The following is a speech given at a conference for Hysterectomy Education Resources and Sources (HERS).
It is a great pleasure to be here and to be on the same program with the first woman elected to Congress from my district, as well as the first and only woman to establish a successful hysterectomy prevention organization. I have reviewed the number of speeches that I have made over the course of the last twenty years for HERS and they are all mainly repetitive of the same themes: Estrogen, unnecessary surgery, the medicalization of our bodies, and the rise of the doctor as a scientist.
Our reproductive organs have been the concern of men from time immemorial. Hormones and surgery have been essential interventions by mainly male scientists-doctors. Interventions effecting male functions are regarded as very serious and are seldom undertaken except to treat pathology. On the other hand, interventions effecting perfectly normal female functions such as the menstrual cycle, menopause, contraception, birth, and surgery are rampant. It is men who determined that we were the weaker sex, who didn’t allow us to vote, who didn’t allow us to own property, who decreed that our place was in the home and our product should be children.
The medicalization of our bodies is particularly ironic because historically, women served as society’s healers, a role that combined wisdom, nurturance, intuition, and skill. The purview of this endeavor often extended no farther than the local community, where women traded home remedies advice though a network of mutual support. However, this expertise of the female lay healer was cast aside with the rise of modern medicine in the mid-19th century. Men “formally” educated in health sciences extended healing into a profession, defined by its exclusivity. They aimed to concentrate medical knowledge amongst an elite class of doctors, hording it as a commodity. Gone were the days of women – neighbors, relatives, and friends – spreading the skills of healing for the greater good. Early feminists did their best to resist male domination of the health professions. Populist-era leader Fanny Wright organized efforts to disperse folk medicine and lay healing techniques to the general public, but these attempts were ultimately unsuccessful in resisting the transformation of health care into a market commodity. Since this time, we have learned that the dangers of the male practice of medicine lies not in the gender of the practitioners but in the economics of their situation.
I will cover a few of the many topics with regard to interventions by the medical/pharmaceutical complex which illustrates the dramatic difference between the emphasis on a link between women’s hormones and disease.
THE MEDICALIZATION OF WOMEN
According to the Western medical model, pre-menstrual syndrome is a disease, menstruation is a disease, pregnancy is a disease, childbirth is a disease, and menopause is a disease. From this model, I have reached the conclusion that being a woman is a disease. We are poisoned by prescriptions or hysterectomized, as 685,000 women are every year at the hands of the medical profession.
Medicalization is a process whereby more and more of everyday life comes under medical influence and supervision so that medical definitions and treatments emerge for previously non-medical problems.
In 1979, Dr. Robert Mendelsohn compared medicine to a religion. It was his opinion that women are urged by their physicians to have faith in them, to generally accept what the ‘experts’ say and to follow blindly. “Around ninety percent of surgery is a waste of time, energy, money and life,” he said, and most surgeries were being done for “non-illnesses.” He urged women not to simply believe, but to question—especially when the subject was surgery.
Now, we are told that “medicine is science.” This mantra convolutes the business of medicine while portraying the doctor as an expert. The business of medicine sells us the idea that our medical system, and the doctor in particular, know best.
Control over women, and especially our bodies, is one of the foundations of the patriarchal system. Our fertility, menstruation, pregnancy, births, menopause, and the broader process of aging now medicalized, are all fuel for economic prosperity.
Women in general make an average of 4.6 doctor visits per year. Their normal bodily stages and functions not only are medicalized but patholigized. In every era of history and in every phase of women’s lives doctors have sought to control or intervene in women’s reproductive functions. Functions have become symptoms, and symptoms have become diseases. Changes in hormone levels have become deficiencies. In 2002, The National Institute of Health (“NIH”) concluded that the terms “deficiency” and “replacement therapy” were not supported by the data. Despite this conclusion, both terms continue to be used liberally by the medical profession today.
I reject the notion that women need treatment from menstruation to death, and I believe that being a woman is perfectly normal for half of the population. Contrary to the women’s model, men don’t usually enter the health care system until they reach middle age. They do not go for regular check-ups until a friend drops dead playing tennis or jogging.
To the detriment of women, medical practice has been dehumanized. The patient – the woman – has become an object on an assembly line – or disassembly line — the medical profession has become a huge, impersonal machine. Women are the victims of so much unnecessary medical and surgical intervention that it makes them sick.
According to their 2008 SEC filings, the largest hospital chain in the U.S., the Hospital Corporation of America (HCA) reports that about 49% of their revenues and 59% of their hospital admissions were Medicare and Medicaid “related.” In 2007, the chain reported revenues of $26.9 billion, approximately $16 billion of which was paid for by American taxpayers.
There is no greater illustration of this point than that of the pharmaceutical industry. Women are prescribed almost 70% of all medications. Not only do we usually take responsibility for contraception, we also visit the doctor four times more than men do, making us the key market for doctors and pharmaceutical companies to target throughout our life.
In fact, the so-called “positive” effect of targeted marketing to women recently was published in a well-established medical journal. The results were a non-annualized rate of return of approximately 625%. This was for an unsafe procedure called Uterine Artery Embolization and the interventional radiologists involved recommend finding a target market i.e. women that can significantly expand existing practices. This trend has been made evident by the recent upsurge in direct to consumer advertising in magazines, television, and on the Internet.
