"How Did Doctors Not Know About the Risks of Hormone Therapy?"
We’ve known about the role of estrogen
in breast cancer going back to the 1800’s,
when in some cases surgical removal of
the ovaries seemed to help.
Ovaries were said to send out mysterious influences
to the rest of the body,
which in 1923 we identified as estrogen.
The medical profession jumped on this discovery
and started injecting menopausal women by the thousands,
shots that gave a respectable hook
on which to hang visits to the doctor.
Soon there were pills and patches
and medical journals like the Journal of the American Medical Association
regaled doctors with ads on how they can help women
to happiness by prescribing estrogen.
You could turn this…
into that.
For when women outlive their ovaries,
there was Premarin.
As far back as the 40s concerns were raised
that this practice might cause breast cancer
noting it would have been nice to figure this out first
before we started dosing women en masse.
But breast cancer risk didn’t matter,
because heart disease is the #1 killer of women,
concluded reviews, and because women taking hormones
appeared to have lower heart attack rates,
that would outweigh the extra breast cancer.
But women taking estrogen tended to be of higher socioeconomic class,
tended to exercise more,
and engage in other healthy lifestyle changes
like increased fiber intake
and getting their cholesterol checked.
So maybe that’s why women taking estrogens appeared
to be protected from heart disease.
Maybe it had nothing to do with the drugs themselves.
Despite the medical profession’s enthusiasm for the stuff,
only a randomized clinical trial
could really resolve this question.
You split women into two groups
half get the hormones, half get a placebo
and you follow them out for a few years,
but there was no such study...
until the 1990s,
when the Women’s Health Initiative study was designed.
Wait a second.
Why did it take the bulk of a century
to decide to definitively study the safety
of something that was prescribed to millions of women?
Maybe it’s because there had never been a female director
of the National Institutes of Health until then.
Just three weeks after being named NIH Director,
she went before Congress to announce,
“We need a moon walk for women.”
And that “moon walk” took the form of
the Women’s Health Initiative study.
The bombshell landed Summer 2002
There was so much more invasive breast cancer
in the hormone users
that they were forced to stop the study prematurely.
Yeah but what about heart disease—
wasn’t that supposed to balance things out?
The women didn’t just have more breast cancer,
they had more heart attacks,
more strokes,
more blood clots to their lungs.
The news that women treated with hormone replacement therapy
experienced higher rates of breast cancer,
cardiovascular disease, and overall harm
rocked women and physicians across the country.
Estrogen started out as the most prescribed drug in America
before the study,
but the number of prescriptions dropped immediately
and within a year, so did the incidence
of breast cancer in the United States.
Here’s the data from California,
a nice drop-off in the rate of invasive breast cancer.
But the most important part of this story
was why were we all so surprised.
There had been decade after decade of repeated warnings
about the risks of cancer.
In fact, the reason breast cancer patients
had so much trouble suing the drug company
was that the drugs contained warning labels for decades,
and having disclosed it, surely any reasonable physician
would have included it in their risk and benefit discussions
with their patients.
It’s like the warning labels on packs of cigarettes.
If you you get lung cancer now you should have known better.
And so if you got breast cancer, don’t blame the drug company.
They warned you about the risks,
right there, clear as day.
Why didn’t more doctors warn their patients?
Even after the study came out millions of prescriptions
continued to be dispensed.
That’s a lot of cancer in our patients we caused, wrote one doctor.
How long will it take us to stop listening
to the drug companies, admit that we are harming
many of our patients,
and start changing our prescription habits?
Why did this practice continue
in the face of mounting evidence of harm?
Well, it is a multibillion dollar industry.
Despite an overwhelming amount of evidence to the contrary,
many physicians still believe that estrogenic hormones
have overall health benefits,
a non-evidence–based perception
that may be the result of decades
of carefully orchestrated corporate influence on the medical literature.
Dozens of ghostwritten reviews were published in medical journals
to promote unproven benefits and downplay the harms
of menopausal hormone therapy.
They paid PR companies to write the articles
and then pass them off as written by some expert.
So gynecologists must switch allegiance
from eminence-based to evidence-based medicine,
consider what the science actually says
and not just what some so-called expert says.
One might say the current culture of gynecology
encourages the dissemination of health advice
based on advertising rather than science.
Women were placed in the way of harm by their physicians,
who acted as unsuspecting patsies for the pharmaceutical companies.
If we really wanted to prevent heart attacks in women,
simple lifestyle behaviors
can eliminate more than 90% of heart attack risk.
So instead of being big pharma’s pawns,
recommending a healthful diet, increased exercise,
and smoking cessation would truly benefit women’s health.