In Our Prime (31 page)

In their book
The Pursuit of Perfection,
David and Sheila Rothman recount how hormone therapy, like plastic surgery, pushed medicine to expand its purpose to include promoting happiness. In the 1930s and 1940s, Emil Novak, a gynecologist at Johns Hopkins, enthusiastically prescribed estrogen for menopausal patients who were depressed. Most gynecologists believed the psychological benefits outweighed the potential risk of cancer. Withholding estrogen because of “a slight theoretical possibility,” said Novak, was “carrying conservatism and caution to an extreme.” The failing of medical hormones has always been that its claims outran the evidence.

Therapies were marketed with the familiar combination of appeals to empowerment and self-improvement. In the fifties, ads for estrogen featured
photographs of kicking showgirls
and beauty queens, suggesting that prolonged youth was possible. “There Goes A Happy Woman,” one ad trumpeted above a picture of a woman exiting her doctor's office.
Charm,
a magazine for working women
, promoted hormone treatments in advertisement and articles. “After 35 you can fool all of the people all of
the time by treating your face, throat and hands regularly with a hormone cream or lotion,” an article in 1954 gushed. “There are hundreds of other ‘miracles' made possible by the progress of science and chemistry.”

In the 1950s, William Masters
, who later won worldwide fame for the sex research he conducted with Virginia Johnson, fervidly promoted hormone therapy to reverse women's aging. Like Elie Metchnikoff and others before him, Masters believed aging was a disease, and one that science should attack with the same enthusiasm it mustered in the fight against polio or tuberculosis. “One of the greatest public health problems of the present and future, is the rapid increase in our aging population,” he wrote in a 1955 paper. Masters laid out an ambitious plan at the 1957 annual meeting of the American Gynecological Society. “The only known member of the female gender to live past her period of reproductivity is the human female,” he told doctors who gathered at Washington University School of Medicine in St. Louis. “The postmenopausal years represent, for her, a socially conditioned phenomenon.” Medical advances, along with social progress, had increased the human life span far beyond what Masters considered normal; now it was science's obligation to undo the side effects of their success and care for these middle-aged women.

Masters's campaign to correct what he characterized as a defect gained many adherents in the profession in the 1960s and 1970s. Middle-aged women, frequently dismissed by doctors as they went through “the change,” were suddenly alluring to physicians and pharmaceutical companies once hormone therapy became widely available. The boundless fortune that could be made by convincing every middle-aged woman to buy a preparation to cope with menopause was an irresistible incentive for drug companies.
Psychotropic drugs were similarly marketed
as menopausal aids to women in midlife. Between 1966 and 1971, doctors prescribed tranquilizers and antidepressants to seventeen percent of all women (compared with eight percent of men). Their median age was 44. A drug marketing executive explained the general process of building a consumer base: “
It's not just about branding the drug
; it's branding the condition and, by inference, a branding of the patient. . . . What kind of patient does a blockbuster create? We're creating patient populations just as we're creating medicine, to make sure that products become blockbusters.”

The end of fertility was commonly portrayed as marring women's desirability so that unattractiveness and frigidity revolved around menopause like satellites.
Simone de Beauvoir observed
that a woman “is still relatively young when she loses the erotic attractiveness and the fertility which, in the view of society and in her own, provide the justification for her existence and her opportunity for happiness. With no future, she still has about one half of her adult life to live. . . . The crisis of the ‘change of life' is felt much less keenly by women who have not staked everything on their femininity.”

Conversations about menopause took place in whispers, as if the subject were unseemly or distasteful.
It is “probably the least glamorous
topic imaginable; and this is interesting, because it is one of the very few topics to which cling some shreds and remnants of taboo,” wrote the feminist novelist Ursula Le Guin. “A serious mention of menopause is usually met with uneasy silence: a sneering reference to it is usually met with relieved sniggers.”

