The Estrogen Elixir: A History of Hormone Replacement Therapy in America (review)

The history of women's health is replete with many "specifics" marketed to women for "female complaints." In the late nineteenth and earlier twentieth centuries, proprietors promoted "polite soothing syrups" such as "Red Cross" and "vegetable tonics" like Lydia Pinkham's. Sporting addictive ingredients including paregoric and alcohol, and boasting crazy curative claims, they were ultimately discredited and either reformulated or removed from the marketplace. Colorful bottles are now collected as quaint curiosities. Lest we of the twenty-first century become smug, however, thinking that we have long since become wise to the ways of those early patent panacea promoters, we now have Elizabeth Watkins' book, The Estrogen Elixir, to remind us of the importance of a healthy dose of therapeutic skepticism when it comes to medicine, in general, and women's health, in particular.

This book has been praised on many fronts—as a social history of menopause and its medicalization with the enormous implications this entailed; as a case study illustrating the tensions between medical authority and the modern medical self-help movement; as a cultural critique of the challenges aging women face in a youth-centered society; and as a commentary on how multiple generations of women have perceived and met the challenges of the climacteric period in their lives, whether medicated or unmedicated. It is also, however, both an evocative and a provocative medical and pharmaceutical history of the most widely prescribed category of drugs for women in the twentieth century.

Unlike other twentieth-century breakthrough drugs and biologics such as insulin, thyroxin, penicillin, or even statin drugs, estrogenic hormones were never fully accepted as a life-saving or life-extending product. From the first advertisement for Premarin as a long-term hormone replacement therapy (HRT) in 1964, millions of women, their husbands, their physicians, scientists, and feminists were confronted with the choice of managing menopause with replacement hormones. Elizabeth Watkins' study persuasively argues that this decision, until very recently, was more often influenced less by sober science than by inadequate science, medical and cultural biases, anecdotal evidence, and just plain wishful thinking. Everywhere, it seems, there were both skeptics and believers in the efficacy of estrogen for a whole host of medical, psychological, and socially constructed ills.

In spite of, and at times because of, the literary and public relations efforts of a diverse array of authors and advertisers over the course of the century—something Watkins examines in exquisite detail—many women and their physicians remained skeptical about the need for menopausal medication, much less post-menopausal medication. Although no one doubted the usefulness of estrogens in treating some of the obvious and more obnoxious symptoms of menopause, especially hot flashes, estrogen preparations never proved to be the antidote to the aging process some had alleged. That did not stop waves of women, however, from taking estrogen and estrogen/progestin pills throughout the course of the century.

Following publication of Dr. Robert Wilson's 1966 book, Feminine Forever, in which he advocated extended hormone use, prescriptions for Premarin alone doubled from 1.6 million to nearly 4 million—in addition to the 16 million plus prescriptions for other non-contraceptive estrogen products (76). In 1975, according to Watkins, estrogen "turned from hero to villain" following publication of two studies showing a five- to eightfold increase in endometrial cancers among estrogen users (96). Falling from the second most prescribed drug in the United States in 1975, it was 18th by 1980. In 1972, however, the Food and Drug Administration had ruled estrogens to be "probably effective" in treating osteoporosis. Even though the supporting evidence was decades old, the claim was still allowed on the product label. In 1979 the first definitive study indeed affirmed estrogen's value in treating the disease. Initial recommendations, however, were that estrogen treatment be limited in duration. In 1984, an NIH Consensus Development Conference issued a new statement on osteoporosis maintaining that the "duration...