With all the recent apparent public attention to the crucial health needs of women, are things really changing for the average woman patient headed to her doctor’s office seeking help? I would honestly have to say that at this point, not a lot has changed for the average woman in this country. In the words of one young woman who recently came to see me for migraine headaches and mood changes before her menstrual period:
What bothers me is that I am thirty-six years old and with all the medical doctors I have seen, only one psychologist (a nonmedical person, who was also a woman), who saw me for four sessions for depression recognized that I may have a hormonal imbalance. It surprises me and makes me angry that I have possibly had this problem for twenty-three years. I always told my physicians my headaches happened right before my period, but they dismissed my ideas. Where is the physician who will listen to my observations about my body?
And this is not unusual. I hear this same story every day from women of all ages, from all parts of the country. There simply is not the information and awareness of just how different male and female bodies really are. The medical establishment is so dominated by men’s thinking and male physiology that women’s different hormonal makeup and health needs are rarely even in the conscious awareness of physicians, much less adequately addressed even by caring physicians. A medical publication in late 1999 illustrates this issue: A woman urologist wrote a review article on interstitial cystitis for publication in a women’s health medical journal. In spite of multiple well-known effects of estrogen on all aspects of bladder function, there was not one word mentioning potential adverse effects in this disorder due to declining estrogen. Yet, look at the profound list of estrogen effects I outline in chapter 12 on the bladder and you will see there are many ways that declining estradiol in the years leading up to menopause could potentially play a role in the development of Interstitial Cystitis. We have a long way to go. After seminars I have given on women’s health, I have had male physicians come to up me and say, “What you are saying makes so much sense. Why hasn’t anyone talked about these connections before? Why hasn’t this been in the medical literature? It certainly fits with what my patients tell me, but I have not known how to put it all together.”
The sad part is that women will guide us in being effective physicians if we will listen to what they say and think about what is happening to them. For the woman quoted above, her migraines did indeed have a major hormonal trigger each month. With treatment to address that hormonal trigger, her recurring premenstrual migraines have been eliminated. She is still susceptible to weather and food triggers for her migraines, but she described feeling an enormous sense of relief that a significant dimension of her migraine problem has been resolved by stabilizing the hormonal changes, a factor she herself had been asking about for many years.
In 1989, the United States General Accounting Office (GAO) audit revealed that less than 3 percent of the National Institutes of Health (NIH) budget had been spent on total women’s health issues, less than 2 percent on obstetrical and gynecological health concerns, and less than 0.5 percent on basic research in the area of breast cancer. Have we made any progress in the years since the GAO first realized women were ignored in most research studies? Yes. Are we where we need to be so women will get the gender-specific health care they need and deserve? No. In fact, we are still a long way away from this goal.
First, let’s review some areas of progress:
1. Federal mandates to include women as subjects in all NIH-funded clinical research trials
2. Launching of the NIH Women’s Health Initiative
3. Establishment of the Office of Women’s Health at the NIH
4. Publication of the results of the Postmenopausal Estrogen and Progestin Intervention (PEPI) trials, the first major U.S. longitudinal double-blind, placebo-controlled study of menopausal hormone therapy regimens. Although this study used only one type of estrogen (native to horses), it did compare synthetic and natural progesterone for the first time in the United States.
5. Discovery of genes linked to hereditary breast-ovarian cancers
6. Discovery of the new estrogen receptor beta
7. Discovery of new causes and treatments for osteoporosis
8. Development of selective estrogen receptor modulator drugs
9. Decline of 6 percent in breast cancer deaths in this country, a trend first noted in this country between 1991 and 1995
10. Passage of more rigid regulatory requirements to improve quality in mammography settings around the United States
11. Improved recognition of the multiple health consequences for women victims of domestic violence and childhood abuse; with increased shelters and support networks for battered women
12. Improved access to prenatal care nationwide—today more than 80 percent of women are getting prenatal care in the first trimester
13. Decline in infant mortality rates, and finally, a beginning decrease in teen pregnancy rates
14. More openness to inclusion of complementary medicine approaches from traditional healing practices of many cultures
15. More physicians willing to discuss hormone therapy options and alternatives with their patients; there is a little less of the “cookbook” approach with Premarin or PremPro for everyone; more physicians are using the bio-identical (sometimes called “natural”) hormone products that are on the market, both commercial FDA-approved ones such as Estrace, Vivelle, Climara, and Alora, as well as ones compounded by specialty pharmacies
16. More extensive use by physicians of the serum (blood) hormone tests that are the gold standard for reliable hormone levels in menopause and perimenopause research, particularly in the international menopause field
17. FDA approval of two new natural progesterone commercial products (Prometrium, Crinone) that are typically covered by health insurance prescription plans (whereas the compounded prescriptions generally were not covered by such plans)
18. Improved protection from HMO abuses of patients in a few states that have passed patient protection bills (Texas legislators were the first to be so progressive in passing a law that allowed patients to sue their health plan for adverse outcomes that occurred due to denial of care, although this bill passed without Gov. Bush’s support.)