Medicine “discovered” early on that female functions were inherently pathological. Doctors from the late nineteenth century to the early twentieth century espoused that “many a young life is battered and forever crippled on the breakers of puberty” and, additionally, that women be “dashed to pieces” by childbirth, eventually arriving “upon the final bar of the menopause where protection is found in the unruffled waters of the harbor beyond reach of sexual storms.”
As late as 1916, doctors advised women to omit all heavy exercise for the entire “menstrual week” and that girls should stay out of school for one to three days, so as to “rest the mind” and get more sleep.
While taboos against menstruation have been reduced – all this for a normal function, there are increasing numbers of women, including women doctors who limit their cycles through the use of oral contraceptives.
PMS and Premenstrual Dysphoric Disorder (PMDD)
Another phenomenon of modern medicine is the medicalization of mood variations in the menstrual cycle. There is no doubt that fluctuations in hormone levels can influence mood and behavior. However, it would appear that men’s peaks and valleys of mood and impulsivity are similar to those of women; but they are simply not cyclical. At some more or less arbitrary point, a function, mood, or behavior becomes a disease. Since hormones do affect mood and behavior, there are probably some individuals whom they affect more intensely than others.
The effects of “male” hormones – most or all hormones are found in both sexes, though in different quantities and proportions – are much less studied and attended to. There is probably a causal link between surges in testosterone in adolescent boys and their tendency to have motor vehicle collisions, but attempts to modulate testosterone would be experienced as castrating, and the very idea rouses terror and indignation. The treatment of premenstrual syndrome, or premenstrual dysphoric disorder, in contrast, is a growth industry.
Premenstrual syndrome is perhaps the only psychological “disorder” that boasts more claimants than sufferers. When women self-referred for premenstrual symptoms are required to keep prospective daily ratings of the symptoms, and then compare them with their menstrual cycles, most prove to have symptoms completely unrelated to hormonal status.
It is unacceptable and, for some women, dangerous, to express justifiable feelings of irritation or anger in our society, they feel “not themselves” when such feelings do manifest. Sometimes it is easier, and more acceptable to their male partners and employers, to blame these episodes on their hormones.
Blaming irritability or sadness on hormones is a double-edged sword. While it may mitigate the social responses these behaviors would otherwise elicit, it does so by insisting that women’s physiologic functions make them weak and unreliable.
Advertisements for the newest contraceptives, YAZ and Yasmin, insist that the drugs can treat premenstrual dysphoric disorder (“PMDD”), another supposed dysfunction of the female menstrual cycle that causes markedly depressed mood, anxiety or tension, and persistent anger or irritability. This is another example of how the medical industry constantly finds new ways to impose itself on women’s biology.
Contraception itself is part of a long history of a culture willing to sacrifice women’s bodies for profit.
At the First International Conference of Intra-Uterine Contraception, Dr. J. Robert Wilson said:
“[P]erhaps the individual patient is expendable in the general scheme of things, particularly if the infection she acquires is sterilizing and not lethal.”
Barbara Seaman deduced that the early birth control pills caused serious life-threatening consequences, including blood clots, heart attacks and strokes, and published The Doctor’s Case Against the Pill to warn women about the dangers.
The birth control pill was tested on 132 Puerto Rican women before marketing. Depo Provera—the shot heard round the world—was tested on so-called women ‘volunteers’ in Bangladesh in exchange for a chicken. Norplant, a five-year contraceptive, was used for social engineering in several developing countries.
Countless women have lost their fertility, their reproductive organs, and their lives because pharmaceutical companies have put unsafe, untested contraceptive drugs and devices on the market in pursuit of profit—and women trusting their doctors take them without question.
Contraceptive developments have been almost completely focused on women who, while the only sex who can get pregnant, are only half the duo required. The possibility that the manipulation of male hormones might interfere with men’s masculinity, virility, or potency is so unacceptable that there is barely a whisper of interest in hormonal contraception for men. Vasectomy is a simple outpatient procedure while female sterilization a more intrusive and complex one, the surgical sterilization of women is still much more common. Men do not allow their genitals to be tampered with and do not want to be “fixed.”
In 1970, A.H. Robins entered the contraceptive business with the Dalkon Shield, an inexpensive intrauterine device said to be tested by a doctor at a prestigious institution. Nine months after marketing the device, the company first began a two-year baboon safety study. One in every eight baboons died, and 30 percent suffered uterine perforation. The results were never made public.
The Shield was promoted as preventing pregnancy without adverse effects, even though it was an untested product. FDA pressure led to suspension of marketing efforts in June of 1974, but not until 1984, 10 years later, did Robins recommend that women wearing a Shield have it removed. Through the 1980s, Dalkon Shields remained in the bodies of women in 80 countries. If our Toyota brakes fail, we return the car to the manufacturer. But if there’s a defective device in women’s bodies, we do nothing.
In 1984, Judge Miles Lord admonished the corporate officials, saying:
“It is not enough to say, ‘I did not know,’ ‘It was not me,’ ‘Look elsewhere.’…If one poor young man were by some act of his—without authority or consent—to inflict such damage upon one woman, he would be jailed for a good portion of the rest of his life. And yet your company, without warning to women, invaded their bodies by the millions and caused them injuries by the thousands…You planted in the bodies of these women instruments of death, of mutilation, of disease.”
