Barbara Seaman's credentials in the anti-estrogen community go way back. She and her colleagues in women's empowerment organizations deserve credit for getting clearer information to the public about potential side-effects of prescription hormones in the early 1970s. She also helped to publicize the dangers of putting pregnant women on the estrogen DES, an all-too-common practice in the 1950s and 60s.
Ms. Seaman's current book, "The Greatest Experiment Ever Performed on Women," is well timed to exploit the generalized confusion and anxiety recently generated among the millions of women who have taken hormone replacement therapy (HRT) in one form or another. Estrogens - "female hormones" - were prescribed for them as treatment for various peri-menopausal conditions, and also to prevent the onset of problems thought to be related to the internal hormonal environment.
Here is where the science gets dicey. Simply put, many physicians (and I was among them for two decades) believed that the apparent was real: If women prior to menopause are less prone to cardiovascular disease than men are, might it not be from a protective effect of . . . female hormones? Woudn't it be a good idea to offer drugs that could do the same?
Why not - these drugs are really just natural hormones, aren't they? There was some evidence to support this approach: blood cholesterol levels were found to be healthier in women on HRT than in those who were not.
So what was the effect on actual heart disease and other health measurements? The evidence started to trickle in a few years ago. But the real bomb dropped last July, with the publication of the large Women's Health Initiative study, under the auspices of the federal NIH. Using that most reliable but least useful of medical devices, the "20/20 retrospectroscope," also known as hindsight, Ms. Seaman has the data and authority to nail the medical community, or "industry" as she calls it.
She is especially harsh on treating physicians and the estrogen manufacturers who encouraged them, for uncharacteristic "wishful prescribing". Not only was there no benefit for heart problems, there was an increase in heart disease, stroke, and blood clots, as well as (previously suspected) breast cancer rates among HRT users.
Although these increases were quite small, and were almost counter-balanced by slight declines in the rates of colorectal cancer and hip fractures (also known from previous data), conscientious physicians should now think, why put anyone on a therapy to protect them from something it actually worsens? To do so flies in the face of doctors' "prime directive": Primum non nocere - First, do no harm.
Ms. Seaman deals with this extensively - indeed, it is the ostensible reason for this book. But rather than stopping at "I told you so," or even "gotcha," she uses these data as a launching pad for an extremely wide-ranging attack on the "medical industry."
You doubt this? Perhaps a few examples will be illustrative:
- While discussing the Long Island Breast Cancer Research Project, the federally-funded study demanded by women living in that region to assess the relationship between "toxins" in the environment and the allegedly higher rate of breast cancer there, the author is amazed that no attempt was made to involve estrogen exposure. She neglects to note that the study was designed by the locals for the express purpose of finding out about pesticides and wastes (the study results found no relationship between breast cancer and environmental "toxins").
- She buys into the "endocrine disrupter" charade and goes so far as to assert that "the sea of estrogens in which we live . . . explains the fact that sperm counts are half of what they were in 1940." This is simply untrue - there is no evidence that the general population is exposed to excessive estrogens, and sperm counts are not markedly different from days of yore.
- She asserts that osteoporosis, thinning of the bones due to loss of bone calcium, is not a condition or disease but merely a "risk factor" for serious fractures. This is of vital importance because osteoporosis-induced hip fractures are common, especially in older women, and it is estimated that one-fifth of those who fracture their hips will die, as a direct or indirect result, within one year. It is almost universally agreed that estrogen replacement therapy is one important agent to slow the loss of bone in women with osteoporosis - but Ms. Seaman is not among those who agree.
Indeed, she finds the NIH study that found HRT effective in treating osteoporosis to be fatally flawed because the chairman of the panel (besides being a professor and later a dean of the Washington University School of Medicine) "would [later] become a paid adviser to a manufacturer of bone-densitometry equipment"- machines useful to diagnose osteoporosis. She advocates herbal remedies, strength training, and Tai Chi exercises as appropriate methods to ward off the ravages of osteoporosis and avoid the toxicities of HRT.
Yet there is a paucity (to say the least) of evidence supporting the efficacy of any of these in the treatment of bone loss or its deadly consequences.
- She says that surgical removal of a woman's ovaries is done too often in this country because "it is a great boost to hormone sales." It may be argued objectively that this procedure (as with many others, including radical prostate removals) is done too often by greedy surgeons, but to maintain that surgeons over-operate so that they can over-prescribe hormone replacements so that the drug companies can profit . . . well, I really don't know what to say to that.
- She complains bitterly that "medicalization" has deprived us - women especially - of natural processes we should accept graciously as a normal part of life. Some conditions she includes in this area of doctor-defined pseudo-illness are: childbirth, osteoporosis, and menopause. "Menopause has been taken away from us [Yes, that's what she said!] and turned into something else . . . the process by which the medical industry has medicalized menopause allows them to gain . . . social control . . . . Doctors and pharmaceutical companies profit by placing women in the sick role . . . ."
Maybe Ms. Seaman has been fortunate enough to escape the excesses of the menopausal syndrome, which makes life miserable for many women and can go on for anywhere from a few months to several years. In my experience, these women demand treatment for disabling symptoms, and appropriately dosed HRT usually works like magic to relieve them.
As for "medicalization" in general, the same statement could logically be applied to many diseases for which we now have more complete understanding and treatment (I wonder whether she also thinks doctors have taken childbed fever and depression "away from us"?).
She attacks the prescribing of cortico-steroid hormones for conditions such as asthma because of the adverse effects long-term use of these cortisone-like drugs have, especially on bone, where they often cause osteoporosis. Here is her position, which by now will come as no surprise:
"It is startling to realize that such documented hazards to bone health are the product . . . of drugs prescribed by doctors. This situation gives the pharmaceutical industry a huge leg up. Drugs they profit from cause bone loss, and drugs they also profit from in turn treat it. Talk about a win-win situation!"
Where to begin? She forgets (since I'm sure she knows that any drug may have side effects, steroids more than others) that doctors treating patients with long-term steroids have decided that the known risks (including bone loss) are bearable to gain the benefits: allowing severe asthmatics to, say, breathe. Yes, such patients may need to go on a drug (and there are now several good therapies for bone loss, aside from HRT) to slow down the loss of mineral, but to say that both the condition and its treatment were arranged so that the drug companies may have a better bottom line goes past paranoia.
This book, masquerading as a science-based alarum for women still considering estrogens, is in fact an anti-hormone, anti-physician, and (especially) anti-pharmaceutical-company-profit polemic. For those not well versed in medical science, it may be convincing. For anyone with experience in endocrinology, pharmacology, or clinical medicine, the veil is easily pierced.
Of course, there are unscrupulous, greedy, and merely lazy physicians, as in any other profession. But to tar all doctors with this same brush does a disservice to those who are true caring professionals - the overwhelming majority - and worse, it does a disservice to her female readers who would benefit from HRT, and who will be misled.