Excerpts: Dr. Robert Wilson, His Book Feminine Forever (1966), and Uncanny Parallels to Dr. William Powers Today
By Aly W. | First published July 1, 2020 | Last modified March 15, 2021
This page contains excerpts from Feminine Forever, Dr. Robert A. Wilson’s famous—or more so infamous—1966 book on hormone therapy for menopausal women. The page additionally contains excerpts relevant to Wilson and Feminine Forever from The Estrogen Elixir, a 2007 book by Elizabeth Watkins. There are overt and uncanny parallels of Wilson and Feminine Forever to certain happenings in the transgender community today, which is my basis for posting these excerpts.
Wilson, Robert A. (1966). Feminine Forever. New York: M. Evans and Company. [Google Books]:
Must Women Tolerate Castration?
WHENEVER I SPEAK of menopause as castration, some shocked nice Nellies of either sex—a good many of them doctors—protest that I am overstating the case. But castration, I believe, is the proper term for a syndrome depriving a person of his (or her) sexual functions. It makes no difference whether castration is brought about by removing the ovaries with a knife as in their surgical removal—or whether the ovaries shrivel up and die as the result of menopause. In either case, the effect is the same: the woman becomes the equivalent of a eunuch.
Castration is a drastic event that affects the entire body. Let the evidence speak for itself:
In all but fifteen percent of menopausal women, the following symptoms develop in varying degrees: the tissues dry out, the muscles weaken, the skin sags. The bones, because of the hormonal deficiency, become brittle and porous, easily fractured. The weakening of the bones often leads to an increasingly hunchbacked condition as the years go by, known as “dowager’s hump.” Moreover, while women during their fertile years are virtually immune to coronary disease and high blood pressure, the menopausal woman—lacking female hormones—soon loses this advantage and becomes as prone to heart trouble and strokes as a man of similar age. These are the secondary effects of her castration.
As for the primary effects, they are quite simple. Deprived of its natural fluids by the general desiccation of tissues, 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.
Additional physical consequences of castration are so varied, obscure, and bizarre that most physicians are hopelessly puzzled at the recital of symptoms from their menopausal patients. What, for example, can the poor doctor make of a woman who complains to him of nervousness, irritability, anxiety, apprehension, hot flushes, night sweats, joint pains, melancholia, palpitations, crying spells, weakness, dizziness, severe headache, poor concentration, loss of memory, chronic indigestion, insomnia, frequent urination, itching of the skin, dryness of eye, nose, and mouth, and a backache?
I haven’t exaggerated the facts in this recital of annoyances, complaints, and irritations. In my own practice I have encountered many post-menopausal women who exhibited every one of these symptoms to a more-or-less-marked degree.
The effects of menopausal castration, as is evident from this list of symptoms, are by no means confined to the sexual organs. Because the chemical balance of the entire organism is disrupted, menopausal castration amounts to a mutilation of the whole body. I have known cases where the resulting physical and mental anguish was so unbearable that the patient committed suicide.
While not all women are affected by menopause to this extreme degree, no woman can be sure of escaping the horror of this living decay. Every woman faces the threat of extreme suffering and incapacity.
I submit that this is a condition intolerable to modern women. Such waste of human life and happiness cannot be justified either medically or philosophically. Least of all can it be justified by sheer ignorance. Despite the conspiracy of silence surrounding the subject, most women are well aware of the extent to which menopause cripples them. Literally, they feel it in their bones, in their minds, and their hearts. A show of bravery might mask their distress for several years until the symptoms become so obvious that even the most valiant woman can no longer hide the fact that she is, in effect, no longer a woman, but a neuter. Ultimately, not even valor offers escape from this physical reality. What we must learn is that there is no need for either valor or pretense. The need is for hormones.
Most of my private patients consulted me at the first signs of menopausal discomfort, early enough to be cured by intensive hormone therapy. And in recent years, a growing percentage of women came for such treatment even before menopause. For these wise women, no symptoms ever developed. But as a consultant in gynecology to Methodist Hospital in Brooklyn, I have had ample opportunity to witness the terrible results of prolonged menopausal neglect. I have seen untreated women who had shriveled into caricatures of their former selves. Some had lost as much as six inches of height due to pathological bone changes caused by lack of estrogen. Others suffered sweeping metabolic disturbances that literally put them in mortal danger.
Though the physical suffering from menopausal effects can be truly dreadful, what impressed me most tragically is the destruction of personality. Some women, when they realize that they are no longer women, subside into a stupor of indifference. Even so, they are relatively lucky. The most heartbreaking cases, I feel, are those sensitive women who witness their own decline with agonizing self-awareness.
It is barbaric to expect that today’s woman—just because she lives longer—must tolerate castration during what should be her best years. Yet this is precisely the attitude maintained by those who still insist that menopause—and the resultant castration—is a natural consequence of age.
How different is the fate of woman. Though modern diets, cosmetics, and fashions make her outwardly look even younger than her husband, her body ultimately betrays her. It destroys her womanhood during her prime. At the very moment when she is most able and eager to enjoy her achievements, her femininity—the very basis of her selfhood—crumbles in ruin. But now, at last, medicine offers a practical escape from this fateful dilemma.
With estrogen therapy, the basic handicap of women with respect to men—their fast and painful aging process—is overcome. Women now need not age faster than men. If a woman’s body is furnished through pills with the needed estrogen (no longer supplied by her own ovaries), her rapid physical decline in post-menopausal years is halted. Her body retains its relative youthfulness just as a man’s does.
It has been argued that the extension of a woman’s femininity by means of estrogen is “interfering with nature.” One might counter such objections by asking whether curing the measles—or any other disease—is also interfering with nature. If so, the art of medicine as a whole would have to be abandoned.
So much for the medical side of the argument. If the question is to be examined on philosophic grounds, I rest my case on the simple contention that castration is a bad thing and that every woman has the right—indeed, the duty—to counteract the chemical castration that befalls her during her middle years. Estrogen therapy is a proven, effective means of restoring the normal balance of her bodily and psychic functions throughout her prolonged life. It is nothing less than the method by which a woman can remain feminine forever.
Estrogen as produced by the egg-sacs in the ovaries, for the most part, does not act directly upon the various cells of the body. Before it becomes effective, it must undergo one more process. It passes in the bloodstream through the liver and is chemically changed into compounds called conjugated estrogens (among them estrone and estriol). It is in this form that estrogen becomes the key to a woman’s femininity.
