The onset of menopause presents a complex set of questions to many women. One of those questions may be whether or not to begin hormone replacement therapy (HRT).
Hormone replacement therapy (also known as estrogen replacement therapy, or ERT) involves taking a daily dose of estrogen, either alone or, more commonly, as part of an estrogen/progesterone combination. The purpose of HRT is to restore the body's hormone levels to a premenopausal state. HRT has long been promoted for its effectiveness in alleviating such symptoms of menopause as "hot flashes" and for the protective effect it has on the bones and the heart. The potential benefits of estrogen have inspired some champions of HRT to call it "youth in a pill." Yet enthusiasm for HRT is often dimmed, if not doused outright, by fears that such therapy may cause serious side effects.
The media can play an important role in a woman's decision to accept or reject hormone replacement. Findings from recent studies have suggested that women tend to learn about HRT from the media and from their friends. Many women rely on magazines, in particular, for health information.
Over the years, the American Council on Science and Health (ACSH) has conducted several surveys of the accuracy of health information in popular magazines. Unfortunately, ACSH's surveys have found that these magazines often fail to provide their readers either with sound health advice or with accurate scientific information.
In the survey summarized in this report, ACSH scientists evaluated 16 magazines' coverage of hormone replacement therapy. Twelve of the magazines surveyed are women's magazines; four are general-interest titles. All of the magazines surveyed have readerships over 2 million. Taken together, the magazines have a median readership age of at least 40 years.
ACSH was pleased to find that when reporting on the issue of HRT, these 16 popular magazines generally appear to present information fairly and sensibly.
The following background on hormone replacement therapy should not be looked upon as a comprehensive review of the subject; rather, it strives to provide a context for ACSH's evaluation of HRT coverage in popular magazines.
Menopause usually occurs around age 50. It marks the lowest point in a gradual decline in the body's concentrations of female hormones. As levels of two key hormones, estrogen and progesterone, decrease, a woman's menstrual cycles first become irregular (perimenopause) and then cease completely (menopause).
The majority of women experience few, if any, symptoms at menopause. For some women, however, the ebbing of the hormones triggers a spate of complaints. These can include hot flashes, depression, vaginal dryness, and incontinence. Additionally, the waning of the body's supply of estrogen can lead to a loss of bone massÂ¬a precursor to osteoporosis.
Enthusiasm for hormone replacement therapy was already evident in the 1960s. Widespread interest in HRT was likely spurred by the 1966 publication of gynecologist Robert Wilson's Feminine Forever. In his book Wilson glorified estrogen as a proverbial "fountain of youth"Â¬and took substantial scientific liberties while doing so. At the time Wilson's book first appeared, doctors were already prescribing estrogen widely to relieve menopausal symptoms. But by the mid 1970s American physicians were writing more than 30 million prescriptions a year for the hormone, and approximately half of all menopausal women were using HRT for a median duration of 5 years.
In the mid 70s some researchers were also raising concerns over estrogen's role in the promotion of breast and endometrial cancer. Then, as now, no strong association between HRT and breast cancer could be established; but doctors found clear evidence for an increased risk of endometrial cancer (otherwise known as uterine cancer) in women undergoing estrogen therapy.
The addition of synthetic progesterone to the estrogen in HRT limits the overgrowth of the uterine lining that contributes to malignancy. With that modification, the increased risk of endometrial cancer appears to have been eliminated. Doctors today commonly prescribe HRT as a combination of estrogen and progesterone. For a woman who has had a hysterectomy, and therefore is not at risk for developing uterine cancer, a physician may recommend estrogen alone.
By the early 1980s research had identified long-term HRT as a way to prevent and manage postmenopausal osteoporosis (loss of bone density) and as a possible measure in treating postmenopausal urinary incontinence. Other studies done in that decade linked continued estrogen use to improvements in cholesterol levels and to a lower incidence of fatal heart disease.1
Recent research has suggested that estrogen may also protect women against Alzheimer's disease, colon cancer, arthritis, and aging skin. While at this time these benefits remain speculative, evidence appears to be accumulating in their favor. The results of the Women's Health InitiativeÂ¬a large randomized study examining a number of outcomes related to hormone replacementÂ¬should help clarify many of the uncertainties still surrounding HRT.
In spite of the well-established advantages of supplemental estrogen, and its long history of safe and effective use, only about 25 percent of menopausal women undergo HRT. Women who reject hormone replacement may be wary of the "medicalization of menopause" or may dislike estrogen's possible unpleasant side effects, among them breast tenderness, headaches, and resumed menses. But it is the fear of breast cancer that dissuades most women and their doctors from choosing HRT, despite the disagreement over the relationship between hormone replacement therapy and breast cancer.