19. Formation of new consumer groups for women’s health
20. Establishment of new medical journals devoted to women’s health
21. Increase in newspaper and magazine articles and television and radio programs on women’s health topics, regardless of their accuracy, depth, or focus
22. Increase in hospital-sponsored women’s health programs that address health concerns beyond birthing and childcare
23. Increased numbers of women taking charge of their health and not settling for answers that don’t make sense, seeking new opinions and changing physicians when needed
24. Most importantly, women doing what we have always done: networking with each other, starting self-help support groups, nurturing each other, and making efforts to ask questions and to learn more about our individual and collective needs
However, we still have a long way to go. Much more work has to be done by all of us with an interest in women’s health and a commitment to sound, responsible approaches. Fundamental and basic hormonal effects must be addressed to better understand crucial needs in health care for women. For example, it is well known clinically that the menstrual cycle is an important factor affecting drug metabolism and interactions; yet, few systematic studies have been done to determine exactly how best to adjust medication dosages according to the menstrual cycle. These clinical observations of menstrual cycle hormonal effects on medication and disease severity and frequency have been observed in areas as diverse as herpes outbreaks, epileptic seizure activity, allergies, migraine headaches, yeast infections, bipolar affective disorder, and depression. But we still have not studied HOW hormonal changes affect these cyclic changes in various disease flare-ups.
Drs. Buchwald and Garrity, authors of a 1994 study of similar clinical patterns in chronic fatigue syndrome (CFS), fibromyalgia syndrome (FMS), and multiple chemical sensitivities (MCS) looked at many characteristics of these clinical problems more common in women. They did correctly identify these disorders as being much more common in women in their forties. Yet, there was not one word in the study about, or any methods used to assess, possible ovarian hormonal factors contributing to these diseases. Interestingly enough, both researchers were women, so we can’t just sit back and say men don’t listen. It seems incredible to me that in the era of “gender-based medicine,” not even women physicians were addressing such an obvious potential trigger factor as the ovarian hormones. The blind spots are overwhelming, and health care professionals must remove the blinders when conducting women’s health studies.
The relationship of premenopausal hormone changes to a variety of disorders seen more commonly in women, such as depression, fibromyalgia, and migraines, have also not been adequately addressed. I have included a chapter on each of these important subjects because each one affects women much more frequently than men. The fluctuations and declines in hormone levels are normal physical changes that may have a significant impact on premenstrual and premenopausal sleep and mood changes.
Mood changes in the years before menopause (from about age thirty to age fifty) have traditionally been assumed to be primarily the result of life stresses and psychological transitions, but almost nothing has been done in systematic research to study hormonal effects on the brain as a factor causing these problems. We live in a culture that hasn’t even been fully convinced that women have a brain, much less that it is connected to the body. If you think I am being too harsh, just look at the cartoons, ads, and body images used to sell products and present health information and notice how many headless bodies there are and how many jokes are printed daily about “brainless” or “nutty” women. We must remember, the brain is connected to the body, and hormones are one of the most potent chemical messenger systems affecting the brain and all its functions, including, of course, mood, sleep, and memory. In particular, both estrogen and progesterone have profound effects on the serotonin, norepinephrine, dopamine, and endorphin receptor systems that are involved in mood regulation; yet, almost no clinical research has integrated these findings to identify effective treatment regimens for premenopausal women. Because this crucial information is so woefully neglected in women’s health, it is a major focus of this book.
In the past, women have been excluded from health and medical research studies for a variety of reasons, including the presence of the very hormonal changes that need to be studied. Here are some of the complex factors that have contributed to the problem:
• The hormonal cycling and complexity of women’s physiology were considered “background noise” that complicated study design.
• The male body has been considered the “norm.” What was learned about men was assumed to apply equally well to women.
• Research done on males without hormonal cycling was deemed to be more reliable. The bias against excluding women in research studies had even extended to a preference for male laboratory rats.
• Men dominated the research-funding committees, medical school, and university research settings, and they determined where the dollars went and for what types of studies.
• Most disorders that were known to be more common in women, such as migraines, FMS, MCS, et cetera, were assumed to be primarily psychological in origin and not as important to study as the “real” diseases more common in men.
• Women in general, until the past two decades, have been almost invisible, apart from their reproductive functions, in our culture as a whole.
Women’s invisibility in health and medical research also extends far beyond what I have just described. For example:
The Baltimore Longitudinal Study of Aging was started in 1958 but excluded women until 1978. The last major report was published in 1984 and was titled Normal Human Aging, and this report contained no data on women. It appears that, even though women generally live longer, in this research, women weren’t even considered “human”!
Bernadine Healy, M.D., the first woman to be appointed director of the NIH, said,
It is now time for a general awakening. Women have unique medical problems. They have greater morbidity [medical term for suffering, disability] than men and are affected by more chronic debilitating illness. Although women live longer than men—i.e., as much as seven years on average—the quality of life of those years is exceptionally burdened by cancer, particularly of the lung, breast, and colon, by heart disease and stroke, osteoporosis, depression and social isolation, Alzheimer’s disease and general frailty. These conditions, which tend to afflict women in the last third of their lives, are not the inevitable ravages of age but are in many cases highly preventable and eminently treatable. We must awaken fully to these facts and address the diseases of women as different from the diseases of men but of equal importance.
To illustrate Dr. Healy’s point about the quality-of-life concerns for elderly women, osteoporosis alone is a major factor in the increased cost of health care and the rising need for nursing-home care for elderly women. It is striking that over 75 percent of nursing home residents over sixty-five are female. The even more tragic aspect of this statistic is that women in this age group who end up so debilitated that they are forced to be in nursing homes are suffering from diseases that are largely preventable through early education about risk factors and emphasis on healthy lifestyle changes.