Despite these frightening lessons of the past, the new generation of contraceptive choices such as Mirena, NuvaRing, and Yaz are advertised as safe and effective, even though there is not enough data to support such claims. In fact, safety and efficacy data shows that they are actually dangerous.
Mirena, on the other hand, is an intra-uterine contraceptive device marketed as preventing pregnancy for up to 5 years. The TV ads for the device trumpet its convenience and effectiveness as a semi-permanent, reversible form of contraception, despite its serious risks such as ectopic pregnancy, sepsis, pelvic inflammatory disease, punctured uterine wall, and irreversible infertility.
The NuvaRing is a once-monthly, vaginally-inserted device that secretes contraceptive hormones directly into the cervix. Marketing materials promote the device as more convenient as the Pill with the same effectiveness at preventing pregnancy. Advertising fails to assert, however, that such exposure to estrogren and progestin causes increased risk of blood clots and other side effects.
YAZ is now the best-selling oral contraceptive in the United States. In 2008, the recorded sales were approximately $616 million. From the first quarter of 2004 through the third quarter of 2008, hundreds of reports of injuries due to YAZ had been filed with the FDA. At least 50 of these reports were of deaths among users of Yasmin and YAZ. These deaths were associated to cardiac arrhythmia, cardiac arrest, pulmonary embolism, deep vein thrombosis, and strokes in women in their child bearing years.
Also in 2008, based on inaccuracies in advertising, Bayer was required to remove their television commercials from the airwaves and replace them with ads containing accurate information. In February 2009, Bayer began a $20 million corrective ad campaign, clarifying information about YAZ, its uses, and the warnings associated with its use.
This action by the FDA, requiring that corrective spots, is highly unusual and indicates the deceptive nature of the ads. Yet YAZ is still the best-selling oral contraceptive in the United States, grossing $391 million in the first half of 2009 alone.
MEDICALIZATION OF CHILDBIRTH
In our highly medicalized and technologically oriented culture, childbirth has not escaped medical intrusion into women’s bodies. Of course, modern obstetrical practices can save the lives of mothers and babies but 99% of c-sections – the most performed operation in the United States – are unnecessary. After a brief interest in natural childbirth practices which reached only a small number of women, we have reverted to surgery that makes women the passive object of medical care. In fact, most husbands and doctors think the baby is theirs. They say, “We’re pregnant, we’re having a test, we’re going into labor, we gave birth to a boy.”
How do pregnant women fare in the United States? Our medical system has made us patients. Recent news tells of world-wide efforts to reduce maternal deaths—which occur every minute and a half. This should be a wake-up call to the United States to reverse the appalling upward trend in maternal deaths where the rate rose 42% from 1980 to 2008. Even though the United States spends more on health care than any other country, a woman’s risk of dying in childbirth is higher here than in 40 other countries. Two to three women die every day, and African-American women are nearly four times more likely to die than white women. It is also a three million dollar industry.
The World Health Organization recommends that outcomes are best for women and babies when c-sections rates are between five and ten percent. In the United States, c-sections account for one-third of the births. Planned pregnancies are in, natural childbirth is out. 1.5 million of these major operations are performed each year and we are shipping our medical technology overseas as we do with our McDonald’s franchises. The c-section rate in China is 46%, in Vietnam it is 36%, it is 34% in Thailand, and 34% in Latin America.
Why are so many women undergoing dangerous and major surgery that is not medically warranted? Money! A recent USA Today article reported that the average initial cost of a planned c-section is 76 percent higher than that of a planned birth and that additional doctor and hospital charges associated with the approximately 1.4 million planned c-sections each year are costing women an estimated $3 billion. What we have now is better décor but the same medical interference in childbirth. The New York Times had a tale of two hospitals, one with the highest rate of c-sections in the city – the other with the fourth lowest. They represent the city’s obstetric extremes, yet they sit just five miles apart in Staten Island serving similar populations. What accounts for the difference?
New York City’s c-section rate has soared in recent years – increasing by 36% between the years of 2000 and 2007, according to the New York State Department of Health. It now accounts for 50% of all births. But Dr. Mitchell Maiman, the Chairman of Obstetrics and Gynecology at Staten Island University Hospital, has kept his hospital’s rate around 23% of all births while the rate at Richmond University Medical Center is 43.8% – the highest rate in the city.
Cesarean births are primarily more prone to complications than natural births. And while hospitals give lip service to reducing them, very few have managed to do it. Dr. Maiman and his colleagues do not allow inductions for first-time pregnancies since that is the main cause of c-sections. They also don’t allow c-sections simply because the mother wants one. Dr. Maiman says if you went to your doctor and said, “I want my gall bladder taken out” electively, your doctor would refuse that. Dr. Maiman favors the same noninterventionist policy for pregnancy, as long as it is safe.
Maybe you believe a mother’s choice should extend to controlling the hour of her delivery and how much it will hurt, and therefore do not like Dr. Maiman’s policy. But you have to give him credit for creating protocols to support women’s health and enforcing them. There is not a lot of incentive for hospitals to let conviction trump convenience. If this can be done in one hospital, it can be done in every hospital and it can be done for every unnecessary c-section and every unnecessary hysterectomy. Cesarean sections are dangerous and expensive operations, but save the doctor time. Perhaps we are saving some babies but we are losing more mothers.
