| Before my grandmother married,
she worked as a milliner, designing and constructing women’s
hats. Despite her artistic eye and crafty hand, she was
no slave to fashion, at least not by the time I knew her.
Her standard going-out uniform was a navy blue dress that
ran from clavicles to ankles, with chunky black shoes
peeking out under her hemline.
She’d seen enough styles come and go in her long
life to believe the whole fashion thing was a silly charade.
Here’s how she described it. “People wear
clothes until they get tired of them. Then they throw
them in a barrel. When the barrel is full up they dump
it out, start picking out clothes from the top of the
pile, and throw them back in the barrel when they’re
tired of them.”
At this stage of my career I could say the same about
some medical practices, which seem to wax and wane at
a rhythm reminiscent of clothing styles. Of course, the
reasons for these vicissitudes in practice are deeper
than the justification an editor at Vogue or Harper’s
might give for why a particular hue is the “it”
color for the current spring line.
As practitioners of scientific medicine, we physicians
ought to base our therapeutic recommendations on the best
objective studies. It’s the fashion today to call
scientific practice “evidence-based medicine.”
If we’re all trying all the time to practice medicine
based on the best of evidence, why then do things change
so much--sometimes one way, then the other, then back?
Because science is always uncovering new truths and these
truths require interpretation and translation into practice.
Unfortunately, we don’t understand nearly as much
as we’d like to about anything, leaving us scientific
doctors less certain of our facts, hence more prone to
fashion, than we care to admit.
Post-menopausal estrogen replacement is a case-in-point.
Early in my career it was to be avoided, then--for at
least a couple of decades--to be strongly recommended,
and now it’s to be avoided again, at almost any
cost. Here are a few brief arguments, by no means an exhaustive
list, categorized as “for,” “against,”
and “maybe,” regarding whether to give hormones
after a woman’s ovaries have quit making them:
FOR
• Osteoporosis is associated with loss of estrogen.
• Menopausal symptoms, including hot flashes, depression
and agitation, are alleviated by estrogen.
• Women get much less heart disease than men do,
maybe in part because estrogen lowers some cardiovascular
risk factors.
• Estrogen maintains the tone of vaginal tissues,
helping to improve sexual comfort and to reduce urinary
incontinence.
• Sex hormones reduce skin aging.
AGAINST
• Estrogen increases the risk of breast cancer.
• Estrogen raises the risk of blood clots in the
legs and pelvis, which can break loose, reach the lungs,
and sometimes kill.
• Women who take estrogen have more gallstones.
MAYBE
• Decreased risk of Alzheimer’s disease.
• Increased risk of ovarian cancer.
• Increased risk of cervical cancer.
• Increased risk of liver cancer.
You get the idea. This is a very complicated issue, with
lots of risks and benefits to be weighed. It’s not
a static list, either. Breast cancer and cardiovascular
disease are two items that have, over the years, moved
more than once among the “for,” “against,”
and “maybe” columns of the hormone replacement
spreadsheet.
Studies had to enroll thousands of women to uncover a
reliable association between post-menopausal estrogen
replacement and breast cancer. In general, the smaller
the effect and the longer the delay between cause and
outcome, the larger and longer a study needs to be. Which
is why it took so long for the party line on hormone replacement
therapy to change. The effect is small and takes quite
a while to show up.
As new studies come in, their validity needs to be examined.
Were treatment and control groups comparable? Were the
right outcomes measured? Were appropriate statistical
techniques used to analyze the data?
There’s still the question, even with an impeccable
study, of what to do with its results. I have to ask every
time I read a new report, how similar were the study participants
to my own patients? If, for example, the research was
done by university-based sub-specialists with urban black
women as subjects, how well does it apply to my overwhelmingly
white and Hispanic family practice patients in rural Colorado?
Then there’s the matter of the individual patient.
How do I weigh months of hot-flash induced insomnia against
increased risk of breast cancer? What if the patient’s
mother died of breast cancer? How about if her depression
has been so affected by flashes and insomnia that her
husband has been threatening to move out?
In my practice, I do make some exceptions to the general
rule of discouraging post-menopausal estrogen. It turns
out that a good share of the women for whom I continue
to prescribe female hormone replacement have enough emotional
issues that they figure, and I agree, they don’t
need to add the hassle of resurgent menopausal symptoms
to their already stressful lives.
At its best, practice is driven by science, with a whole
lot of judgment. As social creatures, even doctors’
judgment has to be colored by fashion. Who says a little
fashion consciousness is bad, anyway? I do know that if
a doctor, male or female, came into my hospital room dressed
like my grandma, I’d get right the hell out of there.
Marc Ringel has spent the majority of his career
as a family doctor working in rural communities, including
the last 12 years in Brush, Colorado. He has written extensively,
for lay and professional audiences, about rural health,
medical informatics and healing. Marc lives in Greeley
with his wife and many pets.
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MAY/JUNE 2009 FEATURE ARTICLES