What contributes to women not getting the information and education they need on these potentially preventable later-life diseases? One factor is clear: The media imbalance in focusing predominately on breast cancer has significantly distorted the real health issues that affect you as you grow older and adversely affect your quality of life: The disabling and potentially deadly conditions of osteoporosis and heart disease.
Osteoporosis has become a national health epidemic, with $8 to $10 billion spent annually on health care for osteoporotic-related fractures and subsequent long-term disability. And these figures do not include the dollar and human cost of pain and suffering or the devastating effects on quality of life. A hip fracture is definitely not easily resolved by a “total hip replacement,” as a popular magazine solution would have you believe. After a hip fracture, nearly one in five women die from complications within three months, and 50 percent never walk independently again. Pretty scary, I think. I am concerned that women do not get an accurate picture of the consequences of bone loss and osteoporosis complications, especially since greater emphasis on preventive approaches to osteoporosis in the twenties, thirties and forties, could dramatically reduce the frailty and debilitation seen in older women.
The issues of older women and bone loss represent only the tip of the iceberg of the potential osteoporosis epidemic in this country. We aren’t even really addressing the millions of young women who are starving themselves to be thin to reach some “magazine ideal” for their bodies. In the process, they are losing bone at the very time in their lives (teens, twenties, and thirties) when they should be building bone toward peak bone density. These women do not even arrive at menopause with optimal bone density. Often, however, they appear healthy on the outside and don’t even know that “silent termites” are eroding their bone from the inside. We think these young women look “great,” “healthy,” “vibrant” because they are thin. The “thin look” is what we have been conditioned to think is normal. But women need about 20 to 25 percent body fat in order to have normal menstruation, fertility, bone growth, hair and nail growth, and other measures of good health. I assure you, the models you see in most of the magazines have less than the 20 percent healthy body fat level. Have you had your body composition checked recently?
Alcohol is another area of challenge in women’s health. Alcohol abuse and alcoholism hit women harder than men in all dimensions: physically, on the body and brain; psychologically; financially; and sociologically. I include it as another one of the risks you don’t hear much about relative to other topics in the popular press. A 1990 study in the New England Journal of Medicine, by a team of Italian and American researchers, revealed that women had smaller quantities of the protective enzyme alcohol dehydrogenase, which breaks down alcohol in the stomach, and that as a result women absorb about 30 percent more alcohol into their bloodstream than do men. The researchers also made another startling discovery: Alcoholic men have about half as much alcohol dehydrogenase as healthy males do, but alcoholic women show almost no enzyme activity. The researchers concluded that alcoholic women appear to lose all gastric protection in the absorption of alcohol; this is one of several reasons alcohol hits women harder and sooner than men.
I hear from women around the country who are terrified of breast cancer. I understand this fear. Did you know, however, that cigarette smoking represents one of the worst threats to women’s health? In 1991 alone, 51,000 women died of lung cancer, and 191,000 new lung cancer cases were diagnosed in women. In 1965, there were 14,000 tobacco-related deaths in women; in 1995, there were about 240,000 tobacco-related deaths in women, almost SIX times the number of breast cancer deaths.
Tobacco use is a hidden epidemic that is killing women. In 1986, lung cancer became the leading cancer death in women, exceeding breast cancer, and remains the leading cause of cancer death in 1999 (American Cancer Society 1999 estimates: 68,000 to 43,300). The dramatic rise in lung cancer in women is directly attributable to the rise in smoking among women since World War II. But 90 percent of women still think their leading cause of cancer death is breast cancer. Other disease risks associated with smoking include heart disease, early menopause, osteoporosis, emphysema, infertility, miscarriages, low-birth-weight babies, and possibly ovarian and breast cancer. Adolescent and young adult women are beginning to smoke in alarming numbers. Those of you who are mothers, take note of this: The fastest-growing group of smokers in the United States are girls under age eleven.
Why don’t you know this? The bottom line is money. All the women’s magazines except Good Housekeeping and Ms. (which accepts no advertising at all) in the United States are heavily supported by advertising from the tobacco companies. Women’s magazines, whose bottom lines would be jeopardized by offending their large advertisers, have not been running stories on the health consequences of cigarette smoking. A study published in the Journal of the American Medical Association objectively documented the correlation that had been long suspected: The greater the percentage of advertising revenue from tobacco companies, the less likely a magazine was to publish any information on the health effects of tobacco use. Go back and look at your typical women’s magazines. How many articles about lung cancer in women do you find? How many full-page color ads do you see showing pretty, smiling, thin young women smoking?
Cigarette smoking has been shown to cause earlier menopause and bone loss both in female smokers and in nonsmoking women whose spouses are smokers; yet, the number of women smokers is increasing, not decreasing. Fewer women than men quit smoking. Reason? Women value their appearance more highly than their health, thinking, “If I quit smoking, I’ll gain weight.”
