Medicalising Normal Human Experience: The Example of Hormone Replacement Therapy
Issue 8, November 2002
The human condition is a mass of contrasting states – wellness and sickness, youth and old age, vigour and increasing frailty, obesity and thinness, baldness and hairiness – the list could go on interminably. Many of the processes cannot be controlled – they are simply a part of what it means to be human. Others, for example excessive weight gain or high blood pressure, can be helped by lifestyle changes such as improved nutrition and increased exercise.
Yet increasingly, these life processes are being targeted by modern medicine and the pharmaceutical industry for treatment as if they were illnesses or diseases which require medication – a process termed medicalisation. This paper will look at menopause and the prescribing of Hormone Replacement Therapy (HRT) as an illustration of this process.
Medicalisation is not a new term. It was a concept that was coined and explored by Ivan Illich in the mid 1970's. Illich argued that death, pain and sickness are part of being human and that all cultures developed ways of helping people to deal with these states. How successful individuals are in coping with these realities defines how healthy they are. It was Illich's view that modern medicine has destroyed these cultural and individual capacities and instead, seeks to treat, control and defeat sickness, pain and death.
The desirability of seeking to reduce the severity of illness and pain appears inarguable. There is however, justifiable debate over the medicalisation of many of life's processes or problems such as birth, ageing, death, sexuality, baldness, unhappiness and cellulite. Richard Smith, editor of the British Medical Journal (2002, pp.883-885) generated a list of almost 200 "non-diseases" in an article designed to draw attention to the increasing tendency to classify people's problems as diseases. By "non-disease" he meant "a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way."
Smith recognised that having a condition labelled as a disease brought with it both benefits and problems. The benefits mean that the individual is likely to gain sympathy rather than blame. There is also likely to be exemption from commitments and various benefits such as sick pay, free prescriptions, insurance payments, and access to facilities denied to healthy people. Problems include possible loss of control such as being locked up or having one's body invaded. Insurance, a mortgage, and employment might be less available. The person may become labelled as a victim, with this label contributing to the person becoming flawed and incapable of "rising above" their problem.
It is argued that pharmaceutical companies with their direct-to-consumer advertising encourage people to seek medical attention for conditions or symptoms that might otherwise not need to be treated. The companies seek to raise the status of an undertreated or underdiagnosed problem to that of being a condition or a disease that is widespread, serious and which requires treatment. The public can thus easily be educated into "being sick" and believe that they are sick, even when expert appraisal would determine that they are not. This self-reported morbidity can be hugely misleading. Sen Amartya points out that despite huge spending on health, people in the US are apparently less healthy than people in Bihar, India where there is a much reduced life expectancy (2002, p.860).
This corporate construction of disease relies on the willingness of the medical profession and the general public to believe that interventions work, even when there is no evidence or what evidence there is, does not support this. This phenomenon has been well illustrated by the ever-growing enthusiasm for and prescribing of HRT since 1990.
HRT was first used in the United Kingdom in 1956 to assist women who were suffering from severe symptoms of menopause. Menopause is the time at "mid-life" when a woman has her last period and it happens when the ovaries stop releasing eggs. For most women, this is a gradual process and the symptoms, while unpleasant, are not disabling. HRT involves the use of artificial oestrogen and (unless the woman has had a hysterectomy) progestogen to replace the natural hormones oestrogen and progesterone which are no longer produced by the ovaries after the menopause. It is very effective at alleviating hot flushes, night sweats, vaginal dryness and it also reduces the rate of bone thinning, which occurs when oestrogen levels drop at menopause.
In 1991, women's health activist Sandra Coney published a book on the menopause industry in which she analysed the increasing medicalisation of menopause. It had become increasingly common for menopause to be referred to as oestrogen deficiency, hypo-oestrogenism and ovarian dysfunction. She quotes the words of UK gynaecologist Dr John Studd who called menopause " a multi-system deficiency disorder" and who said that menopausal women were "wretched women undergoing general atrophy." (Coney, p.66)
Coney also discussed society's expectations of women and the pressure on them to be "feminine forever." Menopause is characterised by those in the "industry" as the time in their lives that women were dangerously on the edge and a time when they feared redundancy of their reproductive and sexual selves. Included in the book are photos of advertisements which portray menopausal women as anxious, weepy and unattractive with captions such as "when 'change of life' seems the end of life". Conversely, advertisements of women who are taking HRT show them as happy and vibrant, with one accompanying caption stating: " So a woman can enjoy continuing to be a woman."