Through an ingenious mechanism by which estrogen acts on the pituitary gland at the base of the brain, it has a direct effect on a woman’s emotional state. To a woman, estrogen acts as the carrier of that mysterious life force that motivates work, study, ambition, and that marvelous urge toward excellence that inspires the best of human beings.
My own observation leads me to conclude that—except in cases of some acute emotional shock—women with an ample supply of estrogen in their blood are not likely to develop psychological difficulties calling for the use of such psychic energizers. Estrogen itself acts as a natural energizer to both mind and body. Women rich in estrogen tend to have a certain mental vigor that gives them self-confidence, a sense of mastery over their destiny, the ability to think out problems effectively, resistance to mental and physical fatigue, and emotional sell-control. Their emotional reactions are proportional to the occasion. They neither over-react hysterically, nor do they tend toward apathy. They are, as a rule, capable of facing the world with a healthful relaxed attitude and thereby able to enjoy their daily life. They are seldom depressed. Irrational crying spells are virtually unknown among them. In a family situation, estrogen makes women adaptable, even-tempered, and generally easy to live with. Consequently, a woman’s estrogen carries significance beyond her own well-being. It also contributes toward the happiness of her family and all those with whom she is in daily contact.
Still another misconception concerning hormone therapy is the notion that estrogen predisposes toward cancer. The truth is exactly the opposite. There is increasing evidence that estrogen has a preventive effect on breast and genital cancers. In 1962, the Journal of the American Medical Association reported on one of my studies, in which a group of 304 women, aged forty to seventy, had been treated with estrogen for periods up to twenty-seven years. Given normal odds, as established by medical statistics, eighteen cases of cancer—either of the breast or the uterus—would normally be expected in this group. Instead, not a single case of cancer occurred!
The most likely explanation of this astonishing result—actual prevention of cancer of the uterine lining—is that estrogen therapy, by restoring menstruation in post-menopausal women maintains one of the most important features of internal hygiene. The monthly flow serves as a kind of internal bath, washing out the womb. Congested tissues—a possible starting point for cancer—continue to be washed away at regular intervals. They don’t get a chance to build up along the uterine lining where they might—due to menopausal inactivity and stagnation—undergo malignant change. Statistically, there is evidence that women who stay estrogen—rich throughout their lives will remain happily cancer-poor.
Among all the patients to whom I administered prolonged estrogen therapy I encountered only a single case of uterine cancer, and that particular woman was a referral from another physician and had apparently begun estrogen therapy too late to gain the benefit of its cancer-preventive effect.
The menstrual flow, which most women regard as such a confounded nuisance, thus appears to be an important clause in nature’s health insurance policy. As long as a woman menstruates naturally—i.e., before menopause—the flow lessens the likelihood of cancer of the uterine lining to a significant degree. And after the beginning of menopause, she can keep her “cancer insurance” in force by continuing to menstruate as the the result of estrogen therapy.
Now that we have outlined the central importance of estrogen in the chemistry of the female organism, it is easy to see why the loss of estrogen due to menopause is indeed a surpassing tragedy, and why the replacement of estrogen is essential to continued good health and happiness.
Again the link to menopause becomes apparent. The hypothalamus—the control center of the autonomic nervous system—takes a terrific buffeting when the pituitary gland reacts to the stoppage of estrogen production in the ovaries. The hypothalamus, in turn, sends out alarms throughout the autonomic nervous system with unpredictable emotional results. The hectic and disorganized messages reach the heart, the liver, the intestines, the colon, and other parts of the body. These organs, previously so well controlled by the hypothalamus, now revolt against the menopausal confusion. In their own way, the organs protest against the panic in the central command. The net result is that the post-menopausal woman suffers a decline in all of her bodily functions—not merely in those connected with reproduction. Such perturbation of the body indeed puts her mind and spirit to a grueling test, and it is hardly surprising that many women become mentally disturbed in their menopausal years.
To summarize the role of estrogen in the pituitary control center in the brain, I should like to quote a simile I once heard at a popular medical lecture. The speaker compared the pituitary to an irascible man who controls his entire family with strict discipline. But if something goes wrong, he is likely to fly into a rage and smash up the whole house. Estrogen, on the other hand, is like a calm, tactful woman who smoothes his irascible temper and keeps him from going to extremes. As long as estrogen is on hand, the temperamental pituitary keeps calm order in the endocrine family. But when estrogen is absent the overwrought pituitary makes a shambles of the entire household of the body.
During pregnancy, the uterus expands to enormous size to hold anywhere from one to five babies, plus the surrounding fluid and the nourishing placenta. Its tissues are drenched in estrogen, which is at that time produced in the placenta as well as in the ovaries. A pregnant woman has an estrogen level up to 600 times greater than that of a non-pregnant woman. […] In my opinion, a woman having experienced several pregnancies is basically healthier, more infection-resistant, and more feminine than her barren sisters. During her period of gestation, every cell in her body, from head to toe, becomes suffused with an abundance of age-retarding estrogen that otherwise would not have been produced.
If such a woman could age gradually and gracefully, like a healthy male, this subconscious hope of personal fulfillment would continue and sustain her until late in life. But nature plays a trick on her. During her best years, she encounters menopause—the end of her womanhood.
To be suddenly desexed is to her a staggering catastrophe that strikes directly at those hidden—and perfectly normal—hopes and motivations that have supported her all along.
Had she been conscious of these feminine longings for the kind of sensual and emotional fulfillment that her marriage failed to provide, she could rationally cope with her disappointment and perhaps even accept menopause as the end of these hopes. But since her hopes and motivations are mostly unconscious, she is incapable of rationally perceiving her own situation. She only knows dimly that the driving power of her existence has somehow failed her. She thrashes about wildly, often venting a special vindictiveness upon her husband and family. Eventually she subsides into an uneasy apathy that is indeed a form of death within life.
The transformation, within a few years, of a formerly pleasant, energetic woman into a dull-minded but sharp-tongued caricature of her former self is one of the saddest of human spectacles. The suffering is not hers alone—it involves her entire family, her business associates, her neighborhood storekeepers, and all others with whom she comes into contact. Multiplied by millions, she is a focus of bitterness and discontent in the whole fabric of our civilization. And the supreme tragedy is that, in the light of present medical possibilities, all this is unnecessary.