The bottom line is that tobacco companies sell glamor, glitz, thinness, and an image of good health in advertisements that specifically target young women to buy a product that will enslave and potentially kill them. Just as we were outraged over the inadequate research and funding for breast cancer, we must raise our voices against this larger threat to the health of the next generation of women, our collective daughters. Cigarette smoking has been found to impair fertility, although the components of cigarette smoke that are toxic to ovarian follicles are unknown. Cigarette smoking has also been implicated as a factor that increases the risk of breast cancer, perhaps by increasing cell mutations. If this turns out to be as important a link as many physicians and researchers suspect, women will have been sold literally a lethal bill of goods. Yes, “you’ve come a long way, baby.” But is more disease what you intended or wanted? Smoking-related costs and deaths affect us all, whether we smoke or not, whether we have daughters or not. We must all have the courage to speak out to stop the glamorization of cigarette smoking and help our young people, especially vulnerable adolescent girls, make the choice not to start smoking.
Eating disorders are other behind-the-scenes problems that affect women in enormous numbers, but rarely generate the same degree of media interest as topics like breast cancer. The cultural “thinness mania” began with Twiggy in the 1960s, continued with the 1993 “waif” look, and is still present in 1999 with the character Ally McBeal and a host of other popular stars. Idealizing extreme thinness in the “star” culture has created a female obsession with weight, dieting, and being thin no matter what the price to one’s health. The ads bombard us constantly with headlines and images: Change your body. Change your self. Fix your flaws. Blast those jiggly hips and thighs. Get that tummy FLAT. Have a “tummy tuck” (major surgery and painful recovery, but they don’t mention that in the ads). Become new and sexy, more attractive and exciting to your man: Spray, powder, paint, nip, and tuck your body until you reach PERFECTION. No matter the cost.
The idealized female body shown in our magazines is thin, bony, slouched, lean, and usually devoid of the normal female curves. These images have been a major factor in the creation of a multibillion-dollar diet industry in the United States, largely aimed at YOU—the women. These ads and images play on our cultural obsession with thinness to ensure continued sales of products. It is an entrepreneur’s dream: Sell the same products over and over to the same group of people. The reason it tends to be the same group of people is that 95 percent of people who go on repeated quick-weight-loss diets end up regaining the weight they lost, and usually an additional five or ten pounds. Chronic “yo-yo” dieting has a major adverse effect on your health; going on and off diets stresses the heart, brain, bones, and other organs. Excessive thinness is associated with increased cancer risk, early menopause, osteoporosis, ulcers, anemia, and emphysema. There has been little research done on the connection between underweight and illness. The preliminary evidence suggests that it is actually healthier to be a little overweight than to be chronically dieting, going on and off fasts and other quick-fix approaches. Chronic dieting can be lethal. With the increased participation in women’s athletics at all levels, perhaps the image of the active, exercising, healthy female will prevail.
Prevention of osteoporosis is a compelling reason for prescribing estrogen to postmenopausal women; yet, many of these women are reluctant to take estrogen because of the distorted picture in the media about the risk of breast and uterine cancer. In an article entitled “Endometrial Cancer From Estrogen Replacement Therapy (ERT): An Unfounded Fear,” distinguished menopause researcher Dr. R. Don Gambrell reported that the absolute risk of endometrial (uterine) cancer is quite small, occurring in one in every thousand women over age fifty each year. This type of cancer is easily detected, very treatable, and less aggressive in women using hormones than in women who are not on hormone therapy. Dr. Gambrell also stated that estrogen itself is not carcinogenic. In patients diagnosed with endometrial cancer while on estrogen therapy, the five-year survival rate is 95 percent, a significantly better survival rate than that of women diagnosed with endometrial cancer who are not on estrogen therapy. Many specialists think that the type of cancer that occurs in women who don’t take hormones is a more aggressive form of cancer than in those who do take hormones. You don’t see this information in the magazine and newspaper articles. It disturbs me, both as a physician and as a consumer, that the available information is not more balanced and current.
Breast cancer is another example. Women who are on estrogen at the time of diagnosis actually have been found to have less aggressive forms of breast cancer, better treatment outcomes, and longer survival times. But you don’t hear about that data either. Estrogen has never been shown to cause breast cancer, yet this is the impression that the majority of women have from reading the popular press articles. Yet another example occurred the week of January 24, 2000. A study published in JAMA reported that women using the combined estrogen-progestin combination had a higher risk of breast cancer than women using estrogen alone. But in my view, one of the most crucial points of all was omitted from national media reports. This point was that Premarin and medroxyprogesterone acetate (MPA or Provera, a synthetic progestin) were the hormone products used by the women in this study, and both of these products are “unnatural” hormones for the human female body, with very different effects from those produced by our own ovary hormones. It seems such an obvious point, and even the study authors failed to mention this in their conclusions as a limitation of the study. I will talk more in chapter 14 about these critical issues with regard to what information you get about breast cancer and how this information is presented. The same types of incomplete or incorrect information are perpetuated in article after article.
Fact You Are Not Told:
Heart disease is an equal-opportunity killer. It is the number one cause of death in women over forty—yet it is generally assumed to be a disease of men. Prior to the Nurse’s Health Study, women had been excluded from every major study of heart disease prevention, diagnosis, and treatment.
Women who are seen in the Emergency Room for chest pain and palpitations are far more commonly given a diagnosis of “anxiety” and sent home with a prescription for a tranquilizer rather than having a full evaluation for heart disease. Young women may die when true heart disease is missed. See cases I describe in chapter 13. Men with similar symptoms are more likely to be kept overnight to rule out a heart attack.
Fact You Are Not Told:
Between the ages of forty to sixty-five, almost 500,000 women die each year from cardiovascular disorders, versus 60,000 deaths annually from all reproductive cancers: breast, uterine, cervix, ovarian, and vaginal. But women and their physicians often don’t think to start screening for heart disease risk factors in women in their forties.