Over the past 25 years more than 50 studies have examined the link between estrogen and breast cancer. Results remain equivocal, but it appears that long-term use (over five years) of hormone therapy may result in a small increased risk of breast cancer. This increased risk becomes more significant for women who are at high risk for the disease, among them women with a prior history of breast malignancies and women with a strong family history of breast cancer.
All women considering HRT should evaluate the benefits of such therapy against the potential risks, however. Heart disease is the leading cause of death among women, and the risk of osteoporosis for women aged 50 to 59 is roughly twice that of breast cancer. Yet an overly heightened perception of breast cancer risk leads many women to forgo the significant benefits of HRT.
SERMs (selective estrogen receptor modulators)Â¬drugs structurally related to estrogenÂ¬have received considerable media attention for their potential for offering women benefits similar to those of HRT while lowering their risk of breast cancer. Yet the SERMs of today are not, nor are they intended to be, substitutes for HRT. While the future of SERMs appears promising, little is known about the long-term effects of these drugs.
Coverage of HRT by Popular Magazines
When it comes to reporting on HRT, writers for the popular media face a difficult task. They must sift through large amounts of often conflicting material on the benefits and risks of HRT and then try to convey this complex issue fairly to their readers.
But how well are they succeeding?
To assess how America's popular magazines are faring in their attempts to present the facts about HRT, ACSH studied articles about HRT published in 16 magazines2 in the months between July 1995 and June 1998.
All told, there were 67 HRT-related articles in the magazines surveyed. Some of these were full-length articles about HRT. Others were shorter pieces on HRTÂ¬one- or two-paragraph health-page items for the most part. Still others were longer pieces on related topicsÂ¬menopause, osteoporosis, and Alzheimer's disease, for exampleÂ¬that included some discussion of HRT.
Over the five-year period surveyed, 11 of the 16 magazines ran fewer than five articles on HRT. Of the others, Health and Ladies' Home Journal each ran six; Newsweek ran eight; and Time ran 11. The magazine running the greatest number of articles on HRTÂ¬18Â¬was Prevention. Only one of the magazines surveyed did not report on hormone replacement therapy at all. Surprisingly, that magazine was Modern Maturity.
The articles surveyed were categorized as offering readers a positive view, a balanced view, or a negative view of HRT. In general, the articles addressed this complex subject in a comprehensive manner, including both pros and cons in their discussions.
Over half (57%) of the articles offered balanced and neutral discussions of HRT. They accurately explained the benefits and potential risks of estrogen use without displaying obvious bias. They acknowledged women's fears of breast cancer (often by recounting personal stories), refrained from hyperbole, and through careful writing managed to convey the equivocal nature of the evidence linking HRT to breast cancer.
Most of these "balanced" articles provided readers with a context for decision making. They did this by responsibly explaining the relative risks to postmenopausal women of heart disease, osteoporosis, and breast cancer. These articles tended to leave readers with two related messages: that the appropriateness of hormone replacement varies from woman to woman, and that it is important for each individual woman to weigh her own personal needs, concerns, and risks when making decisions about HRT.
A balanced article in the March 1996 issue of Better Homes and Gardens , for example, noted that "Doctors don't deny that breast cancer is a fearsome disease. It is however, more detectable and more treatable (and claims far fewer lives) than heart disease." A balanced April 1997 Family Circle piece explained that some, but not all, research bears out the link between HRT and breast cancer and went on to warn readers that "focusing on breast cancer alone . . . can distort the importance of other serious diseases HRT can protect against, such as heart disease and osteoporosis." And an article in September 1995 Woman's Day took a similarly sound and balanced approach by asking, "Given all of these findings, what should you do?" and then offering the following advice: "Clearly, the answer does not depend solely on concerns about breast cancer. . . . You need to carefully weigh the known benefits against the suspected risks and make the decision that's best for you."
Thirty-six percent of the articles surveyed demonstrated a positive bias towards HRT.
These "positive" articles tended to ignore or downplay the negative side effects and possible risks of hormone use. Instead, they focused on the advantages of HRT. Often, they highlighted new research findings. All of the positive articles were prudent in their reporting of HRT's unproved benefits, however. Positive articles in Time, Newsweek, and Prevention, for example, made careful and repeated use of such qualifiers as "may," "seem," and "appears to" when describing the potential effects of estrogen.