When Elsie first came to me, I had already become convinced as the result of my research in hormone therapy during the 1930’s that the entire menopausal syndrome is a preventable disease. And, though several eminent endocrinologists were sympathetic to this view, only a handful of clinical cases had been reported at the time to corroborate the theory. I told Elsie that, if she took her tablet regularly, she would be one of the first women in the history of the human race never to experience the travails of menopause. I anticipated the usual objections—that interfering with nature could only derange the organs and glands, imbue a woman with desires not suitable to her age, and possibly increase the likelihood of cancer—and presented to her some of the arguments outlined in Chapter 8. […] [Elsie] was not disappointed, and I remember her gratefully as one of those many courageous woman who put their trust in me at a time when estrogen therapy was still in its early stages. Hundreds of women like Elsie have since helped me develop the simple and reliable clinical procedures that today makes the attainment or restoration of lasting [femininity] a safe and reliable procedure.
My own activity in estrogen therapy [for menopause] spans this entire history. In more than forty years of gynecological practice I have administered estrogen to an estimated total of 5,000 women. To the best of my knowledge, my personal work in this area represents by a wide margin the greatest accumulation of clinical data by any single practitioner. Without exception, every case I treated since the introduction of estradiol benzoate showed some degree of improvement. In many cases total avoidance of all menopausal symptoms was achieved, and the percentage of marked amelioration was surprisingly high. In the entire realm of medicine, there are few forms of therapy with a more consistent record of beneficence. In the closing years of my medical career, I take a perhaps pardonable pride in the fact that the sheer bulk of medical statistics drawn from my work seems to augur a widening acceptance of this vital therapy.
Thousands of additional cases could be cited to buttress arguments in favor of estrogen therapy. Most of them would lack the dramatic extremes of the two instances I have singled out. The bulk of my medical records tell of women in comparatively normal life situations. The files include women of all ages, from their late teens to their eighties, widely differing in physique, personality, and sexual habits. The one thing they have in common is the desire to safeguard their natural femininity and, concomitantly, their total physical and psychological health.
The regular menstrual flow cleanses the uterus, eliminating congested tissues that are a possible breeding ground of cancers. In effect, the continuation of the menstrual cycle beyond menopause makes it difficult if not impossible for an endometrial cancer (cancer of the uterine lining) to take hold and continue to grow.
The opposition I have encountered to hormone therapy is, for the most part, so utterly irrational and so blind to evidence that I feel these objections are in essence a new facet of the ancient anti-feminine prejudice. Fear of the devil, to be sure, is no longer invoked in denying women the full possibilities of life. Instead two new bogeys are set up: fear of breast and uterine cancer, and fear of masculinization due to hormone therapy.
Both these topics have been discussed in previous chapters, and I have cited evidence to establish two vital points:
1.Estrogen therapy, far from causing cancer, tends to prevent it.
2.Estrogen, far from causing a change to male characteristics, promotes typically feminine appearance. (It is androgen, the male sex hormone, that is responsible for male appearance.)
In both cases, the truth is exactly the opposite of widespread belief. In view of such tragic misunderstandings, additional explanations may be in order.
I have already cited the report in the Journal of the American Medical Association of October 27, 1962, on a group of 304 women treated with estrogen for periods up to twenty-seven years. According to the norm for non-treated women, eighteen cases of breast or uterine cancer would normally be expected in this group. Yet among the estrogen-treated women, not a single case occurred.
The same kinds of results are being now obtained time and again in other studies. Dr. Walter Alvarez, the chief editor of Geriatrics, whose popular writings on medical subjects are widely syndicated in newspapers throughout the country, reports: “For the past twenty-five years … I have been giving female hormones to hundreds of menopausal women, and so far I haven’t seen one develop a cancer that I could blame on the medicine.” A recent meeting of the American College of Obstetricians and Gynecologists also went on record saying that the giving of female hormones is not to be feared.
The medical discoveries cited in this book were, of course, first published in the proper professional journals, including the Journal of the American Medical Association (see Medical Appendix). The therapeutic routines outlined in Chapter 6 have been tested in hundreds of cases, not merely in my own practice but also at Methodist Hospital in Brooklyn, New York, where I have served on the staff for forty-three years.
The elimination of menopause is perhaps the most important technical advance by which women may equip themselves for an enduringly feminine role in modern life. As a physician, it is therefore disconcerting to me that large segments of the medical profession still fail to understand the modern woman’s need to remain fully feminine throughout her lengthened lifespan.
Unreasoning reluctance to accept hormone therapy is, as we have pointed out before, not confined to the uninformed or misinformed public. The medical profession itself, as so often in the past, is slow to make use of new knowledge. The history of medicine is full of unrecognized prophets, missed opportunities, and embarrassed hindsight.
Watkins, Elizabeth Siegel (2007). The Estrogen Elixir: A History of Hormone Replacement Therapy in America. JHU Press. [Google Books]:
The opinion that women should begin to take hormones to combat the disease of estrogen deficiency during menopause and continue to take them for the rest of their lives found its greatest expression in the work and writing of Dr. Robert Wilson, a New York gynecologist affiliated with the Methodist Hospital of Brooklyn. Wilson had been in private practice for more than forty years before he published his first article in 1962, at the age of 67.76 The following year, Wilson and his wife, a nurse, co-authored an article entitled “The Fate of the Nontreated Postmenopausal Woman: A Plea for the Maintenance of Adequate Estrogen from Puberty to Grave,” in which they described, in no uncertain terms, the ravages of nonestrogenated aging. The Wilsons portrayed older women as “castrates” who “exist rather than live.”77 They blamed the loss of estrogen for causing diseases (such as hypertension and osteoporosis), psychological manifestations (such as depression, melancholia, and “a vapid cow-like feeling called a ‘negative state’”), and desexualization (resulting from atrophied genitals and “loss of physical attractiveness”). They claimed that all of these conditions could be avoided if women would replace the estrogen no longer made by their aging bodies.
In 1966, Wilson reached an even larger audience with his best-selling book Feminine Forever, which sold more than 140,000 copies in its first year, and through the tireless promotional efforts of his Wilson Research Foundation, which relied on financial support from the pharmaceutical industry to carry out its mission of educating women about the ravages of menopause and the miracle therapy of estrogen.84 The media picked up Wilson’s message, prompting articles in magazines from Vogue and Good Housekeeping to Newsweek and Science Digest.85 How women responded to this information is considered more fully in chapter 4, but sales figures reveal a significant rise in the use of estrogen. From 1966 to 1975, the annual number of estrogen prescriptions almost doubled,86 and the market value of noncontraceptive estrogen almost quadrupled.87 One survey of women in the Seattle area found that half of the menopausal and postmenopausal women interviewed had taken estrogen for an average duration of ten years.88 Although this rate of estrogen use was certainly among the highest in the country, it does demonstrate the trend of doctors prescribing, and women agreeing to take, estrogen for long periods of time.