Fact You Are Not Told:
A 1991 study published in the New England Journal of Medicine provided further evidence of sex bias in the management of coronary artery disease: Women were significantly less likely to have prescribed coronary angiography, angioplasty, or bypass surgery when admitted with a diagnosis of myocardial infarction, angina, chronic ischemic heart disease, or chest pain. Men are routinely offered these options. In 1999, 44 percent of women—but only 27 percent of men—who have a heart attack die within a year, because men are treated more aggressively earlier.
Fact You Are Not Told:
Postmenopause estrogen therapy (ET) dramatically reduces (more than 50 percent in recent studies) risk of heart disease and osteoporosis, yet less than 15 percent of postmenopausal women take estrogen, in part because of an exaggerated fear of breast cancer in media reports, and lack of adequate information and screening for individual health risks.
Despite the fact that a natural human form of estradiol has been FDA-approved in the United States since 1976, women in this country are usually given only one recipe for hormone therapy [I call it the “cookbook approach” with Premarin and Provera or PremPro]. Rarely are other options offered to women, even if they have adverse reactions and unwanted side effects with the standard therapies.
Fact You Are Not Told:
The United States is 20 years behind Europe in our options for natural hormone therapies for menopause. In other developed nations, many different forms of native human estradiol, progesterone, and testosterone are routinely prescribed.
How many of these facts and health risks did you already know? I suspect not many, since these don’t often make the headlines. The more you look at coverage of women’s health, the more you see the imbalance in focus on topics that are more likely to have an emotional “hook” that gets you to buy the magazine. The distortion in risk has an impact on choices women make in lifestyle changes as well as other interventions to reduce disease risk.
My intent is not to make this a political book. I raise these issues for three primary reasons: (1) to help you see the undercurrents that enhance or distort the health information you receive, (2) to paint an overall picture for you to critically evaluate, and (3) to emphasize the importance of YOU being active in getting information YOU need to make YOUR OWN decisions. When you become an informed consumer working with your physician to individually assess your various health risk factors, you can select the options that best meet your individual needs. What are some of these challenges that still lie ahead during the new millennium? What are some of the impediments to greater improvement in the delivery of health services tailored to the unique needs of women? The following are a few that I see and ones I hear from women consumers.
• Cultural stereotypes of women as hypochondriacal, stressed, neurotic, anxious, or depressed. These stereotypes prevent physicians from looking carefully at underlying causes of symptoms. Such symptoms may have many different causes: from psychological ones such as a history of sexual abuse or domestic violence to physiological ones such as premature decline in ovarian hormones.
• Restrictive HMOs and “managed” (rationed) care plans. These plans abysmally fail to see the importance and cost-effectiveness of properly assessing women’s body chemistry, including hormone levels. In our practice, we encounter daily examples of such shortsighted thinking: health plans that would rather pay $100–200 every month for Prozac or Zoloft or Celexa, but say “it’s too expensive” to check hormone levels and find out that what a woman may need could be thyroid or ovary hormone options that might cost $20 a month.
• Focus on use of “magic bullets” for menopause, PMS, and peri-menopause, including soy supplements, progesterone and “wild yam” creams, OTC forms of DHEA, and melatonin. All of these have potentially harmful effects for women who are already having thyroid or ovarian hormone imbalances. See chapter 16 for critical information on ovarian effects of soy products. Consumers do not usually get this information from their health professionals because most physicians are so overwhelmed with just keeping up with the basics of medical therapies that they are unable to keep up with all the newest supplements. And even doctors get mixed information. As an example, in the summer of 1999, the U.S. medical journal Menopause ran two-page color ads for a red clover isoflavone supplement called Promensil. This happened the same month the international journal Climacteric published the first two placebo-controlled, prospective, randomized, double-blind studies showing that Promensil had no effect greater than placebo on any of the menopausal symptoms measured, including objective measures of estrogen effect. That same month, I received my copy of Menopause Management (a U.S. journal sent to doctors all over the country), and this journal went a step further in promoting soy products—they actually shrink-wrapped with the issue an advertisement and a sample soy protein drink package. Personally and professionally, I found this offensive in view of the very mixed results on soy’s effectiveness and its known potential problems for women with thyroid disorders and early ovarian decline. I was pleased to see that the international editors of Climacteric took a higher road than the U.S. journals: They wrote a position statement that the international menopause journal would not accept advertising for any health product that had not been proved to be effective on the problems for which it was advertised.
• A spate of books with conflicting, out-of-date, or just plain inaccurate information about female hormones and the options available to restore a healthy balance. Books in this category that are designed to sell the authors’ various products end up having the tragic result of leaving consumers more confused.
• Continued dominance of a “cookbook” approach to hormone therapy using one form of estrogen (derived from pregnant mares’ urine) dominating more than 85 percent of all ERT for decades, whether women feel well on it or not. This reliance on the oldest product occurs in spite of options available in the United States since 1976 using hormones identical to those the human ovary makes. Using one product in the same dose for every woman doesn’t make sense to thinking consumers. They know that we don’t approach any other areas of health care that way. Can you imagine giving every patient with an infection the same antibiotic? Do you think that all diabetics are prescribed the same dose and type of insulin? Are all men with heart disease given the same type of medicine? Of course not. So women reject such a one-size-fits-all approach. Study after study on hormone use in the United States has shown that about two-thirds of women who start hormone therapy discontinue it on their own within a year; over a third of women given a prescription never have it filled and usually don’t tell their physicians. One of the primary reasons for this is that women are individuals and require individualized hormone therapy—a concept that makes intuitive sense to women, who then decide not to use the standard “recipe.”