Physicians made authoritative pronouncements about the dire physical and psychological effects of menopause, even though barely any research had been done. (Only in 1991, when Dr. Bernadine Healy, the first woman to run the National Institutes of Health, launched the Women's Health Initiative, a $625 million study on middle-aged women, did researchers shift their gaze from men to women.)
The gynecologist Sherwin Kaufman
wrote in the January 1965 issue of
Ladies' Home Journal
: “It is perfectly natural for women to wish to slow up the aging process and to remain more attractive. They don't hesitate to use contact lenses for failing eyesight, color rinses for drab-looking hair or caps for their teeth. Then why should they put up with the discomforts that afflict about half of them in middle age, when the menopause begins? . . . Treatment doesn't make a woman younger, but it does make her younger-looking.”

A year later, in 1966, the British-born gynecologist Robert Wilson published
Feminine Forever,
arguing that menopause was “chemical castration.” The title was a swipe at Friedan's 1963 seminal work
The Feminine Mystique
. In his eyes, femininity was not the problem but the answer. A menopausal woman becomes the “equivalent of a eunuch,” he wrote. “The entire genital system dries up. The breasts become flabby and
shrink, and the vagina becomes stiff and unyielding. The brittleness often causes chronic inflammation and skin cracks that become infected and make sexual intercourse impossible. . . . Multiplied by millions, she is a focus of bitterness and discontent in the whole fabric of our civilization.” Menopause was a disease, he declared in his bestselling account, which convinced millions of women to sign up for hormone replacement therapy.

Throughout the sixties and seventies
, gynecologists encouraged every woman approaching menopause—and many younger women as well—to down an estrogen pill. Wilson suggested using estrogen from “puberty to the grave.” If relief of menopausal-related symptoms like hot flashes and night sweats were not enough to persuade middle-aged women to buy the drug, then the promise of looking younger might. If your doctor disagreed, Wilson counseled, then find another doctor.
Only after his death did documents
—and his son—confirm that Wilson had been paid by a pharmaceutical company.

The elitist bias that infused
the work of rejuvenation specialists in the 1920s was discernible in the 1960s. Wilson saw hormones as a tool for the wealthy to maintain class differences, writing a nasty, mean-spirited description of those who were unable to afford hormone treatments after menopause. These undeserving women gradually sink “into a state of almost bovine passivity,” he wrote. “Such women generally flock together in small groups of three or four. Not that they have anything to share but their boredom and trivial gossip. Clustering together in monotonous gregariousness, they hid themselves from the rest of the world. They go together to the same hairdresser to have their hair tinted purple. As though they were schoolgirls again, they dress alike and buy the same little hats.”

To Wilson, class differences were what made estrogen socially meaningful. He implied that regular hormone treatments kept one's social status intact, and personally recommended Estradiol, which he called the “Cadillac of hormones.”
His animosity is reminiscent of
the British prime minister in C. P. Snow's dystopian novel
New Lives for Old,
who urges doctors to keep their discovery to elites, “those of the highest gifts, of the finest aims.”

In 1975, doctors wrote
27 million prescriptions for hormone replacements, which generally consisted of estrogen-only pills given in a
variety of high dosages.
Then, in December of that year
, the
New England Journal of Medicine
published a series of articles that reported women who used estrogen for five years were five times more likely to develop endometrial cancer; those on the hormone for seven years were fourteen times as likely.
A few weeks later, the Food
and Drug Administration issued a warning about prolonged use, particularly in women without debilitating menopausal side effects.

As the women's movement rippled out from radical feminists to thousands of small discussion and consciousness-raising groups organized by suburbanites and professionals, women encouraged one another to reclaim responsibility for their health from the medical profession. The Boston Women Health Care Collective published
Our Bodies, Ourselves,
which became a female health bible. Here the empowering aspect of self-help was effectively employed to challenge the patronizing and paternalistic attitudes of mostly male physicians. Wilson's idea of questioning your doctor was one they supported, though not for the reasons he listed. Feminists were critical of the hormone push; they argued the body would naturally reach a new hormonal balance as it aged. Different medical specialties reacted differently to these ideas.
By the end of the 1970s
, for example, standard psychological texts had discounted menopause as a direct cause of depression or crisis, and prescriptions for estrogen dropped to 14 million as evidence mounted that it led to a higher risk of uterine and breast cancer.