This sea change in medical views on estrogen, from caution to enthusiasm, came about as the result of several interacting forces. The zeal of certain promoters was infectious. Masters, Shelton, Barnes, and Wilson offered both case studies and statistical data that seemed to be compelling evidence for the benefits of long-term hormone replacement. Case studies, although anecdotal, had been a long-standing method of reporting observations in medical journals, and therefore readers may have overlooked the idiosyncrasies of individual patient’s circumstances. When assembled into larger groups (Wilson’s data base of 304 women, for example), the findings seemed even more impressive.90 The research studies were the most persuasive of all. With the patina of scientific impartiality, these investigations offered convincing testimony of the effectiveness of estrogen not only in treating menopausal symptoms but also in reversing or forestalling diseases such as osteoporosis, cardiovascular disease, and mental senility. Although these studies were deficient by modern standards in terms of randomization, control of variables, and statistical analysis, they were accepted at the time as adequate and objective. They received no criticism in the contemporary medical literature; on the contrary, the results and conclusions of this research provided the early rationale for long-term estrogen use, as marketed by pharmaceutical companies and prescribed by physicians in the 1960s.
The man who brought hormone replacement therapy to the attention of the American public traced his professional interest in menopause to two key events in his boyhood in Ramsbottom, an industrial town in Lancashire, England, in the early twentieth century. First, he remembered his mother’s “tragic decline” during menopause from “that vital, wonderful woman who had been the dynamic focal point of our family into a pain-racked, petulant individual.”1 Second, he recalled witnessing the recovery of the body of a woman who drowned herself in a reservoir in his town. Neighbors attributed her suicide to “the change of life.” Haunted by the memory of the bloated corpse and stung by his mother’s “senseless rages,” he carried these memories with him when he immigrated to the United States and enrolled as a medical student at the Downstate campus of the State University of New York.
After graduating in 1919, this young doctor set up practice as an obstetrician-gynecologist in Brooklyn, New York. The first four decades of his career were unremarkable. Then, in 1966, he vaulted onto the national scene with the publication of his book Feminine Forever. Overnight, the septuagenarian Robert A. Wilson (about the same age as Brown-Séquard when he announced his rejuvenation with testicular extracts three-quarters of a century earlier) became the latest prophet of the miracles of sex hormone supplements to combat the ravages of aging.
Wilson devoted one of the eleven chapters of his book to autobiographical remarks, “not for the sake of self-aggrandizement, but rather to give my readers some feeling of personal contact with the doctor whom they have consulted through the pages of this book.2 […] [Wilson] confessed that he dealt with the frustration of years of professional indifference to his self-proclaimed medical breakthrough by comparing himself to other unappreciated pioneers, such as Edward Jenner, discoverer of vaccination, Louis Pasteur, creator of the germ theory, and George Papanicolaou, inventor of the Pap smear. Wilson recounted that the more time he spent on his research and writing, the less time he had for his private practice and the income it generated. When he had to sell his beloved Mercedes [to continue his work], he felt that he had “indeed joined the company of the martyrs of science.”4
Wilson addressed his financial concerns by establishing the Wilson Research Foundation in 1963. He secured funding from pharmaceutical companies to support the foundation’s goal of educating both the medical community and the general public about hormone replacement therapy. In addition to relentlessly pursuing press coverage of the hormone replacement solution to the problem of estrogen deficiency at and after menopause, the foundation sponsored an annual conference on HRT, sent representatives to give talks at meetings of medical societies and women’s clubs, and published its own pamphlets to be distributed to women in doctors’ waiting rooms.5 These pamphlets, like the book Feminine Forever, reiterated in laymen’s terms the information conveyed in the half dozen articles Wilson had published in medical journals in the early 1960s. Wilson’s popular publications, combined with the foundation’s successful efforts to interest journalists and magazine writers in reporting on HRT, brought about a dramatic transformation in the messages presented to women about the management of their menopausal and postmenopausal years.
Not until the 1960s, when the Wilson Research Foundation began its aggressive public relations campaign, did popular magazines warm to the possibility of long-term hormone replacement. Some journalists parroted Wilson’s notion that menopause was an estrogen deficiency disease; others, although unwilling to let go of the idea that menopause was a natural process, presented menopause in a much more negative light than in previous years. However, there was a solution at hand, and many of these writers presented estrogen as something close to a miracle drug. […] These articles relied heavily on doctors as experts, promoting estrogen as a panacea for the woes of menopause and aging.34 But nobody made the case for estrogen more persuasively than Robert A. Wilson.
His 1966 book Feminine Forever was an expanded version of the claims he had set forth three years earlier in his article “The Fate of the Nontreated Postmenopausal Woman: A Plea for the Maintenance of Adequate Estrogen from Puberty to Grave,” in the Journal of the American Geriatrics Society. Wilson decided to cut out the medical middle man and appeal directly to women. Although he described menopause and its aftermath in the most pessimistic terms, he presented himself as an advocate for women. Wilson acknowledged the validity of older women’s physical and psychological symptoms, and he criticized his fellow physicians who ignored their patients’ complaints and concerns at midlife. He promised that his plan of long-term hormone replacement therapy would guarantee continued physical attractiveness and sex appeal, and he unabashedly defended “a woman’s right to be feminine.”35 While some scholars have condemned Wilson as misogynistic, historian Judith Houck offers a more nuanced interpretation. Without denying the cruelty of his imagery in portraying women as castrates, she contends that Wilson sympathized with the plight of older women in America’s youth-centered culture and offered them the opportunity to feel like valued and valuable participants in contemporary society.36
Wilson drew stories from his private practice to illustrate the physical, emotional, sexual, and professional problems of menopausal and postmenopausal women. He attributed all of these trials and tribulations to women’s decreased production of estrogen, which robbed them of their femininity, their health, and oftentimes their happiness. He emphasized that the psychosocial troubles were not the fault of the women but the unfortunate by-product of the deficiency disease called menopause.
After more than a hundred pages of sad tales of older women (and their husbands), simplistic descriptions of female physiology and endocrinology, heroic recounting of Doisy and Allen’s isolation of estrogen, and the efforts of physicians to apply this scientific discovery to medical therapeutics (including Wilson’s own forty-year involvement in clinical research and practice), the author finally agreed to “divulge precise and specific details of the treatment that holds such abundant promise.”37 First, however, he made sure to emphasize the danger of self-medication and the absolute necessity of a doctor’s supervision.