Why does this “cookbook” approach to hormone therapy exist? Because gynecologists, family physicians, and internal medicine physicians have not been adequately trained in the finer nuances of individualizing and fine-tuning hormone therapy. There was little emphasis on this in either medical school or specialty training. Many physicians get their primary information from drug manufacturers. The company with the largest market share has also the largest budget for advertising and marketing, and obviously focuses its educational efforts only on its product rather than the many options now available from competitors. In addition, with the limits imposed by HMOs and other forms of managed care, physicians don’t feel they have enough time to spend with women to explore options and answer hormone-related questions.
• A lack of comparative research on the different effects of the various types of estrogens and progestins. As a result, women are often told by their physicians, “we don’t know enough about natural hormones.” Most of the hormone studies done in this country are financed by grants from the makers of the conjugated horse-derived estrogen product.
• The continuing focus on fear to sell products. The fear of breast cancer is used as a tactic to sell new and expensive medications called “designer estrogens” as well as soy supplements and Chinese herbs with unknown components. Instead of educating women with balanced articles, we are inundated with fear tactics, leading many women to develop a terror of estrogen.
• The limits of modern medicine in being unable to heal many patients—the majority of whom are women—who suffer from chronic debilitating disorders. There is a marked female predominance in many of the common, chronic disorders that rob sufferers of quality of life, work productivity, social involvement, and money both in direct dollars spent on health care and indirect dollars from lost productivity or work time. Disorders such as arthritis, migraines, fibromyalgia, depression, anxiety, dementia, asthma, diabetes, allergies, chemical sensitivities, environmental illness, incontinence, osteoporosis, autoimmune disorders, thyroid disease, and others affect women in numbers far greater than men.
• A dichotomy between physicians’ thinking and approaches oriented to treating disease versus consumers, particularly midlife women, focusing on healthy “natural” approaches for staying well. Women are identifying that there is a hormone connection to the symptoms and illnesses they are experiencing, but they are getting turned off by the doctors who are discounting what they are saying . . . this leads them to turn to alternative sources for information and treatment (some reputable, others not—and it is hard to differentiate between the two). Many consumers have become so disenfranchised by traditional medicine that they are questioning everything a physician says and are wary of all prescription medications—but will try anything “natural” or over-the-counter, thinking it must be safe and have no side effects because it comes from a health food store. Yet we need to remember that there can be harm from “harmless” therapies—such as taking a supplement thinking it will preserve bone, only to find out a few years later that it did not and osteoporosis has developed. I have seen some of my patients who have experienced such frustration with the way traditional medical settings and physicians have functioned become so enamored with complementary or herbal medicine that they attribute all of their benefits to the alternative approaches and nothing to the traditional medical treatments they are receiving at the same time.
Additional problems include the media’s substantial role in perpetuating other stereotypes that adversely effect women. Think of the many negative labels applied to women: anxious, overworried about their health, complainers, difficult patients, crocks, neurotic, emotionally-starved, empty-nesters, ditherers, bitchy. As a culture, we laugh at the cartoons about PMS, and we do not take seriously the women who struggle with the problematic symptoms of PMS that can at times be severe enough to adversely affect work, family, and social relationships. Feminists complain that physicians try to make PMS a psychiatric disorder. Women who have PMS complain that physicians aren’t listening. Many physicians who have worked extensively with PMS patients are frustrated that the culture trivializes and discounts the very real physical and psychological symptoms of PMS to such a degree that even physician advocates don’t get listened to when we try to speak up on behalf of our patients.
Women with breast cancer have been treated as breasts rather than persons. One woman wrote an eloquent piece about her experience in a cancer center, describing her depersonalized treatment as feeling like “a piece of baggage on an airline baggage carousel,” going from one physician to another. When women do speak up about their health care desires and needs, they tell me over and over they are then labeled “difficult, demanding” by both nurses (still mostly female) and doctors (still mostly male). How is a woman to figure out what to do? My personal advice is for her to be a well-informed, knowledgeable, articulate “squeaky wheel” armed with thought-out questions, organized symptoms, and a brief history.
Older women in this country aren’t valued for their experience and wisdom as we see in countries of Europe and Asia. So if menopausal women aren’t valued as being very important, then perhaps it isn’t “worth” taking the time to work out an individualized approach. Older, menopausal women are also viewed as complainers, so they are often just given the standard approach and sent home.
To illustrate my points, here is an exercise I would like you to do now, as you are reading this:
TASK: Quickly write down the first three words that come immediately to mind with the phrase “An older man is __________.” Just spontaneously fill in the blank with whatever words pop into mind. What did you come up with? Now do the same thing with this phrase: “An older woman is __________.”