Medicalization of pregnancy, starting in the 1940’s, was through the use of another hormone – a synthetic powerful estrogen known as DES. Its inventor, Sir Charles Dodds, never patented it and was against the automatic prescribing of estrogen for any reason. The men in his laboratory were growing breasts and he thought that DES might cause breast cancer. Dodds sent samples to the National Cancer Institute just being established in the United States to Dr. Morris Shimkin. Dr. Dodds asked Dr. Shimkin to investigate the carcinogenicity of stilbestrol in male rodents. Shimkin and Grady reported in the Journal of the National Cancer Institute in 1950 that stilbestrol produced breast cancers in both male and female mice, which were normally resistant.
Six million American women were given this unsafe, untested, and ineffective drug during their pregnancies. By 1939, more than 40 articles documenting carcinogenic effects of synthetic estrogens, including DES, had been published in medical journals. DES did not save a single baby.
In 1959, the Secretary of Health, Education and Welfare announced the potential cancer hazard to the public “occasioned by the use of Stilbestrol-treated poultry.” He ordered a blanket ban on the use of diethylstilbestrol die as a poultry additive.
On December 15, 1961, Deputy Food and Drug Commissioner Harvey also ordered a blanket ban on the use of DES as a poultry additive, saying: “There is a substantial evidence that this drug may be expected to produce, incite, or stimulate cancer growth in human beings.”
However, DES was not banned for pregnancy – yes for chickens, no for childbirth – until 1975. How much cancer, infertility, miscarriages – expense and worry – could have been prevented? Eli Lilly’s expert stated at trial that the human (woman) was the best test animal and Lilly’s lawyer said succinctly: “Eli Lilly is like any other company … I would be a dummy to stand up here and say it is not in business to make money … of course it is.”
While we no longer use DES, there are still many modern obstetrical interventions that increase the incidence of obstetrical complications and emergencies. It is questionable whether our society, understands in which a woman’s body extrudes a baby rather than a process by which a medical professional removes a baby from a woman’s body.
MENOPAUSE AND HORMONES
Of course we know the road for menopausal treatment is more like a street lined with gold leading up to the door of the pharmaceutical companies. The drug industry has quite a number of elaborate ways to make you buy their products. One method is to enlist the help of doctors in boosting their product. The pharmaceutical companies accomplish this by spending $8,000 to $13,000 per physician annually in gifts to physicians such as lunches, books, and stethoscopes; free attendance at conferences; and all-expenses-paid trips to meetings. These methods pay off when you realize that only 27 percent of physicians prescribe generic options for their patients; this means the other 83 percent are pushing higher-priced brand-name drugs. Another way the drug industry gets you is through direct-to-consumer advertising; in 2005 the pharmaceutical industry spent more than $4.2 billion to get your attention.
Menopause is described in medical literature as “the death of the woman in the woman.” How does it happen that the natural occurrence in life drives us to the doctor’s office in such numbers?
Derived from the Greek words for month and cessation, the term menopause was first used in 1872. By that date, Western medicine viewed menopause as a medical crisis that had the potential of causing a variety of diseases, from diarrhea to diabetes. The crisis was deemed greatest for women who had acted indiscreetly in the past. Such indiscretions included getting too much education, having too much sex, attempting to use birth control, or even being insufficiently devoted to husband and children. As a prescription for menopause, doctors recommended a quiet lifestyle centered on the family.
Sometimes more drastic measures were taken. Leeches were often put on a woman’s ears or on the nape of her neck to cure menopausal complaints. Another popular remedy was an oophorectomy, or surgical removal of the ovaries. Such an operation was considered especially helpful in curing menopausal depression and “disorderliness.”
Not all nineteenth-century physicians, however, shared their peers’ negative views of menopause. One trend-breaker dared to refer to menopause as “a period of increased vigor, optimism, and even of physical beauty.” Another physician publicly criticized his medical colleagues for subjecting women to unnecessary oophorectomies, stating in a medical journal that he had “yet to see a woman made better in health by the removal of her ovaries.”
By the middle of the twentieth century, the medical profession switched from looking upon menopause as the cause of disease and began to think of it as a disease itself – a deficiency disease, like diabetes. This gave doctors the exclusive right to diagnose menopause and to treat its symptoms with estrogen, the hormone women were said to be lacking.
Estrogen was first prescribed for menopausal symptoms in the 1930s. It could be taken as a pill, administered via injection, applied directly to the vagina as a cream, or even taken as a “pleasant-tasting cordial” – 14% alcohol! But in 1947, an alarming report revealed that estrogen therapy could seriously disturb the endometria, thickening the uterine tissue and ultimately causing cancer. Barbara Seaman became aware of the dangers of the hormone in 1959, when her aunt died of endometrial cancer after taking Premarin, a form of estrogen derived from pregnant mares’ urine.
By 1966, however, these warnings had not been disseminated. In Forever Feminine, gynecologist Dr. Robert Wilson trumpeted estrogen therapy as an “elixir of youth” to protect women from the “living decay” of menopause. He declared that estrogen could cure nervousness, crying spells, memory loss, chronic indigestion, aching joints, neuroses, and even suicidal thoughts. In addition to making his book a best-seller, these claims also fueled skyrocketing sales of estrogen, from $20 million before 1966 to $83 million in 1975. Not surprisingly, Wilson had received money from the drug companies for conducting his so-called “research.”