Wilson’s treatment plan was clear-cut: replace the missing estrogen. As part of the physician’s complete physical examination of the patient, Wilson advised, he should perform a diagnostic test based on an adaptation of the Pap smear. This test, which Wilson dubbed the ‘femininity index,” measured the relative proportions of different types of cells in the vaginal lining. The goal of hormone replacement therapy was to restore the femininity index back to the “normal” ratio found in women during their reproductive years.38
Wilson reinforced this classification scheme by basing it on a quantifiable measurement; the numerical femininity index wore the patina of scientific objectivity. He recommended that “every woman over thirty . . . have her Femininity Index checked once a year. This quick, painless test may prove a turning point in her life, an assurance of continued health and happiness.”39 One of Wilson’s critics objected to the implications of this cavalier advice, describing patients who came to him, “asking for the ‘youth pill’ and they say ‘Check my estrogen level.’ From what they’re read, they think it’s as simple as driving into a gasoline station and having their oil checked.”40 Clearly, a number of women bought the message that their femininity could be revealed by the cells in their vaginas and also that they could be rejuvenated by hormone replacement therapy. They understood that postmenopausal meant abnormal, and they looked to medical science to bring them back to normal.
Estrogen, according to Wilson, could turn back time. “The skin becomes supple again, the muscles regain their tone and strength, the breasts are restored to almost their former fullness and contours, the genitals again become supple and distensible, skin cracks and genital inflammations heal. Bones that have become more brittle regain most of their former strength.41 Magazine writers picked up this message and brought it to an even wider audience; whereas Feminine Forever was read by hundreds of thousands, articles in popular periodicals reached millions.
[Discussion about research findings of health risks with menopausal hormone therapy, like endometrial cancer and cardiovascular complications, following publication of Wilson’s book.]
Noticeably absent from the controversy about the health effects of estrogen was the voice of its staunchest supporter, Robert Wilson. Indeed, after the publication of Feminine Forever in 1966, there is little trace of Wilson in either the medical literature or the popular press. No records exist to document the remainder of Wilson’s life after the peak of his influence in the mid-1960s. Wilson would have been 80 years old in 1975; it may be that he had retired from his professional career and public life. It may be that he chose, or was pressured, to retire from the debate because of evidence collected about his research foundation by the American Medical Association’s Department of Investigation.19 Although no formal charges were ever filed, Wilson’s proselytizing campaign caused some concern in the nation’s largest medical society. It may also be that a new generation of clinical scientists demanded more rigorous standards in medical research. Those trained in the decades after World War II learned a healthy respect for statistics and came increasingly to rely on the participation of biostatisticians in the design and evaluation of clinical studies.20 Less tolerance for shoddy experimental methods meant less acceptance of conclusions and recommendations based on data collected from those experiments. Physicians like Wilson continued to see patients in medical practice, but their amateur investigations were no longer recognized as valid contributions to modern medical research.
Watkins doesn’t really say it directly, and maybe it doesn’t need to be said, but subsequent rigorous scientific research contradicted most of Wilson’s claims and showed them to be false (example).
Watkins, E. S. (2002). Changing Rationales for Longterm Hormone Replacement Therapy in America, 1960-2000. Health and History, 4(1), 20–36. [DOI:10.2307/40111419]:
In the Spring of 2000, American newspapers reported disturbing preliminary results from the Hormone Replacement Therapy trial of the Women’s Health Initiative, a study sponsored by the National Institutes of Health involving 25,000 postmenopausal women.1 Data collected from the first several years of the projected nine-year investigation indicated that women taking oestrogen had a slightly greater risk of having heart attacks, strokes and blood clots than did those assigned to a placebo. This finding cast doubt on the prevalent medical practice of advising older women to take oestrogen on a long-term basis, allegedly to prevent both osteoporosis and heart disease. Although the study did not challenge the role of oestrogen in slowing bone loss, its dispute of the indication for heart disease made a whole new generation of women begin to question the wisdom of taking hormones for the rest of their lives.
I say a ‘whole new generation’, because a similar scenario played out some twenty-five years ago. In the mid to late 1970s, the fate of oestrogen replacement therapy was very much in question. By that time, physicians had been prescribing oestrogen for menopausal and postmenopausal women for more than thirty years. In 1975, scientific studies demonstrated that oestrogen use increased the risk of endometrial cancer. This announcement followed on the heels of several other disturbing correlations within women’s health care: the link between oral contraceptives and blood clotting disorders; the discovery that women whose mothers had used DES while pregnant had a higher incidence of vaginal cancer; and reports of perforations, infections and septic abortions in users of the Dalkon Shield IUD. The 1970s also witnessed a loss of confidence in medicine, as doctors and hospitals faced challenges to their political influence, economic power and cultural authority from the women’s movement, the consumers’ movement and the patients’ rights movement. The women’s health movement, in particular, sought to reclaim events such as childbirth and menopause from the forces of medicalisation. Given this social context, one might expect that hormone replacement therapy would have gone out of favor. While oestrogen prescriptions did decline in the late 1970s, long-term hormone replacement therapy for postmenopausal women soon regained popularity. By the early 1990s the Premarin brand had become one of the most frequently dispensed drugs in America, thanks to changes in the prescription regimen and new clinical and epidemiological evidence about its long-term health benefits. Earlier promises that oestrogen would keep women ‘feminine forever’ later gave way to claims that the hormones would ‘prevent disease and prolong life’.2 Today, I would like to discuss the nature and circumstances of the rise and fall and rise again of long-term hormone replacement therapy for postmenopausal women, and offer some thoughts on the cultural context in which these transitions took place.