By the mid to late 1990's, HRT was being touted as a cure all for the ageing woman. It was increasingly prescribed, not to control severe symptoms of menopause but for the relief of tiredness, insomnia, anxiety, memory loss, loss of sex drive and to delay the onset of Alzheimer's Disease and the prevention of heart disease. A study on the use of HRT by 200 women, commissioned by HRT Aware, an organisation funded by HRT manufacturers, was published in May 2002. It was widely publicised and the headline "Life's fab at 50 for the golden girls" in the Daily Express, 8 May 2002 and "Happier, healthier, sexier - and over 50" in the Daily Telegraph the same day are headlines representative of the glowing publicity the study received in the British press. The study was so effusive about the benefits of HRT that it said women on HRT should be called HRH – Hormone Rich and Happy.
By May 2002, it was estimated that between a fifth and a third of women over 50 in Britain used some form of HRT, with the NHS spending about £150 million a year on HRT prescriptions (Daily Telegraph, 24 March 2002). A contemporaneous article in the Dominion (23 March 2002), reporting a trial of a new hormonal nasal spray, estimated that about 15% of New Zealand women used some form of hormone replacement therapy. The doctor in charge of the trial stated that this figure reflected the "limited availability of the therapy" and the lack of, or only partial, subsidies on various HRT treatments. The inference to be drawn from her comments was that HRT should be made more available. Sandra Coney's response was that evidence published in an article in the NZ Medical Journal in 1997 showed usage to be higher than 15% but in any case, the issue was not over the availability of HRT but whether women needed it at all. She cautioned that "we should be very cautious about promoting HRT to women" as the benefits were questionable and the risks gave cause for concern.
This difference of opinion between the medical profession and consumer-led groups has been mirrored in the United Kingdom. The Menopause Research Information Service claimed that complications of HRT are "happening under doctors' noses and they still refuse to see it. HRT is being promoted with false claims. All it is doing is giving women a feeling of wellbeing - and susceptible women are ending up with fatal diseases." (Daily Telegraph, 24 March 2002)
Advocates of HRT dismissed these assertions as unscientific, emotive and scaremongering and they asserted in turn that opponents of HRT were saying that women past their child-bearing years should not expect to remain vibrant, vivacious, healthy and sexually active. Neither could they expect to avoid such symptoms of the menopause as depression, hot flushes and night sweats. As late as March 2002, the consensus among specialists in HRT was that the risks of breast cancer and blood clots that it brings are "slight" and should be considered against the benefits. A British consultant, the same Dr John Studd referred to in Coney's book and termed a "great advocate of the treatment" admitted: "The benefits are not as clear cut as they appeared to be five years ago. We did think it would help women with established coronary heart disease, but it doesn't. The same applies to strokes. It almost certainly prevents strokes and heart attacks. But once you have these, it is not going to help." (Daily Telegraph, 24 March 2002)
In July this year, the huge multi-national Women's Health Initiative trial on HRT was halted in the United States. Three months later, the British, Australian and New Zealand arms of the study were also stopped. The trial's Data Safety and Monitoring Board had determined that combined oestrogen and progesterone, far from "almost certainly" preventing strokes and heart attacks, increased the incidence of heart disease, strokes, venous thromboembolism and breast cancer. Of major significance was the finding that within the first year of taking HRT, the risk of blood clots doubled, meaning that for every 10,000 women, there would be 18 extra adverse events. Authorities determined that the benefits from HRT, notably a reduced incidence of colorectal cancer and hip fractures, were significantly outweighed by the risks.