In 1975 an article in the New England Journal of Medicine firmly announced what the 1947 study had suspected – women who took estrogen were about 5 to 14 times more likely to develop cancer of the endometrial lining than women who never used the drug. Further, the longer a woman remained on estrogen therapy, the greater her cancer risk. Finally, in 1976, after lobbying by the women’s health movement, the FDA passed a regulation that any estrogen drug had to have a patient package insert describing its health risks. The medical and pharmaceutical lobby opposed this regulation vigorously, arguing interference with the physician-patient relationship. One doctor went so far as to say that seeing such a package insert might be too emotionally upsetting for women seeking estrogen treatment. However, women seemed to heed the warnings about the dangers of estrogen. Between 1975 and 1978, sales of estrogen decreased by 40%, and the incidence of endometrial cancer fell by about 27% nationwide.
Revenues from the Premarin family of products, including Prempro, had declined by 25 percent. But according to SEC filings, Wyeth Pharmaceuticals earned over $245 million from the Premarin family in 2009. Wyeth is perhaps best known for producing Phen-Fen, a diet drug marketed almost entirely to women before it was pulled from drugstore shelves in September 1997. This occurred amid scandalous reports that famed obesity experts, such as the University of Pennsylvania’s Dr. Albert Stunkard, had signed their names to medical articles that were prepared and paid for by Wyeth.
Last Sunday, the New York Times Magazine was devoted to The Science of Living a Healthy Life. Listed on the cover was an article that was called The Estrogen Dilemma. The story quoted a woman ‘brain scientist,’ who was interested in the relationship of estrogen to the health of the brain.
The paper made this one of the most important articles on health by placing it on the front cover. However, there is no research quoted in the article, no study quoted in the article, no conclusions to be drawn from the article, there is only a supposition that if estrogen is aimed at a 40 to 60 yr old cohort it will prove to be the cure of depression symptoms, Alzheimers, and attention deficit disorder.
Since 68% of all victims of Alzheimers are women, she believes that their brains ‘might have been protected from eventual damage if those women had taken estrogen, and taken it before they were long past their menopause.’ Estrogen must be given during what is called the ‘Window of Opportunity for Estrogen Therapy for Neuroprotection,’ the name of a recent scientific symposium at Stanford University which attracted professionals from all over. In reality, this ‘window’ means that, if adhered to, women will be given estrogen at a much younger age.
In 2002, the W.H.I. hormones-versus-placebo trial was ended three years earlier than planned. W.H.I. officials ‘were persuaded that the trial was dangerous too the hormone-taking participants to let them continue.’ Women on hormones were having more heart trouble than placebo taking counterparts, the risk for stroke went up, the risk for blood clots went up, and the risk for breast cancer increased by 24%. The thrust of the Estrogen Dilemma was that the study failed because of timing, meaning that it was given to menopausal women versus peri-menopausal women, but there is not a scintilla of evidence to support that this would make a difference.
The author, Cynthia Gorney, fails to cite a single study showing that estradial is a safer form of estrogen. No clinical trials have shown that it is effective in treating depression.
In the article, a nursery-school director says, “I’d rather monitor something I know can go wrong than go on living in the state I was in,” she continues, “I could have my breasts removed. I like them, but they’re not my life.” The author of the article adds that in her own opinion replacement estrogen is ‘not an elixir of youth [but is] more like….reading glasses.”
Tens of thousands of women have already had heart attacks, strokes or contracted breast cancer. Without a single conclusive scientific study, the “scientists” in this article are proselytizing for the drug industry, which stands to profit enormously from the process of medicalizing normal female aging.
Pharmacies offer menopausal women so-called “bio-identical hormones,” which are supposedly “natural” because they are derived from plant materials. But it is important to remember that “natural” is a marketing term, and not a medical term. These drugs were featured on a recent episode of Oprah, wherein Suzanne Somers discussed her extensive regimen of estrogen and progesterone creams, vitamins, supplements, and self-administered injections. She argued that mainstream doctors lag behind in their knowledge of these sorts of products, and that although she looks like “some kind of freak or fanatic” she believes these hormones will help her live to age 110. This kind of celebrity endorsement insures that women will flock to pharmacies in search of these supposedly “natural” products.
In addition, pharmacies have begun what is known as “compounding” – the mixing of drugs as tailored to the needs of a particular patient. Says the medical industry:
“Individualizing hormone replacement addresses the No. 1 problem with HRT: compliance. Many women tire of taking numerous medications a day. A compounding pharmacist has the ability to combine the medications into one capsule, encouraging compliance through ease of dosing.”
According to a national survey, 86% of women were unaware that these custom-made treatments lack FDA approval.
Further, in spite of conflicting data on both efficacy and side effects, doctors have begun prescribing testosterone supplements to women who complain of sexual dysfunction. Testosterone is also heralded as a “bone-builder”, and a remedy for depression and muscle loss. Dose-related side effects of excess testosterone include oily skin, acne, and irritability.
Companies are also developing new products that deliver estrogen therapy to menopausal women. Ascend Therapeutics’ “EstroGel”, a form of estradiol applied to the arm once per day, purports to “manage” menopause symptoms such as hot flashes, night sweats, and vaginal dryness. Upsher-Smith Laboratories produces Divigel, a similar drug. Estrodial gels are also marketed to improve bone mineral density (BMD). The warnings associated with these estrogen gels include cancer, heart attack, stroke, and dementia.