In the 1940s and early 1950s, most doctors regarded hormone therapy as a short-term palliative for the temporary symptoms of menopause (primarily, hot flashes).3 But by the mid-1950s, some began to promote the long-term use of hormones to combat a variety of alleged menopause-related conditions. As early as 1941, researchers suggested that oestrogen could prevent the progression of postmenopausal osteoporosis and, in 1954, that it could lower the postmenopausal woman’s risk of heart disease. A few physicians went even further, claiming that oestrogen could forestall the ageing process. Although these doctors’ ideas fell outside the medical consensus of the time, they did articulate a position toward long-term hormone therapy that would become increasingly popular in the next decade.4
The opinion that women should take hormones during menopause and continue taking them for the rest of their lives found its greatest expression in the work and writing of Dr Robert Wilson, a New York gynaecologist. In 1963, Wilson and his wife published an article entitied The Fate of the Nontreated Postmenopausal Woman: A Plea for the Maintenance of Adequate Estrogen from Puberty to Grave’, in which they portrayed older women as ‘castrates’ who ‘exist rather than live’.5 They blamed the loss of oestrogen for causing diseases (such as hypertension and osteoporosis), psychological manifestations (such as depression, melancholia, and ‘a vapid cow-like feeling called a “negative state”’), and desexualisation (resulting from atrophied genitals and ‘loss of physical attractiveness’). They claimed that all of these conditions could be avoided if women would replace the oestrogen no longer made by their ageing bodies. Wilson reached an even larger audience in 1966 with his best-selling book Feminine Forever, which sold more than 100,000 copies in its first year, and through the tireless promotional efforts of his Wilson Research Foundation, which relied on financial support from the pharmaceutical industry to carry out its mission of educating women about the ravages of menopause and the miracle therapy of oestrogen.6 The media picked up Wilson’s message, prompting dozens of articles in magazines from Vogue and Good Housekeeping to Newsweek and Science Digest.7
What is notable about Wilson’s proposition is that it assumed that the decrease in oestrogen production not only caused difficulties during the transition period of menopause, but also affected the quality of a woman’s life for decades after the menopause. Wilson’s negative portrayal of the postmenopausal female emphasised her looks and her attitude, in addition to her increased risk of disease. His comment that ‘the desexed women found on our streets today . . . pass unnoticed and, in turn, notice little’ both reflected and sustained the marginalisation of older women in the youth-centered culture of postwar America. His proposed therapy—maintaining hormone levels from puberty to grave—was consistent with the prevailing conviction that medicine could supply the solutions to social, as well as health-related, problems. Oestrogen replacement, Wilson implied, could end the ‘untold misery of alcoholism, drug addiction, divorce, and broken homes caused by these unstable, estrogen-starved women’.8
Among doctors who advocated long-term hormone therapy, rationales for this regimen ranged from the extreme view that oestrogen would keep women youthful, sexy and happily married, to more conservative estimates that oestrogen would forestall diseases associated with ageing. However, the media picked up the more extravagant claims and passed them on to the public. Women’s agency in making decisions about their health care, although not addressed here, should not be overlooked. Within the context of a culture that valued youth as the standard for beauty, particularly for females, women sought ways to thwart the ageing process.9 Hormone therapy was one more weapon in an arsenal that included vitamins, hair dyes and cosmetics.
From 1966 to 1975, the annual number of oestrogen prescriptions almost doubled,10 the market value of non-contraceptive oestrogen almost quadrupled11 and Premarin, the most popular brand, became one of the top five prescription medications in the US.12 One survey in the Seattle area found that half of the menopausal and postmenopausal women interviewed had taken oestrogen for an average duration of ten years.13 Although this rate of oestrogen use was certainly among the highest in the country, it does demonstrate the trend of doctors prescribing, and women agreeing to take, oestrogen for long periods of time.
The Women’s Health Initiative’s clinical trial to assess hormone replacement therapy ended research early because after five years of using the drug, women had elevated chances of breast cancer, heart attack, stroke and blood clots. The scientists believed it would be unethical to continue to test the drugs, marketed by Wyeth under the brand-name Prempro. The study results came as a shock to millions of women who had been sold on the drug by their doctors, many of whom strongly and routinely urged older women to take HRT, and by a decades-long, aggressive marketing campaign from the drug’s manufacturer.
THE WOMEN’S HEALTH INITIATIVE study on the benefits and risks of hormone replacement therapy (HRT) in July drove a stake into the drug treatment taken by millions of women in the United States.
The Women’s Health Initiative, a clinical trial to assess HRT - a combination of estrogen and progestin - for use by healthy women, ended the research early because the risks became painfully obvious. After five years of using the drug, women had elevated chances of breast cancer, heart attack, stroke and blood clots. The scientists believed it would be unethical to continue to test the drugs, marketed by Wyeth under the brand-name Prempro.
The study results, published in the Journal of the American Medical Association, show that long-term HRT increases the risks of breast cancer, heart attack, stroke and pulmonary embolism. Those risks outweigh the benefits of long-term use of the drug: reducing the risks of bone fracture and colon cancer.
The study results came as a shock to millions of women who had been sold on the drug by their doctors, many of whom strongly and routinely urged older women to take HRT, and by a decades-long, aggressive marketing campaign from the drug’s manufacturer.
HRT was touted as preventing bone loss, heart disease, Alzheimer’s disease, cancer and wrinkles; and as a way to improve women’s sex life and make them more beautiful.
However, despite the hype around HRT, many of the benefits claimed for it have never been proven in a randomized-control study - where the effect of a drug is compared to a placebo. The evidence for the benefits of HRT came from “observational studies” - a review of the reported effects on women taking the drug. The problem with observational studies is that women who chose to take hormones may be healthier than women who chose not to take hormones. Also, observational studies do not include dead people, so would not have picked up women who died from hormone use.
The peddling of hormones began on a mass scale in 1966, with the publication of Dr. Robert Wilson’s bestseller, Feminine Forever. The book promoted estrogen as a wonder drug that could counter the changes of menopause and keep women young, attractive, sexually vital and happy.
Wilson set up a foundation and traveled around the country, preaching the gospel of estrogen and describing the experience of menopause in frightening, Gothic terms: warning that “no woman can be sure of escaping the horror of this living decay.” Menopausal women, whom Wilson called an “intersex” because they supposedly are no longer truly female, could, however, save themselves by taking estrogen. It would make them “more pleasant to live with” and prevent them from becoming “dull and unattractive.”
Estrogen had been in use since the 1930s to treat hot flashes and other menopause symptoms. But Wilson’s claims were grander, playing on aging women’s desire for longevity and on their fear of losing beauty and health. By 1975, Ayerst-manufactured Premarin, the leading estrogen pill, was one of the top five most-prescribed drugs in the United States.
It was only years after Wilson had gained fame that the Washington Post revealed that Ayerst - which later merged into Wyeth - secretly financed Wilson’s book and his foundation.
More than 35 years later, drug companies are still selling hormones to menopausal and post-menopausal women. The marketing is more sophisticated today, but the underlying message is the same: There’s a pill that will make you healthy, happy and beautiful - never mind whether it has been scientifically proven.
Although the theories about HRT’s benefits were plausible, they were not proven. That did not stop drug companies and doctors from treating the drugs as if they were.