In ACSH's experience, the American media have shown a tendency to inflate certain health risks, and especially to inflate risks associated with pharmaceuticals and with breast cancer. Consequently, when ACSH began planning this survey, our researchers hypothesized that most articles would exaggerate the possible risks of HRTÂ¬that most would put a special emphasis on the potential increase in breast cancer risk and thus discourage the use of HRT.
Surprisingly, however, fewer than 8 percent of the HRT-related articles surveyedÂ¬five in allÂ¬portrayed HRT in a wholly negative light. These five "negative" articles emphasized or exaggerated the unfavorable effects of hormone use and did, indeed, emphasize the possible increase in breast cancer risk.
Three of the negative piecesÂ¬one in Time and two in NewsweekÂ¬were reports of specific studies that focused on estrogen-related health risks.
Two of the negative articles steered women toward such "safe alternatives" to HRT as eating soy products, eating the herb black cohosh, exercising, and reducing stress. Both of these articles were based on Dr. Susan Love's Hormone Book, a controversial 1997 bestseller.
An article in the March 1997 issue of U.S. News & World Report showcased Dr. Love's argument that menopause is misrepresented in our culture as a disease. The article noted that Dr. Love believes that "taking drugs for 30 years to prevent something normal is questionable."
Despite overwhelming evidence in the hormone's favor, Dr. Love remains skeptical of estrogen's protective effect on bones and the cardiovascular system. At the same time, she tends to overstate the risk of breast cancer associated with HRT. "If you've been considering hormone therapy to help prevent heart disease and osteoporosis," she stated in the February 1997 issue of Good House-keeping, "bear in mind that there's no definitive evidence showing that hormone therapy protects against these conditions. We do know that it increases a women's risk of developing breast cancer."
Natural "Alternatives" to Hormone Replacement Therapy
Nine of the articles surveyedÂ¬one positive, six balanced, and two negativeÂ¬offered readers information about natural "alternatives" to hormone replacement therapy. All nine suggested that women eat foods (such as soy) that are high in phytoestrogensÂ¬plant chemicals thought to have estrogenic activity.
The word "alternative" suggests comparable effects, but little research has been done on the natural alternatives to HRT to determine their relative benefits or risks. Moreover, although many people believe that "natural" products are, by definition, risk free, natural phytoestrogens may well carry the same risks as their "artificial" pharmaceutical counterparts. Controlled studies have not assessed the safety of phytoestrogens, and neither the quality nor the optimum quantities of these so-called HRT substitutes are required or can be guaranteed. In short, when misconceptions and the lack of controlled studies are taken into consideration, it becomes clear that the recommendation of these natural alternatives to HRT may be misleading and could, in fact, be harmful.
An article in April 1997 Family Circle overstepped scientific boundaries when it advised readers to "protect [their] bones with soy foods that can halt bone breakdown and possibly stimulate new bone formation." And the excerpt from Dr. Love's book in February 1997 Good Housekeeping prefaced a list of "safe alternatives" to HRT with the following sweeping statement: "Here are the most effective lifestyle changes to lower your risk for heart disease, osteoporosis, and other diseases associated with aging." Dr. Love's list included such perfectly sound advice as abstaining from smoking and getting exercise; but it also included such unproved or less effective strategies as eating soy and fiber to protect yourself against heart disease, breast cancer, and colon cancer.
To combine established health measures with speculative ones as Dr. Love does merely serves to spread erroneous perceptions of risk reduction. Com-mendably, however, many of the articles ACSH read for this survey communicated clearly to readers the lack of evidence behind the various unproved substitutes for HRT that the articles discussed.
As popular sources of health information, magazines can play an important role in their readers' decisions to pursue hormone replacement therapy. Writing about HRT is not an easy task, however. New findings continue to be reported; and as with most drug regimens, the benefits of HRT are accompanied by risks, both certain and speculated. Magazines that wish to report fairly and accurately on HRT must make sure that their writers keep up to date on the latest research. And those writers must scrupulously set out the pros and cons of the subject for their readers even as they carefully traverse a minefield of political and ideological disputation.
In their reporting on HRT the majority of the magazines surveyed admirably presented the current state of scientific knowledge. Rather than fuel women's already heightened fears of breast cancer, many of the articles contrasted the small, potential risk of breast cancer associated with HRT with the risks of other, more prevalent, diseases that postmenopausal women faceÂ¬conditions such as heart disease and osteoporosis that HRT may help to prevent.
Several of the magazines employed a similar successful strategy in their HRT articles. They began by asking, "Is hormone replacement therapy right for you?" and ended by leaving that initial question unanswered. In short, they gave their readers information designed to help them make their own informed decisions about HRT. And those, of course, are decisions best made, not by magazines, but by individual women acting in partnership with their physicians.