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c h a p t e r t h i r t e e n Meno-Boomers Another Generation Confronts Estrogen The 1990s were boom years for estrogen. In 1992 the American College of Physicians (ACP) recommended that ‘‘all women, regardless of race, should consider preventive hormone therapy,’’ as part of its ‘‘guidelines for counseling asymptomatic postmenopausal women about using hormone therapy to prevent disease and to prolong life.’’∞ In 1994, the American Family Physician published a ‘‘Clinical Opinion’’ that identified estrogen replacement therapy as one of eight underused prescriptions, along with aspirin (to prevent myocardial infarction), beta-blockers (after myocardial infarction to reduce mortality), nicotine substitutes (for smoking cessation), anti-inflammatory agents (to treat asthma), antidepressants , fiber, and regular exercise. The primary reason given for prescribing long-term estrogen was the prevention of heart disease, followed by the prevention of osteoporosis.≤ The ACP, the nation’s largest society of medical specialists, published its guidelines in its journal, Annals of Internal Medicine, which went out to a membership of more than one hundred thousand doctors and medical students in internal medicine and related subspecialties. The American Family Physician was sent to the more than ninety thousand general practitioners who belonged to the American Academy of Family Physicians. Together, these two articles reached about a third of all doctors in the United States, specifically the two groups who, besides gynecologists, were most likely to see menopausal women in their o≈ces. The message conveyed to these physicians was clear: longterm estrogen therapy made good sense. And the news about estrogen just kept getting better, as medical researchers confirmed the alleged health e√ects associated with hormone use. In November 1994 the results of the first NIH-funded large-scale randomized double-blind placebo-controlled trial of combined hormone replacement therapy (estrogen and progestin) were announced at the annual meeting of the American Heart Asso- Another Generation Confronts Estrogen 241 ciation; the o≈cial report of this ‘‘gold standard’’ study was published in the Journal of the American Medical Association two months later.≥ Known as the Postmenopausal Estrogen/Progestin Interventions (PEPI, for short) Trial, the study enlisted 875 women between the ages of 45 and 64 at seven clinical centers across the country to take one of three estrogen/progestin regimens, estrogen alone, or placebo. The objective of the trial was to determine the e√ect of hormone therapies on four known risk factors for heart disease: cholesterol (HDL and LDL levels), fibrinogen (as a marker for blood clotting), serum insulin (to measure carbohydrate metabolism), and blood pressure. It is important to point out that evidence of actual heart disease (such as angina or heart attack or death) was not measured. At the end of the three-year study period, the women who took estrogen or estrogen and progestin had better cholesterol profiles (more of the socalled good cholesterol, HDL, and less of the so-called bad cholesterol, LDL) and lower (that is, better) levels of fibrinogen than those who took the placebo. Insulin levels and blood pressure were una√ected. The researchers cautiously interpreted these results as evidence that the addition of progestin—necessary to prevent endometrial cancer in women with a uterus—did not vitiate the cardio-protective e√ect of estrogen. Journalists were much more enthusiastic; the New York Times gave the story a prominent spot on the front page, summarizing for its readers, ‘‘A mixture of the two hormones estrogen and progestin is better than estrogen alone, protecting women not only against the risk of uterine cancer but heart attacks as well.’’∂ Medical researchers also discovered new benefits for women who used estrogen , and these findings were enthusiastically reported in the popular press. Thosephysicianswhodidnotkeepupwiththemedicalliteraturewouldhavecome across the good tidings about estrogen while scanning the headlines of their local newspapers. In 1995 and 1996, hormone replacement therapy was associated with reduced risk of colon cancer, prevention of tooth loss, lower incidence of osteoarthritis, increase in bone mass, reduced risk of Alzheimer’s disease, and lower rates of death from all causes.∑ The finding about Alzheimer’s was especially welcomed in the wake of increased publicity and heightened awareness about the ravages of the disease and the absence of e√ective treatment. In 1994 Americans had been saddened (but by that time not necessarily surprised) by President Ronald Reagan’s disclosure that he had been diagnosed with Alzheimer’s. Even when the news about HRT was not so good, it was presented to the public...

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