Do you see any pattern to your responses? When I ask these two questions in my seminars, the words that most frequently come to mind in the audience for describing older men are “distinguished,” “successful,” “powerful,” “attractive.” I rarely hear a negative word used to characterize older men. The common audience responses for the statement about older women are words like “dowdy,” “old,” “tired,” “fat,” “alone,” “invisible,” “poor,” “over the hill,” “unattractive.” These stereotypes of older women are so deeply ingrained in our minds that we don’t even consciously realize how differently we view aging men and women. We can’t help but feel these images and incorporate them into our sense of self. The cumulative impact for women, adds up to an even lower sense of self-worth as we grow older, since we have been part of the culture far too long to easily shrug off such belittling messages. We need to know such stereotypes are alive and thriving in our culture in order to understand why our questions and concerns are frequently overlooked or ignored.
“Healing wisdom” is women’s intuitive sense about body changes and what might be the cause. Women have been living with body changes since adolescence and recognize when their body is out of sync, and they often have ideas about why. They want to be affirmed and informed and involved. Without research specifically taking into account women’s body chemistry, however, physicians are hampered in suggesting what changes to make or how to make them. If scientific advances were able to put a man on the moon in 1969, why haven’t we been able to determine whether we can give a woman half an aspirin a day to help prevent strokes or whether medication should be adjusted according to the menstrual cycle?
I have been making medication adjustments based on the menstrual cycle phase for my patients for about fifteen years, but this is not an approach I was taught in medical school or found in the medical literature. I learned it by listening to my patients, and by observing cyclical patterns to their experiences. Women’s body wisdom knows the hormonal rhythms; women’s mind wisdom knows there are connections to these hormonal shifts. It is a magnificent symphony each month, but sometimes one section may be out of tune with the rest, creating discord and disharmony. Women know this, feel it, observe it, ask good questions about it. This is another aspect of what I mean by women’s body wisdom. Why have health professionals not done a better job of paying attention to and heeding what our female patients have been telling us for decades?
One answer may be that our scales and formats of evaluation are a result of research based on males and male body physiology and the assumption that those findings would apply equally well to female patients. Of course, this assumption of similarity ignores a fairly obvious fact: Women’s body chemistry and hormonal cycles are markedly different from men’s. Symptoms female patients report may not fit in any one column or they may cut across several columns. I keep reading about diseases that are 60 percent, 70 percent, or 80 percent female predominant, followed by comments such as, “We don’t know why there are these gender differences.” There is rarely ever mention of studying the most obvious factor that differentiates males and females: the hormones that make women female! Why have we overlooked or ignored researching something so obvious? It certainly isn’t because women are unwilling to accept a hormonal connection. We already know it is there. Women would like to know more about what it is and what to do about it.
This book is about these overlooked and ignored hormonal connections; what we do know about hormonal effects on brain-body systems and how these hormonal effects interact with the endocrine, immune, metabolic, cardiovascular, respiratory, musculoskeletal, reproductive, urinary, and nervous systems. Every cell of our bodies participates in the flow of our menstrual rhythm. Changes occur in almost all body functions and secretions as the levels of female hormones rise and fall every month. These changes have been measured and objectively documented in many factors as the following partial list illustrates.
Menstrual Cycle Measurable Body Changes
• body temperature
• blood glucose regulation
• breast size, texture, skin/nipple color
• energy levels and sleep patterns
• neurotransmitter production
• thyroid and adrenal hormone production
• red and white blood cell counts
• fluid balance
• skin color, texture, permeability
• respiration functions: CO2, O2
• blood pH
• memory and concentration
• citric acid (Vitamin C) content of mucus
• brain wave (EEG) patterns
• heart rate and rhythm
• balance, fine motor coordination
• ESR (“sed rate”) measure of inflammation
• pupil size and reactivity
• platelet counts
• basal metabolism rate
• estrogen levels in blood and urinary metabolites
• progesterone levels in blood and urinary metabolites
• levels of brain hormones
• bile pigments (to digest fat)
• blood levels of adrenaline
• body weight
• GSR (galvanic skin resistance)
• pulmonary (lungs) vital capacity
• blood protein levels and amounts
• vaginal mucus characteristics
• vaginal cytology (cell types)
• visual, auditory, olfactory acuity
• serum bicarbonate
• pain threshold
• feeling state and behavior
• Concentrations of vitamins A, C, E, and B group
• cervix changes: size, color, position
• urine volume, pH, specific gravity
© Elizabeth Lee Vliet, M.D., 1995, revised 2000
Does this list begin to give you an idea of just how profound the relationships are in every part of our body to the changing hormone levels each month? It seems to me there is a wealth of opportunity to study these and learn ways of working with women’s natural body cycles for optimal health and well-being.
The Women’s Health Initiative (WHI), launched by Dr. Bernadine Healy and the NIH in the early 1990s, was long overdue and much welcomed by physicians, health professionals, and researchers in many fields, as well as by patients. The landmark decade-long study focused on the effects of hormone treatment on breast cancer risk, the role of diet in contributing to cancer, the effects of taking or not taking hormones on weight gain after menopause, and the effectiveness of estrogen in preventing bone fractures and in modifying heart disease risk factors. The WHI study results are due to be reported in 2005. Other major studies of medications are being implemented to specifically include women and to address public outcry over the lack of such information, but even these studies aren’t optimal. Only one type of estrogen, derived from horses and not natural to a woman’s body, has been used in most of these studies, and this product doesn’t even deliver adequate levels of the native human estrogen, 17-beta estradiol. As a result of using only this “foreign” estrogen, even the WHI results won’t provide all the answers we had hoped to find about the overall benefits of 17-beta estradiol. We still have a long way to go. We need to keep the pressure on. It helps that women’s interest groups have taken up the banner and are raising the public consciousness and politicians’ awareness.