It has therefore become evident that despite the contra-indications and side effects resulting from hormones given for a non-disease, the pharmaceutical industry will not stop promoting them because it is a $3 billion industry.
Of course, at a HERS conference we must address hysterectomies. Perhaps the most over-medicalized aspect of our biology involves removal of the reproductive organs. A comedy sketch on British television some years ago illustrated the perceived expendability of women’s genitals as compared with men’s. A male patient sat on an examining table, in gynecological stirrups, with a female physician examining his pelvic region. Appearing embarrassed and uncomfortable, the patient answered questions from the doctor about how many children he had, their health, and whether he was satisfied with the number. The doctor concluded that the patient had “finished his family,” and casually suggested that he “just have them [his testicles] off” in order to relieve certain unspecified “symptoms” and forestall possible negative developments, such as cancer. This is funny (to men, anyway) because no doctor would ever seriously suggest this course of action as a preventative measure. However, women are routinely submitted to unnecessary hysterectomies and ovariectomies by doctors who insist that such surgery is needed to prevent disease. Indeed, doctors at an Ob/Gyn conference once agreed that “no ovary is good enough to leave in and no testicle is bad enough to take out.”
The history of the hysterectomy reveals that as far back as Hippocrates’ day, during the 5th and 6th centuries BC, doctors believed that the female reproductive system was a source of hysteria and even insanity. For more than two thousand years, if a woman stepped out of the expected pattern of subservience and humility, her ovaries and uterus were blamed. Aristotle wrote that the uterus was “the seat of womanhood”. The Greek term “hystera”, meaning womb, is where the surgery gets its name. Soranus, a Greek obstetrician, reportedly performed the first known hysterectomy in the 2nd century, removing the uterus through the vagina. The woman died during surgery.
More definitive evidence places the first hysterectomy in the16th century. Between 1560 and 1624, physicians removed the uterus, either in whole or in part, also through the vagina. Some writings even detail self-inflicted hysterectomies. During the Renaissance, Italian physician Jacopo Berengario DiCapri astutely correlated a loss of sexual feeling with hysterectomy.
Medical historians credit C.J.M. Langenbeck, of Gottingen, Germany, with performing the first “modern” hysterectomy in 1813. This was the first reported total hysterectomy that the patient survived. However, following his second procedure, the woman died two days post-operation. In 1829, John Collins Warren performed the first American hysterectomy; his patient died four days later.
By 1830, several reports on hysterectomies indicated that the operative mortality rate was 90%. The long-term prognoses were equally dismal since these operations were performed for cervical cancer, and the patient invariably died shortly after the surgery from that disease. The technique often led to rectal and bladder injuries, and death due to peritonitis. In 1842, the introduction of ether as the first anesthetic increased the likelihood that a woman would live through surgery, but most hysterectomy patients still died of complications in subsequent days.
Thus, discontent with the operation ensued. Said 19th century German surgeon Johann Friedrich Dieffenback:
“To take the entire womb from the belly of a woman means the removal of that woman’s soul even if it be a diseased soul. Still, some daring men attempted it and they deserve our thanks in as much as the results of their terrible operation furnish us all the proof needed to banish this procedure from the field of surgery. According to my opinion, an indication for this operation does not exist. The attempted extirpation of the womb partakes more of the character of murder tales than of curative surgical operations.”
At the time, removal of the ovaries was widely practiced. Victorians, who considered ovaries the seat of femininity, removed them to cure everything from irritability to insanity. Medical literature from this time is replete with references to the frailty and hysteria of women, with removal of the ovaries touted as a way to keep them under the social control of men. In 1896, Dr. David Gilliam wrote that “castration pays… the patients are improved, some of them cured… my own experience in this line has been most happy.” By 1906, 150,000 American women had undergone the procedure.
Meanwhile, despite the so-called “success” of the ovariectomy, intraabdominal uterine removal was still thought to be impossible up until the mid-19th century. In 1842, Dr. A.M. Heath, of the Manchester School of Medicine and Surgery, performed his first abdominal hysterectomy somewhat inadvertently. The surgeon planned to extract an enlarged ovary, a relatively routine procedure, but discovered instead a uterine tumor. After removing the patient’s uterus, he reported: “No bleeding ensued from the cut cervix. After the first division of the skin, few complaints of suffering were made by the patient herself.” The patient died 13 hours after the operation’s completion.
In 1844, Charles Clay performed the first abdominal hysterectomy and bilateral salpingo-oopherectomy. His patient died 15 days post-operation. Gynecologist and ovariatomist Walter Burnham of Lowell, Massachusetts, performed the first successful abdominal hysterectomy in 1853. He performed just 15 hysterectomies in total, reporting only three in which the patient ultimately survived. In contrast, between 1851 and 1882 he also performed 300 ovariatomies with a mortality rate of around 25% — relatively good for those days. So despite his early success, he too doubted the propriety of the hysterectomy as a safe medical procedure.
