Why Is HRT Still Prescribed? Well, Let's Try Listening to Women

I’m as curmudgeonly as anyone about Big Pharma. I’ll readily agree that their pursuit of profit has driven up drug prices (direct-marketing ads, woo hooo!) and cost lives (Vioxx, anyone?). But I’m also realistic about why we take drugs and how they can, in fact, improve our lives. For instance, there’s a good argument to be made for not having yanked Vioxx from the market, but instead packaging it with stern warnings, because for some people, it may have been the least bad choice.

So, too, with hormone replacement therapy. Yet the critical media (which we need, don’t get me wrong) sometimes present HRT as a nasty conspiracy between careless doctors and greedy Big Pharma. Martha Rosenberg, frequent contributor at Alternet, does it again with an article titled “The Dangers of Hormone Therapy: Why Is It Still Prescribed?”

Why, indeed? You’d hardly know from reading Rosenberg’s piece. It’s an interview with Dr. Rowan Chlebowski, a lead investigator of the Women’s Health Initiative, the massive double-blinded study that revealed the dangers of HRT: an elevated risk of cardiovascular events (instead of the protection women had been promised) and significantly more breast cancers than predicted. In their conversation, they come to the reasonable conclusion that HRT doesn’t offer long-term protection against cardio and memory problems. Dr. Chlebowski states:

HT is still not a desirable chronic disease risk reduction agent though for short term relief of vasomotor systems like hot flashes no other therapy comes close.

Where the article falls down is in its failure to explore what women can do about those immediate symptoms, and why women are still willing to try HRT in the face of its well-known risks. For instance, as an alternative to HRT doctors are prescribing antidepressants to help women cope with miserable, sleep-stealing vasomotor symptoms. There’s some doubt about their efficacy, since placebo achieved very similar results. If a woman is depressed, it might well make sense to try antidepressants, but estrogen is still much more effective for vasomotor disturbances.

And then there’s the collision between antidepressants’ sexual side effects and the other, often unspoken quality-of-life reason women try HRT. This second motive only rates a parenthetical mention in the interview’s final paragraph, where Dr. Chlebowski asks:

Unless you have limiting climacteric symptoms (hot flashes, sexual difficulty), when you look at the emerging cancer data, is this really something you want to take?

Ah, yes, “sexual difficulty”! Problems with lubrication can be addressed with, well, lube. Vaginal atrophy? That’s tougher, especially for those women who don’t benefit (enough) from the old adage, “use it or lose it.” Topical estrogen can help slow atrophy. But then there’s also the matter of libido … and when you add up all the sexual troubles and top ‘em off with sleep deprivation and hot flashes, oral estrogen therapy starts sounding like just the ticket.

I’m not there yet, but I’m no longer a twentysomething who still thinks menopause only happens to other women – you know, those older ladies. Shortly after the WHI dropped its bombshell about the risks of HRT back in 2002, Salon published a letter from reader Susan Young on why women will continue to demand estrogen therapy until a substitute is found. I guess it must have impressed me, because I was sure it was a full-blown article, not just a letter. Here’s the crux of it:

I know I’m going to die of something someday; I want to stay sexually active till then, and it’s difficult or impossible without HRT. That’s the real truth that no one wants to admit. Mother Nature, that unhelpful old bitch, castrates women “naturally,” long before the end of life, and yet now it seems that we’re going to go back 50 years and be told to just grin and bear it (Oh, and exercise and avoiding caffeine will make everything OK, sweetie!). Viagra is A-OK with the media and medical hysteria mongers, although it has sudden death as one of its potential side effects. Why is preserving men’s sexual functioning approved of no matter what the cost? Why aren’t castrated men told to think positive thoughts and wear loose clothes?

Lots of things are natural; death, disease, labor pains, impotence and menopause among them. Why is it important to overcome the discomforts of all but the last? This is a feminist issue, folks.

I don’t know what I’ll experience – whether I’ll be greatly troubled by menopausal symptoms. Maybe I’ll have an easy ride and remain randy into my dotage. If not, I don’t know what I’ll choose. But I do know I’d want to have a choice, even if it entails risks. Better yet, I’d like to have multiple options. So far, we’ve got vaginal estrogen creams and “bioidentical” hormone therapy, which seem safer than regular Prempro (the estrogen-progesterone cocktail prescribed to women who still have a uterus). What else might be possible?

Maybe it’s time to say we deserve treatment of hot flashes and sexual issues that’s both safe and effective – not because it’d be a cash cow for Big Pharma (though it would), but because women want to sleep well and enjoy sex for as long as they’re physically able. That’s not ageism. That’s not caving into medicalization. That’s not pandering to capitalism.

“This is a feminist issue, folks.”