‘She will not become dull and unattractive’: The charming history of menopause and HRT – The Guardian

For centuries the symptoms of menopause were documented, but women went through it with little intervention. It wasn’t until the advent of science as we know it that physicians (all male at the time obviously) started more commonly “treating” its symptoms. It’s clear now they had no idea what they were dealing with, since treatments ranged from the benign (cupping, cold water) to downright mutilation (clitoridectomy, anyone?).

Suffice it to say, the history of misogyny in medicine goes way, way back; all founded in the idea of women as inferior, and of menstrual blood as evil and poisonous. Fast-forward to the early 20th century, when it was discovered that oestrogen, in the form of conjugated equine oestrogen – yes, from horses – could be used as a hormone treatment for the symptoms of menopause. In 1942 the first oestrogen product was marketed under the name Premarin.

Premarin was marketed as not only a “cure” for menopause (which had by this time started to be framed as a disease to be treated) but as a fountain of youth. And it was promoted in ways that to our modern eyes are pretty sexist. Advertising of the era speaks of women’s misery and fear. One ad I found spells it out: “[A woman] is likely to feel that her charm is gone, and the golden days of her womanhood are irrevocably past”.

There were also ads targeted at men, who were obviously the real victims here. “Husbands, too, like Premarin,” said one ad from the 1950s. The hormone pills, men are assured, make a woman “pleasant to live with once again”. A particularly low point was the publication in 1966 of Feminine Forever by Robert A Wilson, an American gynaecologist. In the bestselling book, he called menopause “a serious, painful and often crippling disease”. Even more alarming: “All post-menopausal women are castrates”. Charming.

But no worries – all could be solved. HRT meant a woman’s “breasts and genital organs will not shrivel. She will be much more pleasant to live with and will not become dull and unattractive.” These misogynistic assertions did the trick; the drug companies making HRT – one of which, it was later revealed, had paid Wilson for his trouble – got great value from their stealth salesperson. Sales of HRT quadrupled in the years after the release of Wilson’s book.

One of the most prescribed drugs in the US

From the 40s through until the mid-1970s, oestrogen for menopause was given to women on its own. But in 1975, evidence started to emerge that without another hormone – a progestogen – “unopposed” oestrogen therapy led to an increased risk of endometrial cancer.

Sales of Premarin nosedived, until it was found that adding a progestogen to a lower dose of oestrogen mitigated this risk. The result was combined oestrogen– progestogen therapy, marketed as Prempro.

Sales of HRT took off again, along with aggressive marketing. This was helped by popular culture promoting the idea of menopause as a terrible disease of decline that needed treating. By the early 90s, Premarin was one of the most prescribed drugs in the US.

Evidence over the first decades of its use backed HRT as an effective therapy, not only for menopause symptoms but also as a preventative treatment for some chronic diseases. Studies showed it as useful for bones and heart health. In 1988 it was approved by the US Food and Drug Administration as a preventative treatment for osteoporosis. There was emerging evidence around HRT’s possible benefit in preventing heart disease, and so in 1991, a big study was started that changed the course of how HRT would be perceived for the next 30 years.

A ‘huge disservice’ to women

The Women’s Health Initiative (WHI) trial was the largest randomised study to date on HRT, and it would be a gamechanger. Unfortunately, not in a good way. It was, according to endocrinologist Megan Ogilvie, “one of the worst things to happen to women’s health in a long time. It did a whole generation of women, and probably two generations of women, a huge disservice.”

The reasons for that are many. The WHI was set up to find the effect of HRT (along with other, non-HRT-related interventions) on the most common causes of death and disability in post-menopausal women: things like cardiovascular disease, cancer and osteoporosis. It’s important to note that this study wasn’t about testing HRT’s effectiveness in treating actual menopause symptoms. What the researchers wanted to know was whether HRT could be used in other ways – to prevent other diseases that happened to women after menopause.

In 2002 a shocking announcement came from the researchers running the WHI study: the HRT arm of the study was being stopped early, after just five years.

In those first trial results, the researchers had observed that in women with a uterus who were taking combined HRT, there was an increased incidence of coronary heart disease and breast cancer. There was also, incidentally, some good news: a reduction of osteoporotic fractures and in incidence of colorectal cancer. Still, they concluded, it seemed the risks outweighed the benefits, and the trial was prematurely discontinued.

At the time, this was big news. The media published stories with sensational headlines and the message women – and doctors – took from them was that HRT was dangerous.

The effect was large-scale stopping of HRT. Women threw away their pills, and doctors – newly afraid of prescribing something that might do more harm than good – stopped prescribing HRT. The drug companies were spooked too – not least because, predictably, they started getting sued.

There’s nothing like a lawsuit to make a drug company wary of developing new drugs in the same area. Predictably, funding for and interest in research and development for HRT, and midlife women’s health in general, waned.

‘Pandering to women’s greatest fear’

However, the results of the WHI study were misreported – even by the people who wrote the initial results paper.

This emerged as a bit of a scandal, in a 2017 paper written by one of the WHI study’s authors, Prof Robert D Langer. In it he revealed that “highly unusual circumstances prevailed” when the WHI trial was stopped prematurely.

He went on to detail how he and other researchers were “aghast” at what they read in the paper that had been submitted in their names to the Journal of the American Medical Association, which they only saw for the first time when the paper was about to be published. Though they tried to submit edits to correct the misinterpretations and reword the press release, it was too late. The paper was published, the press conference held, and the rest is history.

“That headline,” wrote Langer, “pandering to women’s greatest fear – the fear of breast cancer – ensured that word of the study would spread like wildfire. And it ensured that the conversation would be driven much more by emotion and politics than by science.”

The WHI reporting meant that many doctors were too scared to continue prescribing HRT to any woman. Now, they told women, basically, you’re on your own. Government health bodies didn’t help; they issued new advice to doctors to only prescribe HRT to the most severely affected women, and then in the lowest possible dose, for the shortest possible time.

Prescribing rates went down all over the world. What this also meant was that doctors stopped learning much at all about menopause and its potential treatments.

“One of the things the WHI reporting did is it allowed menopause education to be removed from medical schools,” notes Ogilvie. “And it lost us funding on a lot of different HRT products.”

Even now, there’s limited education on menopause for trainee and practising doctors, unless they seek it out or are particularly interested. This is really sad, because it can lead to women suffering unnecessarily. As Langer noted in his 2017 paper, “the ‘facts’ that most women and clinicians consider in making the decision to use, or not use, HRT, are frequently wrong or incorrectly applied.”

• This is an edited extract from This Changes Everything: The Honest Guide to Menopause and Perimenopause by Niki Bezzant (Penguin, NZ$37)