A pill that prolongs the prime of life
Medicine's new boon to women:
Until recently the terrors and discomforts of middle life were thought to be inescapable. Now tests prove that with two hormones, estrogen and progesterone, they can be avoided. But doctors are divided on the important question: should nature be interfered with?
A FIFTY-EIGHT-YEAR-OLD woman, who for ten years had been complaining of fatigue, nervous tension, aching joints, occasional headaches and fits of heavy depression, announced recently to her doctor, “I feel happy, well and gay.” .To the same doctor, a second patient, a woman of thirty-nine, reported, “I have joined the ranks of the living again.” Still another patient, a woman of thirty-seven, told him, “I feel simply wonderful now.”
None of the three had undergone a miracle. Along with thirty-two other women, all with symptoms of ovarian failure—the menopause—they had been treated for up to two years by a Calgary gynecologist, Dr. Donald C. McEwen, who administered in every case carefully controlled doses of two hormones, estrogen and progesterone (estrogens being a family of hormones and progesterone one of them).
This therapy was based on the theory that the menopause is a deficiency disease, not a normal physiological process, as inevitable as middle age.
Thousands of doctors in Canada and the U.S. are today challenging medicine’s traditional management of the menopause and woman’s acceptance of this deep and irrevocable “change of life” in middle age. These doctors’ hormone-replacement therapy has implications that a few years ago would have been dismissed as fantastic. “Estrogens are not the fountain of youth,” the American College of Obstetricians andGynecologists was told at its annual meeting last April, “but they may well be the springs that feed the fountains.”
The concept of the menopause as a deficiency disease, controllable, like
diabetes, by drugs, casts doubt on the traditional treatment not only of female ailments characteristic of middle age, but of many major health problems afflicting older women. According to this new concept, the menopause is not merely the end of a woman’s reproductive powers; far more importantly, it is the beginning of deep and damaging metabolic changes due to her deprivation of sex hormones. A woman’s bones are affected : they become brittle and thin. Her skin begins to sag and crease. She loses the protection against atherosclerosis—the cause of heart attacks and strokes—that was previously built into her femininity. She becomes more vulnerable than before to cancer of the breast and uterus. And all because, many doctors now believe, she has not been supplied with man-made hormones to compensate for her body’s inability, following the menopause, to manufacture them.
Many other doctors disagree. It is a safe prediction that the estrogens will continue for some years to be immensely contro-
versial. An impressive amount of research into their function has already been done; much more is needed to convert a conservative profession to an idea as radical as that the menopause is no longer natural or necessary. Some facts, however, have been established.
Artificial hormones are now available that alter two of the three fundamental features of the menopause. They cannot prolong a woman’s ability to produce children. When the ovaries die, a woman is done reproducing. But estrogen, in tablets or injections, along with oral progesterone, can, with rare exceptions, stimulate the menstrual periods of a woman’s child-bearing years and eliminate or assuage many of the unpleasant or painful symptoms and aftereffects of the so-called change of life. What is still controversial is whether these drugs should be used for this purpose. Even among those doctors who accept the efficacy of hormone replacement, there is disagreement over when and for how long it should be administered.
The Canadian Medical Association Journal, in a recent editorial, left no doubt about where it stands in the controversy. As for whether the drug should be used, the Journal remarked dryly, “Many students of the problem are convinced that if men were faced with the problem of sudden gonadal failure during the middle years of life, the necessity of replacement therapy would never be questioned but would be accepted at once.” How long should the drugs be administered? The CM A Journal replied, “In the present state of knowledge it seems that unless specific contraindications exist (indications that continued on page 30
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Can doubters be won away from the myths and taboos built up over centuries?
NEW BOON TO WOMEN
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the treatment is harmful) the patients themselves should be allowed to provide the answer to this question.”
It is only within the last few generations that the menopause has become a heavy problem to women and their doctors. A female born in 1900 had a life expectancy of only fortyeight years; she launched her family and then was spent. Today a woman can expect to live to seventy-five. One in three women now sixty-five will survive for another twenty years. For most women the menopause begins in middle age, between forty and fifty. This means that for one third of the average woman’s life, she is essentially sexless, deprived of the hormones that sharply distinguish her from the male. This deprivation can age her abruptly, affect her physical health and drain the color from her personality. It can turn a joyous woman into a poor thing, ailing and apprehensive, a nuisance to her doctor, her family, and herself.