The cost of exposure to risk was considered high, particularly when it is accepted that the women taking HRT are "well" women. Certainly, HRT is prescribed and is effective for the relief of what can be debilitating menopausal symptoms but, unpleasant as they can be, menopause is not a lethal condition. Many women are on HRT for prevention purposes, such as those at increased risk of osteoporosis. Still others take it for never proven or now discredited benefits. The good news for these women is that there are alternatives to HRT, both of the pharmaceutical and natural kind and a number of these have been the subject of well-conducted research.
What are some of the lessons from the medicalisation of menopause and the infatuation with HRT? One might go back to the natural order and ask the question why has nature determined, with the evolution of countless generations of women, that the secretion of hormones should alter at and after menopause? If, as seems logical given the nature of evolution, that there are valid reasons that the hormones are restricted to the reproductive phase of a woman's life, is there a likelihood of causing harm by modern medicine attempting to remedy the putative deficiency?
There should also be a heightened awareness of the dangers of the medicalisation of normal human experience and of "disease mongering." A General Practitioner, reflecting on the Women's Health Initiative study, wrote to the British Medical Journal:
This should make us cautious of the role of pharmaceutical companies.... Chronic disease is the "Golden Goose" for the pharmaceutical industry .... These drugs represent huge vested interests in chronic disease promotion and proliferation. (Spence et al, 2002 pp.113-114)
The public needs to know more about the controversy surrounding definitions of diseases and conditions and that there is a balance which should properly be sought between undertreatment and medicalisation.
Finally, the HRT affair underlines the need for objectivity in assessing the efficacy of new drugs and a distancing between the marketing campaigns of the pharmaceutical industry, the medical profession and the general public. The World Health Organisation has identified there is "an inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of providers and the public to select and use drugs in the most rational way." Direct to Consumer advertising and the pharmaceutical industry's marketing strategies are well researched, with the medical profession being constantly visited, entertained, treated and rewarded in different ways for prescribing particular drugs. The medical profession and consumers alike must have access to independent and objective information on medical conditions and on life's processes.
It is essential therefore, that drugs and therapeutic claims made on their behalf, are assessed by objective and independent bodies. In New Zealand, this role could be filled by the New Zealand Guidelines Group, which is committed to promoting all aspects of effective practice in the health and disability sector, in particular the use of evidence-based best practice guidelines. The role could also be filled by the Pharmacology and Therapeutics Advisory Committee (PTAC) whose primary purpose is to provide PHARMAC with independent advice on the pharmacological and therapeutic consequences of proposed amendments to the Pharmaceutical Schedule.
HRT is a conspicuous example of the current approach to the medicalisation of life's normal processes and the success of pharmaceutical companies persuading healthy people that they are sick. There is a consistent message, both overt and subtle, that to age is bad or more accurately, to display the signs that inevitably accompany ageing, is bad. The western world has been wooed and largely won over by clever marketers who constantly sell the message that not only is there a pill for every ill but there is an ill for every pill. But, as refection on the medicalisation of menopause has demonstrated, there are dangers in taking unnecessarily to the sickbed.
Coney,S. (1991). The Menopause Industry. A Guide to Medicine's Discovery of the Mid-life Woman. Auckland: Penguin.
(2002, March 24). HRT: Miracle or Killer? Daily Telegraph.
Illich, I. (1976). Limits to Medicine. London: Marion Boyars.
Sen, Amartya. (2002). Health: Perception versus Observation. British Medical Journal, 324, 860-861.
Smith,R. (2002). In Search of 'Non-disease'. British Medical Journal, 324, 883-885.
Spence, D. et al (2002). Cook the Goose. British Medical Journal, 325, 113–114.
(2002, March 23). Women 'need more hormone replacement therapy choice' The Dominion
UK Social Issues Research Centre. (2002). Jubilee Women Fiftysomething women - lifestyle and attitudes now and fifty years ago. (http://www.sirc.org/publik/jubilee_women.shtml)
World Health Organisation. (1993). Clinical Pharmacological Evaluation in Drug Control. Copenhagen: WHO (EUR/ICP/DSE 173).
Sharron Cole is a member of the Hutt Valley District Health Board and a member of the Panel of Advisors for The Nathaniel Centre