We as women also need to challenge medical schools to see that they are in a primary position to elevate awareness of gender concerns in the new generation of physicians. I am a strong advocate of having continuing medical education (CME) programs better designed to address the male-female differences in disease recognition and treatment. I have designed a number of CME programs with this integrated approach.
Pharmaceutical companies must demonstrate their involvement in increasing the knowledge of male-female body/mind differences through research and support of educational programs for all health professionals as well as consumers. It is very aggravating to me that some of the same groups who criticize physicians and “those bad drug companies” for such jointly sponsored programs are often the same people who have a vested interest in their own products: vitamins, herbs, over-the-counter hormone creams, evaluation kits, self-improvement tapes—you name it.
Women have sometimes asked why I agreed to be on national speaker’s programs that have educational grants from pharmaceutical companies. Although I resigned my position on all of the pharmaceutical-sponsored speakers’ bureaus as of 1998-99 to maintain complete independence from potential commercial sponsors, this is why I participated in the past:
• I would convey the message I knew to be sound, based on insights taught by my patients and my clinical experience, based on basic principles of normal physiology and current science, regardless of who was providing financial support. If a company or organization did not agree with my position and my clinical program content, then they didn’t invite me as a speaker. I have continued to be alarmed by the fact that women are not told about available options such as FDA-approved products of natural hormones. If there are products on the market deemed safe by the FDA, and they are ones I would use myself or recommend for my family and patients, wouldn’t you want me to also be telling you about such options?
• I want to advance the knowledge base in women’s health issues by speaking to as many groups of both consumers and practitioners as possible, and I believe it is part of the social responsibility of for-profit companies to invest some of their profits back into the educational process. Educational grants from large companies are one way to accomplish these goals.
I don’t have many illusions about what has motivated the current surge of interest in women’s health when many of us have been “screaming to be heard” for many, many years. Women’s collective economic clout is finally too great to ignore any longer. Collectively, we women have in our hands about 500 billion health care dollars. Two out of every three health care dollars are spent by women. With $500 billion in our pockets, we ought to be more demanding, more assertive about getting our needs met. Our economic potential gets the attention of businesses in all sectors.
Even women’s health has become a hot topic, getting more attention in magazines because it sells. Have you noticed how many new women’s health newsletters have popped up in the last few years? Many of these contain the same information recycled in a new design. There is very little that I have read in any of these “new” newsletters that is truly cutting-edge information for women. You are buying magazines and books because you are hungry for the information and answers. I am glad to see more such articles, newsletters, and shows on these topics. I also want to see information available that is sound and up to date, not just perpetuating old myths and old polarizations. I say to all of you: Be aware of underlying motives that may bias the selection of information presented, and evaluate carefully what you hear in the news, in magazines, in health education programs, in conversations with friends, or wherever. Follow the “money trail”—if the author or speaker is trying to get you to buy products on which they make commissions, then you need to be more skeptical of the claims being made. If something sounds like a miracle cure, it is probably too good to be true. Remember, each of us is an individual with different needs. No one approach works for everyone, and no one authority has all the answers for everyone.
Setting the stage for, and implementing, change will continue to be our task in the interest of future generations of women. We can work to see that pressures are intensified in the search for answers by encouraging research and educational activities, and by helping to develop sources of funds to create more health care options and choices for all of us. We must become “activated” patients, in a partnership with our health professionals, to improve communication, increase awareness of the special needs of women’s bodies, and further enhance awareness of gender differences and gender concerns as they impact prevention and health care. We can, and should, “vote with our feet” by changing physicians and other health professionals when we feel we are not being listened to adequately.
Another resource is the increasing number of women in the health professions in all fields. We must be the ones to lead this agenda into the twenty-first century. We can be, and should be, in the forefront of the women’s health agenda efforts. Health costs can be reduced and health care improved by attention to the significant differences between the needs and body chemistry of men and women. You will find in this book some often unrecognized connections, and issues, that are crucial to our understanding of how women’s bodies work. You have known or suspected some of these hormonal connections because you live them. Some will seem so obvious you will wonder why they haven’t been addressed before. Some will make you cry; some will make you angry. “I knew it was real,” women say in my office. “At least I don’t feel like I’m crazy. There’s something going on that now makes sense.” “Finally, someone is telling it like it is and putting it together.” For example, I have drawn a number of diagrams throughout the book to show hormonal connections that seem basic to me. I have never seen these connections laid out like this before. I continue to be astounded by the apparent blind spots about the role of female hormones in so many different body-brain functions.
I have provided a lot of medical information in the chapters ahead. Use this information to become a powerful advocate for your own health and well-being. Write me with your comments, your feedback, your experiences in health care settings, and your ideas or suggestions for how we can all work together to reach our goals to improve the delivery of women’s health care: for ourselves, for our collective daughters’ and granddaughters’ generations. Because of my daily patient appointments and my writing and speaking schedules, I won’t be able to respond personally to your letters. I can assure you, however, that your voice WILL be heard, taken seriously, and I will incorporate your letters and comments into future programs, courses, services, and research in women’s health. Each of you reading this can make a difference. Let’s work together to make the slogan “You’ve come a long way, baby” mean something HEALTHY!