A few women continue to manufacture some hormones until sixty; most cease much earlier. Similarly, a lew women sail through their menopause. while others are profoundly affected by it. Of the thirty - five women treated in a recent Canadian medical survey, twenty-nine arrived at their doctors’ offices feeling “poorly”; five described their health as “average” and one was “perfectly well.” All had menopausal symptoms, in some cases due to surgical removal of one ovary or both, in others because of ovarian atrophy in middle age. One woman had not menstruated for twenty years.
The twenty-nine who felt poorly provided a composite picture of the menopausal woman, a creature beset by aches, edginess, insomnia and intimations of old age. Their complaints ranged from the characteristic “hot flashes” of the menopause, often followed by a soaking sweat, to a melancholy so crushing that it had sent one woman to hospital five times for treatment of a manic-depressive psychosis.
Under hormone replacement therapy, twenty - four of the thirty - five reported “no problems.” One thirtynine-year-old woman who had suffered from erratic bleeding, fatigue, rheumatoid arthritis and frequent fits of weeping for two years following the removal of an ovary, reported, “I am cool, calm and collected where before, I am sure. I was at the manic level ... 1 am waking full of bounce, eagerly looking forward to a full day of living.” Not only her mood but her arthritis had improved.
A thirty-seven-year-old who, after deep X-ray ablation of her ovaries twenty-two years earlier, had immediately suffered hot flashes and then sustained nervous tension and fatigue, began estrogen therapy feeling tired, she said, but otherwise “fine.” Soon after, she told her doctor, “1 feel wonderful now . . . My husband is fascinated and wants me to continue.” The forty-year-old patient, who had
been hospitalized for manic-depressive psychosis, gained in weight from a frail 104 pounds to 139 in eleven months of estrogen treatment, slept twelve to sixteen hours a day and, under light sedation, was able, the report stated, “to manage her problems without concern to her family or herself.”
Although the role of estrogens in the maintenance of health is only now being realized, it has been known for more than forty years that they are vital ingredients of femininity. Dr. Edward A. Doisy, a U. S. Nobel Prize winner, discovered in 1923 that the ovaries, in addition to producing the eggs necessary for reproduction, also secrete the hormones estrogen and progesterone. Not until those hormones are manufactured does a girl begin to assume the shape and functions of a woman. In middle life, when the ovaries gradually die, a woman’s supply of sex hormones also withers. The male does not suffer a similarly abrupt and severe hormonal imbalance; androgens, the male sex hormones, decline only gradually until advanced old age.
Discovery in a side effect
Estrogen therapy has been practised for more than twenty-five years. What is new is the quickening acceptance by the public and the medical profession of hormone treatment for women. This acceptance, paradoxically, is a by-product of the mass use in recent years of contraceptive pills. The essential elements of those pills are estrogen and progesterone. Now it turns out that the same pills have a secondary use: they can also prevent the menopausal symptoms and aftereffects.
A Brooklyn gynecologist, Dr. Robert Wilson, recently observed this dramatic side effect of contraceptive pills. A fifty-two-year-old woman, a new patient, had come to his office for a routine checkup. She showed none of
the usual signs of a woman past childbearing age. Her skin and muscles were firm; there was no visible genital atrophy; her carriage was erect. Dr. Wilson inquired if she had hormone treatment following menopause.
“No treatment,” she said, “and 1 haven’t reached the menopause yet. I’m still taking birth-control pills.”
A year later the woman had a hysterectomy. Her ovaries, Dr. Wilson di covered, had not been functional for some time. The woman had sailed through the menopause without suspecting it, her estrogen level boosted by the contraceptive pill.
Yet most doctors still prescribe estrogens only for the young, to correct delayed puberty, adjust erratic menstrual cycles and compensate for estrogen-progesterone deficiencies due to hysterectomies. The idea of sex hormones for the menopausal and older woman is still entangled in the myth and taboo that have accumulated over the centuries about the menses
— woman’s “curse” — and the female climacteric: nature ought not to be interfered with.