In the 1980s, estrogen-only formulas were replaced by a combination of estrogen and progestin, and many gynecologists recommended their use for postmenopausal women, hoping additional benefits, such as preventing heart disease, memory loss, and the bone-weakening effects of osteoporosis, would surface. (Few did.) The platoons of female baby boomers, more outspoken about menopause and more committed to retaining their youth, constituted a large pool of consumers. “
More than 30 million women in the
baby boom generation . . . will pass age 40 over the next two decades,” the
Los Angeles Times
noted in a story on the “meno boom” in 1989. Whispers about menopause were replaced by public discussion. Gail Sheehy, Gloria Steinem, and Germaine Greer published books on the subject in 1992 and 1993. The following year,
a workshop sponsored by the National Institutes of Health concluded that menopause has unfortunately been associated with illness and was often “treated” as a medical problem rather than as a normal part of a woman's life.
For most women, menopause was not
a watershed event but more like hair growth, something that happened gradually over a period of years. Hormone therapy was what the medical sociologist John McKinlay called “a treatment in search of a disease.” Conflicts over dosages, treatment length, and benefits continued, but through the close of the century, hormones remained a huge business, if not for the supposed miseries of menopause, then as an antiaging treatment—just as Sherman Kaufman had suggested in
Ladies' Home Journal
in 1965.
MIDUS I researchers found that women most
frequently cited concern over a youthful appearance as the reason for taking the pills.

Attitudes abruptly veered in 2002. The National Institutes of Health unexpectedly halted the Women's Health Initiative's clinical trials of a hormone therapy that combined estrogen and progestin because of the stunning news that the treatments increased the risk of breast cancer, heart disease, blood clots, and stroke. Sales of hormones plunged.

Many doctors and antiaging practitioners still recommend hormone therapy in lower doses, and public confusion about the benefits and drawbacks persists.
In April 2011, the Women's Health
Initiative created a new muddle when it announced that women from the study who had hysterectomies and had taken an estrogen-only pill were significantly less likely to suffer from breast cancer and heart attacks. (About one-third of American women in their fifties have had their uteruses removed.) Experts reacted to the news with wariness, especially because the older women in the study had taken a prescription, Premarin, which is not used much anymore. The health initiative repeated that its recommendations were unchanged: a woman with a uterus should take a low-dose combination of estrogen and progestin only if she had severe symptoms and for as short a period as possible.

The expert reversals and qualifications can have the unfortunate effect of undermining confidence in scientific findings, as people come to expect that today's cutting-edge pronouncement will be contradicted by tomorrow's. Perhaps more usefully, the tangle of information should
instill caution about astonishing medical claims, reminding us of how little we know about the human body's mysteries.

The gradual decline in regular, heart-pounding sex is a familiar midlife regret.
Fifteen, twenty, or thirty years
into a marriage or relationship, it is not surprising that sex can become, as the novelist William Kennedy put it, like “striking out the pitcher,” satisfying though predictable. The impression fostered by the current lineup of wet-lipped women and randy men on display in print and on-screen, however, is that ubiquitous desire is common and normal. Twenty-something or 60-something, these knowledgeably carnal adults eagerly hop into bed whenever possible, enjoying multiple partners and orgasms. In the popular culture, female independence is often signaled by sexual aggression rather than accomplishments, financial security, or intelligence. Openness about sex is certainly preferable to the Victorian era's embarrassed silence, yet today's overexposure to standardized portrayals of Stepford sex asserts its own form of tyranny, raising expectations and anxieties about sexual performance and appetite at all ages, especially the middle decades.
What's wrong with me? Why am I missing out on all the fun?