The first big scare about taking estrogen came in December 1975, when two studies linked estrogen to endometrial cancer, in the lining of the uterus. Estrogen prescriptions dropped off until the 1980s, when research showed that the risk of uterine cancer was reduced when estrogen was combined with a second hormone, progestin.
The popularity of hormone therapy exploded as doctors and many women embraced it enthusiastically. Although the drugs are now available together in one pill, many women still take estrogen and progestin in separate dosages. Estrogen pill sales rose from 13.6 million prescriptions in 1982 to 31.7 million in 1992. In 1995, Premarin estrogen pills were the top-selling brand-name pharmaceutical in the United States. Sales of progestin pills rose five-fold in the same period, to 11.3 million.
In 1990, the Nurses Health Study, then the largest U.S. women’s health study, showed a strong association between taking estrogen and breast cancer. It did not prove that estrogen caused breast cancer, but there was a strong association.
Hormone proponents responded by assuring women the combination HRT drug was not associated with increased risk of breast cancer, and by asserting that hormones offered benefits that far offset the small increased risk of breast cancer. Both of these arguments have now been proven false.
In 1993, the National Institutes of Health launched the Women’s Health Initiative to get definitive answers to questions about HRT.
That led to June’s announcement warning women off HRT for longterm use and prevention of disease, a culmination that Dr. Wulf Utian, an advocate of HRT, called “the biggest bombshell that ever hit … in the menopause area.”
For those who had tracked the science, rather than the marketing propaganda, the results from the Women’s Health Initiative were much less of a surprise. They knew that clinical trials had never demonstrated the purported benefits of HRT.
Following the Women’s Health Initiative, Wyeth’s stock value plummeted, losing approximately one-third of its value.
The company continues to market HRT for short-term use in women suffering severe effects of menopause, and for use for osteoporosis, trying to salvage something from its one-time golden goose.
Voda, A. M., & Ashton, C. A. (2006). Fallout from the Women’s Health Study: A Short-lived Vindication for Feminists and the Resurrection of Hormone Therapies. Sex Roles, 54(5-6), 401–411. [DOI:10.1007/s11199-006-9010-6]:
Estrogen forever, feminine forever
The primary hormone mythmaker was Robert Wilson (1966) who, in the 1960s, proclaimed that estrogen taken for life (beginning around menopause) would keep women young and feminine forever. Wilson’s publications and admonitions to colleagues created a quake of seismic proportions in medical practice. Wilson described menopause as an estrogen deficiency disease treatable with estrogen replacement therapy. From the 1960s to the late 1970s, menopausal women were treated with hormones to prevent disease, particularly to protect the heart, to prevent cancer, and to maintain youth and vigor. Some colleagues and lay women listened to Wilson. In the 1960s, if a doctor said that menopause was a serious but treatable condition, the doctor’s opinion was not questioned.
The negative view of menopause as a disease was aggressively marketed in major women’s magazines and general magazines, television, and other forms of media. According to Grossman and Bart (1980), while the articles would focus on menopause, they also contained discreet references to products a doctor would prescribe, for example, estrogen replacement, in the form of Premarin which was and is manufactured by Wyeth/Ayerst Pharmaceutical Company. Later, Perlmutter and Bart (1982) conducted an in-depth review of the menopause literature published over a period of 150 years and concluded that the view of menopause as catastrophic is based more on cultural attitudes than scientific study. Coney (1994), writing 12 years after Perlmutter and Bart’s review, provided examples of pharmaceutical advertisements that portrayed a menopausal woman as depressed, miserable, anxious, out of control, at war with herself, and many other negative stereotypes to again support the view that menopause is a catastrophic event. Evidence that information provided to women in the popular press not only influenced their attitudes toward menopause, but later their decisions to take hormones is provided by Chrisler, Torrey, and Matthes (1991). Following a review of 77 articles on menopause, they concluded that most of the articles that were written in the 1960s were influenced by Wilson’s negative view of menopause.
It is clear from the foregoing that while Wilson was influencing his medical colleagues, feminists began to question why menopause, a normal event in a woman’s life, needed to be treated at all. A dramatic shift of consciousness-raising was taking shape in the 1960s in the form of the women’s movement, out of which grew the women’s health movement (Voda, 1996, 1997).
Barbara Seaman, a feminist women’s health activist, early on criticized the medical establishment for treating normal reproductive processes in women as diseases. Seaman and Seaman’s (1977) famous quote “promise her anything but give her cancer” (p. 377), was prophetic. Instead of estrogen protecting a woman’s uterus from cancer, estrogen was characterized as a “carcinogen” (Smith et al., 1975; Ziel & Finkle, 1975). As expected, rebuttals to the estrogen-cancer connection, similar to what is now being discussed about the WHI findings, were forthcoming. But, following close upon the heels of the uterine cancer news, the women’s health movement gathered momentum. MacPherson (1981), for example, openly criticized the medicalization of menopause, challenging the dogma-driven science used to transform normal physiological events in a woman’s life into a disease. Such criticisms were seismic events in and of their own right and contributed to the newly emerging women’s health movement. An increasing number of voices from women’s communities and various professional groups criticized medical practitioners and scientists, challenging them to provide research-based evidence for the need to replace reproductive hormones. As cited above, some feminists described the information in the literature as either myth-based or long held cultural attitudes about the frailty of women, e.g., that for all practical purposes, a woman without reproductive hormones, particularly estrogen, was not a woman. A postmenopausal woman, according to Wilson (1966), without reproductive hormones had nothing to look forward to except a life of “living decay.”
Much of the early feminist criticism coalesced at the 1979 gathering of the Society for Menstrual Cycle Research in Tucson, Arizona where research on menopause was analyzed as biased, reductionistic, and embedded in flawed theoretical frameworks by researchers who utilized flawed methods of analyses (Voda, Dinnerstein, & O’Donnell, 1982). Feminist women’s health activists declared war on the dogma (Voda, 1997). A line was drawn that can be likened to a menopausal fault line. On one side of the line were medical professionals who believed that menopause was a disease in need of treatment. Positioned on the other side of the fault were feminist women’s health activists who vehemently protested the disease characterization (Voda, 1996). For the next 30 or so years, women tried to find solid footing on either side of the fault line. Some straddled the line, confused, not knowing whom to trust. Others fell into and/or through the cracks, undergoing unnecessary hormone treatment and/or surgeries. Still others received no treatment, believing that any form of assistance from the medical community was suspect (Voda, 1996).