Moreover, the menopause has traditionally been dismissed by doctors
— and still is by many — as a temporary upset. Dr. C. Lee Buxton, chairman of the department of obstetrics and gynecology at the Yale School of Medicine, wrote in 1951: “It is apparently normal for women after the menopause to progress normally in a state of estrogen production.” Four years later the Toronto obstetrician and gynecologist, Dr. Marion Hilliard, wrote reassuringly in Chatelaine magazine about the menopause as a relatively brief storm, to be followed by years of serenity and sexual satisfaction, undiluted by fear of pregnancy. Until her death in 1958, Dr. Hilliard practised the traditional method of dealing with middle age, not by hormone treatment, but by the therapy of faith in the mellow future.
Yale’s Dr. Buxton still opposes the intervention of hormones in the
menopause. He insists, “It is part of the process of aging and should not be considered a disease unless aging is considered a disease.”
Dr. Buxton’s counterpart at Johns Hopkins, Dr. Allan C. Barnes, disagrees. He wrote recently: “If the climacteric is a normal process . . . so is falling hair in the adult male, change of vision in the 40s, arteriosclerosis in the aging and death itself. But we are fighting off, delaying and substituting for those so-called natural changes as far as possible.” Dr. Barnes prescribes estrogen and progesterone for his patients who have reached or passed the menopause.
The most thorough-going campaigner for estrogens is Dr. Wilson, the Brooklyn gynecologist who is one of the U. S. pioneers in its use. For more than twenty years, in his private practice and as a consultant at Brooklyn’s Methodist Hospital, Dr. Wilson has treated the menopause as a deficiency disease to be offset by doses of estrogen and progesterone in the same way that substitution therapy is common practice in the control of thyroid, pancreatic and adrenal insufficiencies. Now seventy and retired from private practice, Dr. Wilson continues not only to study the long-term effects of the menopause, but to campaign for treatment.
The Wilson Research Foundation, a nonprofit organization of which he is president, was established two years ago to collect and circulate information about the growing role of substitute estrogens in the general health of women. Requests for its pamphlets, medical literature (available only to doctors) and lecture services arrive now at the foundation’s offices at 111 Third Avenue, New York, at the rate of about one hundred a day. Some thirty-five hundred U. S. and Canadian doctors regularly receive its reprints of medical reports on estrogen research.
Dr. Wilson’s campaign is for “the maintenance of adequate estrogen from puberty to the grave” and he aims not only at his fellow gynecologists but also at internists, geriatrists, orthopedists and general practitioners. The consequences of estrogen deficiency, he holds, are “primarily medical rather than gynecologic.” He refers not only to the symptoms of the menopause—the “hot flashes,” nervousness, irritability and lassitude that most women suffer—but to the more damaging metabolic changes triggered hy the climacteric. “Women differ,” according to Dr. Wilson, “in the extent of these changes, but probably every woman suffers from them to a significant extent.”
These are the health problems that can result from those changes and some of the evidence, accumulated so far, that estrogens can control or even prevent these problems:
1. Loss of protein and calcium from the hones, causing a thinning and weakening of hone structure. This condition, called osteoporosis, is at the root of the acute back pains suffered by many women past middle age. Dr. Stanley Wallach and Dr. Philip H. Hennemann of the Harvard
Medical School reported recently on their use of estrogens in one hundred and ten cases of severe osteoporosis. Within two months, pain diminished markedly in ninety percent of their patients. As treatment continued, discomfort was further reduced and freedom of movement improved. In still another group of women. Dr. Wallach and Dr. Henneman found that when estrogens were started early enough, the homones had a preventive effect; the bone disorder did not develop.
In elderly women brittle bones present a serious hazard. Eighty-five percent of disabling hip fractures happen to women. Yet Dr. Max Goldzieher, a former consultant in gerontology to the U. S. surgeon - general, reported recently that during twentyfive years of treating elderly women with estrogens he had observed none who “ever broke a hip.” In Dr. Wilson’s observation, “the eighty-yearold woman who suffers a fractured hip in a minor fall can blame it on the fact that her ovaries ceased functioning thirty years before and substitution treatment was never given.”
2. Loss of the normal female protection against atherosclerosis. This condition—a narrowing of the arteries due to fatty deposits on their walls —causes heart attacks and strokes. In their thirties, women rarely suffer from heart disease; men in the same age group are twenty times more susceptible than women. But by their sixties the sexes are equally vulnerable to heart attacks. Dr. M. Edward Davis and his associates at the University of Chicago believe that estrogen deprivation is the explanation. In long-term studies of two hundred women receiving female hormones following the menopause, they found lower levels of cholesterol and other fats in the blood and a lower incidence of abnormal electro-cardiograms than were usual in untreated women of the same age. Brooklyn's Dr. Robert Wilson has recorded a drop in the blood pressure of his patients of twenty to thirty points during estrogen therapy.
