ripple effect throughout the endocrine system.
If all the hormones that are needed for replacement in deficiency are already available, what are the new hormonal treatments of the future likely to be?
Increasingly we will see medicalization of lifestyle issues, with solutions provided by hormones and ferociously hyped by the big pharmaceutical companies, hungry for these vast new markets. We are already beginning to see female sexual dysfunction marketed as a disease state which can be cured by testosterone. Recently, patches have been marketed for women, which have been fast-tracked through the regulatory process in the US, although very little has appeared in peer reviewed literature to support their use, or indeed to establish the true incidence of the ‘disease’ they are treating. We have examined the way in which we seem to be repeating the mistakes of female hormone replacement therapy with testosterone replacement therapy for men. There has already been a noticeable upward drift in levels at which ‘deficiency’ is said to exist.
There is a fair attempt being made to turn endocrinologists from serious academics to purveyors of hormones aimed at solving lifestyle issues. There are two big growth areas. The first is ageing, increasingly being represented as a hormone deficiency state. The current anti-ageing industry is no better, and sometimes rather worse, than the rejuvenators and organotherapists of the 1920s and 1930s. In this sense, endocrinology has moved no further forward since the era of goat gland implants.
Meanwhile, the second growth area and the biggest lifestyle issue of all – obesity – will make someone very, very rich indeed. Obesity will yield to a hormone-based drug, although it may be ten years before we see it. Yet, while the drug companies are relentlessly pursuing a solution to obesity, diabetes, the most common endocrine disorder of all, which has seen no paradigm shifts in treatment for the best part of ninety years, seems to have been overlooked. When Banting and Best made their momentous discovery of insulin in 1921, diabetes was a rare hormonal disease, treated by endocrinologists. Type 2 diabetes was almost unknown. Today diabetes affects between 5 per cent (Europe) and 7.8 per cent (USA) of those continents’ entire populations. Just 5 per cent of those diabetes cases are the insulin-dependent sort, so dramatically cured by Banting’s hormone. All the remainder are Type 2 diabetes.
Type 2 diabetes, caused by resistance to insulin, has been heavily medicalized, with nearly everyone affected taking a cocktail of up to eight different drugs over a twenty-four-hour period to control the consequences of their disease, particularly the cardiovascular problems. Yet in a prediction model for the Dutch population, it was calculated that if increased exercise were to eliminate obesity, it would prevent 75 per cent of all cases of Type 2 diabetes in women, and 64 per cent of cases in men. So what on earth are we doing?
It takes no rub of the crystal to predict that endocrine disruptors will continue to be an issue. For wildlife, they are a disaster, but I wonder whether people will be prepared to pay extra on their water bills each year to finally eliminate all steroid hormones from sewage effluent? I suspect not. As for the harms to the human population, the evidence that endocrine disruptors are important is very slim indeed and it would seem that our own internal hormones are far more dangerous. However, this will not prevent campaigners from claiming that chemicals, specifically endocrine disruptors, threaten human health and should be removed. Meanwhile all those things which have a far more potent effect on our hormones and our fertility – obesity, our sedentary lifestyle and smoking – are ignored.
Hormones rule your internal world. Long may their reign continue.