Ashford, S. A. (2005). Hormone therapy decision-making of postmenopausal women in the Women’s Health Initiative-Emory (Doctoral dissertation, Emory University). [URL]:
[…] In spite of these early recommendations, [hormone therapy] was not widely used by women until the mid-1960s following the publication of the book Feminine Forever by Dr. Robert Wilson (1966) extolling the virtues of estrogen for the prevention of aging and the preservation of youth. Wilson (1966) described all postmenopausal women as castrates and menopause as an insidious disease intertwined with chronological aging. This was followed in 1969 by David Rubin’s best-selling book, Everything You Always Wanted to Know About Sex. Rubin reported that menopausal women were no longer functional as women having outlived their ovaries, therefore their usefulness as human beings had expired (McCrea, 1983). By 1973, the increase in estrogen sales skyrocketed in response to these publications.
Dhont, M. (2010). Treatment of the menopause: the swinging pendulum. Facts, Views & Vision in Obgyn, 2(3), 173–176. [PubMed Central]:
The rise of HRT
The start for a systematic hormone therapy of all postmenopausal woman was given in the U.S by dr. Robert A Wilson who promoted this therapy in his book ‘Feminine Forever’ (1969). He was the first to consider the menopause as a disease which should be treated in a proper way ‘Many physicians simply refuse to recognize menopause for what it is — a serious, painful and often crippling disease. Every woman alive today has the option of remaining feminine forever.’ The term hormone replacement therapy was hitherto reserved for young women who went either spontaneously or artificially into premature menopause. The proselytizing endeavour of dr. Wilson in the U.S. led to the large-scale use of Premarin® which contained estrogens extracted from pregnant mare urine. This first wave of enthusiasm, mostly limited to the U.S., was temporarily tempered when observational studies indicated that long-term administration of unopposed estrogens increased the risk for endometrial carcinoma sevenfold (Ziel and Finkle, 1975). When it became clear that this risk could be countered by the addition of progestagens either in a sequential or continuous fashion, several formulas of oestro-progestagen combinations were marketed. The rationale for HRT was further supported by several observational studies which indicated that HRT, besides its beneficial effects on menopausal symptoms, also could have a role in the prevention of osteoporosis and cardiovascular disease. The most notable among them was The Nurses’ Health Study (Grodstein et al., 1996). This was a prospective observational study involving 121.700 nurses of 30 to 55 years old, the results of which indicated that the risk of cardiovascular disease was significantly less in women taking HRT. A later analysis also revealed that the risk of lethal disease was also significantly lower in HRT users, particularly for women with existing coronary risk factors (RR 0.63) (Grodstein et al., 1997). With this preliminary evidence of the beneficial effects of HRT for postmenopausal women a potential mass consumption could be anticipated. Numerous new hormone preparations were developed and actively promoted by pharmaceutical companies. The dream of Wilson was on the verge of coming true.
The reverse swing of the pendulum
The swing of the pendulum went into reverse in the beginning of the 21st century in the wake of the publication of two prospective randomized studies on the effect of HRT. The starting point of both studies was to prove or refute the alleged beneficial effects of the systematic administration of HRT to postmenopausal women. The first study (the HERS trial) was intended to investigate the cardiovascular effects of HRT in women with coronary risk factors (Hulley et al., 1998). When the results were published in August 1998 it was clear that in contrast with the Nurses’ Health study (Grodstein et al., 1997), HRT had no place in the prevention of cardiovascular disease, at least in cardiovascularly compromised women. The final blow, however, was given by the publication of the results of a large prospective randomized trial on the effect of HRT in healthy postmenopausal women, the ‘Women Health Initiative Trial’. In the first arm of this study 16.608 healthy postmenopausal women with an intact uterus were randomised for a treatment with conjugated oestrogens (Premarin®, 0.625 mg) combined with medroxyprogesteronacetaat, 2.5 mg per day or placebo. The second arm comprised 10.789 healthy women without uterus which were randomised for a treatment with Premarin® 0.625 mg per day. The first arm, which was meant to last 8,5 years was discontinued after 5 years because an interim analysis showed that the balance of beneficial and adverse effects was negative. The three main adverse effects were an increased risk for deep vein thrombosis, breast cancer and cardiovascular events. […] The general conclusion of the authors of the WHI trial was that long-term HRT is associated with more adverse than beneficial effects. This publication got extensive coverage in the media worldwide and unleashed a torrent of comments in leading medical journals. The editorial of the Lancet of 9 August 2003 was very explicit: ‘The new evidence of breast cancer mortality dictates an explicit position: HRT should be discouraged and practitioners should seek alternative solutions’ (Lagro-Janssen et al., 2003). Another editorial read like an outright diatribe against gynaecologists and pharmaceutical companies alike (3). In this editorial Prof. D. L. Sackett wrote: ‘There is a need for a higher standard of evidence before an agent is advocated solely for disease prevention. The blame is to be set on the shoulders of medical experts who advocated ‘preventive’ manoeuvres that have never been validated in rigorous randomized trials to: gain profit from industry affiliation, to satisfy a narcissistic need for public acclaim or in a misguided attempt to do good.’ (Sackett, 2002). Although this statement held some truth, it risked to throw away the baby with the bathwater. Indeed, the first conclusion of the WHI was that the risks for breast cancer and cardiovascular disease do not outweigh the benefits of HRT for the treatment of menopausal symptoms in young women (< 56 years). Unfortunately, in all the criticisms of HRT, this statement was, deliberately or not, overlooked. Moreover, the results of the WHI trial are only applicable to the population studied and should not be indiscriminately applied to all postmenopausal women. Nevertheless, the consumption of HRT dropped worldwide with 50%.
Premature conclusions from the WHI study, which were largely overstated by the mass media have led to a negative appraisal of the beneficial role of HRT. The first conclusion of the WHI study, however, stated that the balance of risks and benefits of HRT in symptomatic women in early menopause is positive. Reanalyses of both the WHI study and the observational studies have shown that there is in fact less contradiction between observational studies and randomised trials but that differences are mainly due to the timing of HRT therapy (Phillips and Langer, 2005). Considering all data now available, hormonal treatment of the menopause has now become full circle. In contrast with the policy of ten years ago, menopausal symptoms and not prevention of whatever potential disease is the main indication for treatment. It can safely be given to all symptomatic women during the perimenopause or shortly after the menopause. If symptoms warrant further treatment after 5 years, a small increase in the risk of breast cancer should be taken into account and discussed with the patient.
The excerpts above largely speak for themselves I think. It should be obvious to many that these happenings in the world of menopausal hormone therapy in the 1960s show eerie parallels to those relating to Dr. William Powers in the transgender community today. I guess history repeats itself.