3. Degenerative changes to the skin and mucous membranes. In appearance the average woman ages earlier and more abruptly than does her husband. When she stops menstruating her skin, for lack of protein, loses its elasticity. Moreover, her genital system, deprived of its natural fluids, begins to wither and becomes prone to infection. She looks and feels old.
Dr. Wilson, while reporting skin rejuvenation as one of the benefits from hormone therapy, cautions against expectations of a return to the rosy bloom of youth. Degenerative changes to the genitals can, however, be prevented or reversed, he guarantees, in almost all cases. The object ol the hormone therapy is to allow women to age no more quickly than do their husbands and with as much grace.
Some doctors believe that there is also a link between estrogen deficiency and premature senility. One of Dr. Wilson's associates, Dr. Edmund R. Marino, a pathologist, is studying the effect of estrogens on patients with menopausal - depressive psychosis and is encouraged to believe, he told me, that before long, we may be emptying institutions of those patients.”
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Are there reasons why estrogens, with their rich benefits, should not be universally prescribed, along with exercise, sleep and careful nutrition, for all women who are past their prime? Until recently a lingering fear of these hormones as a possible cause of cancer has deterred many doctors from their use. But the accumulated research of twenty-five years has largely dispelled that fear. The University of Chicago’s cancer expert, Dr. Charles B. Huggins, says of estrogens, “There’s no evidence that they’ve caused a single case of cancer.” Dr. Robert Kistner of Harvard Medical School believes that “you can actually prevent the development of cancer by cyclic estrogen - progesterone treatment.”
Dr. Wilson and his associates at Brooklyn’s Methodist Hospital recently investigated the incidence of breast and genital cancer in a group of three hundred and four women of between forty and seventy years of age who had been treated with estrogens for an average period of eight years. Eighteen
cases of cancer could have been expected during that period in those age groups. None occurred.
The American Medical Association recently announced that it could find no evidence of cancers being caused by cyclic hormone therapy after menopause.
In Canada, according to Dr. L. S. Harris, a Toronto gynecologist who has used estrogen therapy in “a substantial number of cases over a number of years,” acceptance of the idea of hormone replacement for middleaged and older women has been slow and reluctant until recent years. Now, Dr. Harris finds, an increasing number of general practitioners as well as gynecologists are becoming convinced that its “beneficial effects far outnumber its drawbacks.” And there are drawbacks, Dr. Harris himself is careful to point out to his own patients. Some of his patients, under estrogen therapy, complain about an increase in the size and sensitivity of their breasts. Others report a weight gain, which they attribute to the pills.
In a few cases nausea occurs. For women with fibroid tumors, the pill is not advised; it may cause such tumors to grow.
As for the reappearance of menstrual periods, only a very few patients are distressed by this effect of their treatment. The simulated periods are usually mild and short. Most women, according to Dr. Harris, welcome them. “They’re evidence that the pill is working. They make most women feel happier and younger.”
Reporting to The Canadian Medical Association Journal, another gynecologist has made much the same observation: “Some patients who have not had menstrual function for five to twenty years are actually enjoying the phenomenon.”
The Journal, in an accompanying editorial, asked the important question that many Canadian women are now, or soon will be, putting to their doctors. With estrogens, the Journal asked, can the menopausal and postmenopausal woman be “kept physically, functionally and spiritually younger”?
The Journal replied: “The time for debate is now over and it is imperative that the relationship of the menopausal symptom complex to the deficiency of gonadal steroids be assessed objectively and studied scientifically.” In other words, the rich benefits of the estrogens can only be realized by carefully controlled use. Their most enthusiastic advocates in the medical profession are the most strenuously opposed to indiscriminate dosing of the powerful sex hormones. The “Pap” (Papanicolaou) smear, used to detect uterine cancer, also reveals estrogen levels. With this as a scientific guide, doctors can regulate treatment precisely to their patients’ requirements.
Within five years, Dr. Wilson predicts, the vaginal smear for hormone function will be a routine part of every woman’s annual checkup. When that happens, that will be the end of the menopause problem. It may also mean for women an old age as golden as only sentimentalists now suppose it to be. ★