1. Freda, Margaret Comerford EdD, RN, CHES, FAAN, EDITOR

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What a jolt to the healthcare community. As this editorial is being written, it has been 1 week since the shocking halt of the estrogen-progestin (HRT) arm of the Women's Health Initiative (WHI). As all of you surely know by now, this well-designed longitudinal randomized placebo-control study of the effects of estrogen-progestin (Prempro) in healthy women had to be stopped 3 years early because the WHI Data Monitoring Board found troubling increases in strokes, heart disease, breast cancer, and blood clots in the women who took the drug as part of the study. This was not at all what was expected, for the drug was being given to healthy women, and previous observational studies (not experimental studies) had suggested that this hormone therapy would be beneficial in preventing these diseases.


Approximately 16 million healthy women in the United States take these drugs daily, despite the fact that there has never before been a true experimental study that could determine whether these drugs were good for us. During the past few decades, women agonized over whether they should take HRT. Now we know. In my book, that's good news. Research is done, always, to find out an answer.


Of course there is a backlash. Providers who don't want to believe what was found in the WHI abound. They surmise that different dosages of HRT might be better (read "less harmful"), or that routes other than p.o. might prevent these devastating side effects. As a physician friend of mine said to a group of providers yesterday, "Get over it. The answer is in. It wasn't the answer you wanted, but no other large studies like this will be done. HRT should not be given to healthy women to prevent future disease." I couldn't agree more. We're all supposed to be practicing "evidence-based practice" these days, aren't we? Yes, it's sometimes difficult to give up old beliefs and change the way we practice, but nursing and medicine are sciences, and science is based on research evidence.


How did we ever get into this pickle? Why have healthy women been convinced that they needed to take a drug (or several drugs) during and after menopause? I feel certain that there has been no malice among providers who have been prescribing HRT, but I do believe that the origin of HRT (40 years ago) was in sexism and ageism. I remember the book Feminine Forever. Do you? It was published in 1966 by Dr. Robert Wilson, and its basic premise was that menopause was a disease; he called it a "living decay," and wrote, "...This condition in itself represents an overwhelming crisis in a woman's life...The degree of mental disturbance varies widely...In some women it may manifest itself merely as slight absent-mindedness or irritability. In others, it may grow into a neurosis so severe as to make normal personal adjustments impossible. Many women endure the passing years with cow-like passivity and disinterest; and a disturbingly high number take refuge in alcohol, sleeping pills, and sometimes even in suicide." The cure for this "disease," he wrote, was estrogen. It alone would make women "feminine forever" (especially if your definition of "feminine" coincided with Dr. Wilson's-young looking, sexual, agreeable, and compliant). Doesn't this strike you as odd? First that a normal process such as menopause would be considered a disease, and second that youth (or looking youthful) should be so highly desirable. Why have generations of women become fearful of looking their age? Who decided that age-appropriate appearance was to be avoided?


Let me say on the record that I know there's a small subset of women who suffer terribly during menopause, and they should not be discounted. I don't discount them. HRT, or other treatments should be available if they are needed. Medicating all women who have reached a natural stage in their lives, however, has always seemed intuitively wrong to me.


I believe the days ahead will be difficult for all of us in women's health, and for menopausal and postmenopausal women. Women in the U.S. have been told throughout their lives that menopause is bad. Lauren Hutton and Patty LaBelle push HRT on television ads. The ads no longer say that menopausal women "endure the passing years with cow-like passivity," but the message is really the same: all women of a certain age have a disease that needs to be cured. So here's our challenge. If we believe in evidence-based practice, now is the time for us to read the studies and practice accordingly, teaching our patients and helping them to understand this issue. HRT should not be given to prevent heart disease, stroke, or breast cancer. Our practice, as well as our collective mind-set about menopause, needs to change. This portion of WHI may have surprised us, but at least we now have real evidence for our practice.