In the 1870s, refinements were made to the techniques of both abdominal and vaginal hysterectomies. Improvements in anesthesia, antisepsis measures, and the use of ligatures to prevent blood loss increased the expected survival of each procedure. By 1886, the mortality rate of the vaginal hysterectomy had dropped to 15%. By 1890 it further decreased to 10%.
In the 1890s, the Schuchardt method of radical hysterectomy emerged. Friedrich Schaouta developed the technique and reported his findings in 1908, which popularized the method in Europe. By 1910, the mortality rate from vaginal hysterectomy had dropped to 2.5%, and in 1914 the Mayo Clinic concluded that with such a low risk of death the surgery could be performed for reasons other than strictly uterine indications, such as cystocele repair.
By 1930, the mortality rate for total abdominal hysterectomy had dropped to 3%, which made the procedure more popular than surpracervical hysterectomy. In 1955, 99.5% of hysterectomies were total, compared to just 31% in 1946. By 1985, 20th century developments such as antibiotics and blood replacement, further lowered the mortality rate to 1 in 1000, where it remains today.
Apparently, the safety of the hysterectomy in modern times has served as an invitation to doctors to perform the procedure even when it is medically unnecessary, as it is 99% of the time. As late as the 1970s, the physician overseeing a Cesarean birth by a minority or indigent woman would ask how many children the patient had. If the number seemed excessive, the operating resident would be invited to perform a hysterectomy to increase his experience with this procedure. The patient, under general anesthesia, obviously could not give her consent, so the operative report would note excessive bleeding or some other excuse for the hysterectomy. Also in the 1970s, Diana Scully observed Ob/Gyn residency programs and found that doctors were taught to “think of the uterus as a cradle. After you’ve had all your babies there’s no reason to keep the cradle. And removing your uterus will save you from the risk of developing cancer in later life.”
More than 30 years later, this cradle analogy is still being used. The New York State Department of Health produces a pamphlet about the dangers of hysterectomy and alternative treatment options. The pamphlet continues to assert that the only function of the uterus is to “cradle and nourish a fetus from conception to birth, and aid in the delivery of the baby. It also produces the monthly menstrual flow, or period.” No other function of the uterus is mentioned, nor is any further information about this important part of our body described. It vaguely asserts that after a hysterectomy, ovaries still produce hormones but “may have reduced activity.” It fails to explain that removal of the uterus and ovaries constitutes castration. It also does not explain that sex will never be the same, or describe other consequences such as personality change, difficulty with social interaction, memory loss, pain, loss of energy, and even suicidal thoughts.
The uterus and ovaries have been a favorite target for surgeons – only the reasons for their removal seem to change. During the last 200 years gynecologists have proceeded from their first tentative attempts to perform hysterectomies to where it is the second-most performed operation in the United States – at the rate of about 1,643 a day. That is more than one every minute. Clearly this qualifies as fad proportions. In total, American doctors perform 685,000 hysterectomies each year. Compare this to another industrialized Western nation, England, where only 40,000 such procedures are performed per year. The United States has four times the hysterectomy rate of any industrialized nation.
In Saudi Arabia a gynecologist may perform only one hysterectomy a year, usually due to a life-threatening event such as an obstetric hemorrhage. In Somalia, uterus removal is viewed as so rare and abhorrent that in 2004 the family of a hysterectomy patient dispatched gunmen to threaten her doctor. They argued that she was as good as dead without a womb, and demanded 50 camels – the usual Somali compensation offered upon a woman’s death. The doctor, who was fined $2,000, promised that in the future he would consult patients’ families before performing such operations.
In the U.S., 45.1% or more of women ages 65 and under in the U.S. report having undergone a hysterectomy. Rates vary by state; in New York the rate is 13.3% with 3.2% in the 44 and under group. Mississippi has the highest rate at 57.1%. No wonder hysterectomies are often called “Mississippi appendectomies.” In California, only about half of the female population will die with their uteruses intact. (Another joke – What do you call a woman in San Diego who still has a uterus? A tourist.) Regionally, the South continues to have the highest rate of hysterectomies at 60.2 out of 1,000 women, while the Northeast has the lowest rate at 3.7 out of 1,000. But do women’s reproductive organs differ by geography?
Approximately 1 in 2 American women will have a hysterectomy by the time she is 70. 400,000 are performed for uterine fibroids, which is usually a benign condition. Even by conservative estimates, 9 out of 10 American hysterectomies are elective procedures. That means that there is no medical imperative that a hysterectomy is done and that if it is not done, nothing dire will happen. In many cases, if the hysterectomy is not done, the women would be much better off and only the doctors’ wallets would suffer. In addition, surgical removal of the ovaries is done in about 75% of women who have hysterectomies, without medical justification.
Hysterectomies have often been referred to as ‘hip pocket surgeries’ because in most cases they serve only to line the pockets of the surgeons and hospitals that do the surgery. In this country, hysterectomies and oopherectomies have boomed into an industry worth $17 billion per year. The long-term cost of treatment and corrective surgeries for the problems cause by hysterectomy and ovary removal could easily exceed this amount.
Further, Medicare and Medicaid statistics reveal that the more body parts a doctor removes, the more money he and the hospital receive. In 2006, the rate of reimbursement for treatments for uterine fibroids from Medicare and Medicaid were as follows:
1. total hysterectomy $5,200
2. vaginal hysterectomy, including removal of fallopian tubes and/or ovaries $5,140
3. abdominal myomectemy $5,132
4. vaginal hysterectomy $5,051
5. vaginal myomectemy $1,746
This provides zero incentive to doctors to change their ways. Meanwhile, the increasing number of women physicians has been ineffectual in curtailing the contrast in attitudes towards women’s and men’s reproductive organs. Women doctors may relate better to women patients, but their training is the same as their male counterparts. Perhaps because men still control the overall medical establishment, the terms for these procedures remain misleading. The plain meaning of “total hysterectomy” seems to entail removal of the uterus in its entirety; instead, it refers to removal of the uterus, ovaries, and fallopian tubes. And only a male-dominated profession could use the term “simple hysterectomy” to refer to removal of the uterus – which is decidedly not simple!
Osteoporosis is another condition that inspires fear in the hearts of millions of elderly women. But when we ask what osteoporosis is, it becomes clear that the definition of osteoporosis has gone through many permutations over the years. For most doctors, an osteoporotic woman is identified through a series of bone mineral density (BMD) tests. The National Osteoporosis Foundation recommends BMD tests for all women 65 and older, as well as for all post-menopausal women and women who have been taking hormones for a prolonged period of time. The more deviation from the bone density score of a normal young adult of the same sex, the more negative the number and the greater the risk of fracture. A score higher than -2.5 marks the point at which doctors diagnose a woman as suffering from osteoporosis.
It is estimated that more than 20% of most menopausal women have osteoporosis and that estimate has reached as high as 50%. Scaring women about their bone strength is a burgeoning industry which urges us to “talk to our doctors before it’s too late.” Free bone mineral density tests are offered to see “how much we lost.”
During the 1990s, the immediate response to a diagnosis of osteoporosis was to put a woman on a hormone therapy regimen. Estrogen was recommended as a preventive treatment for post-menopausal osteoporosis as early as 1941, and by 1975 the annual number of estrogen prescriptions written was nearly double the number written in 1966. Premarin, the country’s leading estrogen product, became one of the top five prescription drugs in the country. Although it was marketed for the psychological discomforts of menopause, keeping bones strong was an important part of its purported youth-giving properties – feminine forever equaled estrogen forever.
After 5 years of cancer warnings, the number of annual prescriptions for Premarin fell by 50%. The advertising claims were altered to include only menopausal symptoms and vaginal dryness. The company found salvation later by aggressively promoting hormone therapy as the preferred treatment for osteoporosis. A risk factor had been turned into a disease and there was a situation in which the people profiting from osteoporosis as a disease were the ones defining it.
Young women should also be aware of the side effects before deciding to go on Depo-Provera, a progesterone contraceptive given by injection that has been shown to cause bone loss in some users. In her book The Menopause Industry, Sandra Coney writes that “after measuring the bones of young women who had been using Depo-Provera for over five years, it was found that they had 7.5% less bone in the spine and 6.5% less bone in the hip than women who had never used the drug.” The bone loss seems to result from the drug’s blocking of estrogen and causing amenorrhea (the absence of menstruation).
The FDA has now placed black boxes not only on estrogen, but on some of the newer osteoporosis treatments that are coming to market warning that serious side effects may occur. Instead of science by press release, living a healthy lifestyle, including nutrition and exercise, will be a lot better for your health than Wyeth Ayerst products.
As the first decade of the new century comes to a close, the trend of medicalizing women’s biology shows no signs of abating. According to the American College of Obstetricians and Gynecologists, about two-thirds of American women rely on their gynecologists for primary care. Unsafe and questionable methods of contraception are still used. The Today Sponge, as featured on a popular Seinfeld episode, is still advertised as a “safe, hormone-free birth control alternative for women that provides 24 hour protection.” The Mirena intrauterine device promises effective birth control for up to 5 years. During pregnancy, upwards of 20 tests are performed on both mother and unborn child, some of which are more perilous than the conditions they purport to detect. Pharmacies offer menopausal women so-called “bio-identical hormones,” which are supposedly “natural” because they are derived from plant materials. In addition, pharmacies have begun what is known as “compounding” – the mixing of drugs as tailored to the needs of a particular patient. These products, including hormone replacements, are dispensed in quantities and combinations not approved by the FDA.
Surgically, women undergo numerous unnecessary C-sections, hysterectomies, oopherectomies, and other procedures.
Nada L. Stotland, whose article “Women’s Bodies, Doctor’s Dynamics” provided a great deal of background for this speech, summarizes the current scenario:
“Many of the procedures performed on women’s reproductive organs, and medications administered to control them, have been unsupported by empirical evidence. They have been driven by women’s desire to have babies, on the one hand, and unconscious motivations of historically male medical professionals on the other. Reproductive technologies penetrate the female genitalia, whether medically or surgically. They allow physicians to fantasize that it is they, rather than mothers, who conceive and gestate children. They expose every secret of the hidden female anatomy to view, study, and treatment. Finally, women’s doctors decreed that menopausal women are deficient, that women must maintain childbearing levels of hormones rather than progress through the normal stages of life. Each of these interventions has been justified by ‘science’… [but] seldom have we examined the reasons we ask the ‘scientific’ questions.”
Despite the social progress made by women in recent decades, we have not advanced far enough when it comes to our biology. In the face of overwhelming medical literature, reports, and advice, we must assert our rights and retain control over our own bodies.