Scientific Gynaecology

Damn! They did it again –just when I thought I’d finally got it straight about why HDL was the ‘good’ cholesterol and how beneficial it is, they changed it on me. Well, modified it, I guess. Lipoproteins are molecules that carry fats (lipids like cholesterol and triglycerides) to and from cells in the body. HDL (High Density Lipoprotein), however, transfers these fats away from artery walls and so helps to decrease the accumulation in arteriosclerotic plaques that can cause heart attacks and strokes.

Okay, good. Eat foods rich in HDLs and Bob’s your uncle. Right? Uhmm, not so fast. At the 2015 annual meeting of the North American Menopause Society (NAMS) some scientists from the University of Pittsburgh studied 225 healthy women in their mid and late forties for almost 9 years. ‘The study revealed that elevated HDL levels during menopause were associated with increased atherosclerosis. “These findings suggest that the quality of HDL may be altered over the menopausal transition, thus rendering it ineffective in delivering the expected cardiac benefits”, said study author Samar Khoudary.

Researchers hypothesize that the hormonal changes may be associated with the modified effect of HDL, especially estradiol reduction’.

Great! Now what am I going to tell my patients? A lot of them are already confused by the plethora of conflicting data in the scientific literature to which Dr. Google so readily directs them. Don’t we know anything for certain anymore? For that matter, did we ever deal in certainties? It’s a question written in their eyes –a silent reproof for my previous dicta, a withering acknowledgement that doctors may not speak ex cathedra.

Well, the very nature of Science, is that it uses Inductive Logic to derive general principles from observations. So, as the usual example goes, if we only ever see crows that are black, then it seems reasonable to conclude that all crows are black –until, that is, someone sees a white crow. Or -my favourite: ‘absence of evidence is not necessarily evidence of absence’. As Karl Popper insisted, Scientific knowledge should always be able to be falsified with contrary evidence. Hence, it is usually couched in statistics to reflect the probability of its truth.

It’s also why the world is so exciting: there are always surprises.

But Juna was unimpressed. For her, the purpose of Life was to hunt for certainty and then cling to it like a parental hand. She seemed resistant to any prescriptive opinion that I offered although she would always listen politely and smile at the appropriate times. Then she would offer her personal assessment of where she felt her problem lay as if it were a debate that required equal time for rebuttal. Equal consideration for the opposing side.

“That’s very interesting, doctor,” was how she would start her counter-argument. Then would come the pause. “But, isn’t it possible that there could be another way of looking at the same issue?”

And then she would have me; there’s always another way of looking at something.

She’d notice my expression, smile mischievously and continue the attack. “I mean, how can we say for certain that diet doesn’t play a major role in yeast acquisition?” And she would sit back in her chair, cross her arms like a prosecuting attorney and challenge me to counter that.

Whenever I apprise my colleagues of what goes on in my office, they always tell me that I shouldn’t run it like a courtroom, but I have to admit that I’m often curious to hear the opinions of the other side.

Juna was always delightfully provocative; she seemed to sense where the boundary was and although she’d sometimes reach across it, she never stayed for long. “You guys always seem to get it wrong, doctor,” she volunteered one time with a twinkle in her eyes. She had recently crossed the threshold into menopause and was intrigued both by the changes and the variety of opinions as to what to do about it.

I raised one eyebrow -our signal that I was willing to engage- and smiled. “I mean, look at the fiasco over hormone replacement…” she said, pretending confusion.

“We still use them occasionally.” I felt I had to defend them for some reason, although I hadn’t prescribed them for a long time. But the look of disbelief on her face –a mother listening to her son’s feeble defence- demanded an explanation.

“Knowledge is constantly expanding, Juna. What we believe today may be superseded by additional knowledge tomorrow.”

It was her turn to raise an eyebrow –she loved the gesture. “Then is it knowledge that is expanding, or simply conjecture?”

I rolled my eyes –the necessary next step in the process. “Science is conjecture in a way. It gathers together observations and tries to make sense of them with a general principle –a conjecture, if you will.”

She shook her head slowly –a teacher confronting a slow pupil. “If things are always subject to change, then how am I to decide? What am I to believe?”

I sighed politely. Philosophers have been wrestling with the same problem for millennia and Juna wanted a definitive resolution in the thirty minutes I had allotted in my busy day for her appointment. Things were getting out of control. “Using current knowledge…” I started slowly, choosing my words carefully as I tip-toed through the minefield she had set in front of me. “… is sort of like a buying a car. Despite how advanced the current model is, there are usually improvements in a new one… So, even if you need it, do you never buy one because it will soon be out of date?”

Her face stayed neutral as she thought about it. Sometimes even a desperately conceived metaphor can accomplish what erudition finds difficult.

“You mean like Ovid’s All things change; nothing perishes?”

I have to admit I’d never heard that one before, but it sounded sort of like a concession.

“What’s past is prologue,” I tried to reply in kind, quoting Antonio from Shakespeare’s Tempest, but it was a feeble attempt -I’m just a gynaecologist after all. But she smiled nonetheless: a truce.

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The Art of Medicine

The purpose of art is washing the dust of daily life off our souls’, as Picasso said. I suppose he was on to something there, but I rather fancy Francis Bacon’s take on it: ‘The job of the artist is always to deepen the mystery’. The reproductions that hang on the walls of my office have certainly deepened mine –well, to be accurate, more the patients who comment on them.

Of course not all of my visitors even look at the walls; they’re often too fixated on describing their symptoms, and watching for my reaction. Trust is awarded or subtracted in the first few moments of an interview of course, but once the merit badges have been allotted, and rank assigned, their eyes often wander to more interesting things. For some reason, I can’t seem to monopolize their attention once they have decided to relax. But, of course, art is therapeutic as well -although perhaps less helpful for most gynaecologic conditions than some more hopeful alternative practitioners might wish.

And yet it does provide a certain continuity that my more regular customers seem to appreciate. Some of them have developed unusual affinities for, say, a certain painting hanging on a particular wall. Or the smile of a character in a photograph… I’d like to think that it is actually a recognition of my taste in art, my ability to select soothing yet interesting subjects that reflect my own philosophy of life. In fact, I think Janet, one of my more perceptive patients, described it best. She was biding her time as I struggled to fill out some laboratory forms for her. And to stay awake I suppose, she began to look around the office. I glanced up once, after trying unsuccessfully to correct an egregious mistake on the screen, and saw a puzzled expression writing itself on her face. When she noticed my attention, she immediately erased any traces of concern and replaced them with those of a frustrated teacher.

And then, when she saw my eyebrows raised inquisitively, she blushed as if caught in some secret and embarrassing act. “You certainly have a…” There was a moment’s hesitation as she rummaged desperately for a more neutral word than she was about to utter. “…An eclectic taste in art…” Her eyes inadvertently strayed back to a reproduction that I’d hung on one wall. It depicted two young girls standing side by side looking in opposite directions while only partially covered by some sort of blanket or quilt. Their faces were beautiful, although one looked a bit worried about something. I saw it as, I don’t know, youthful hope, or maybe the puzzle of growing up.

“I was just thinking of an art gallery,” she said, trying to smile -and yet I could almost see the ‘buts’ slinking in the shadows behind her eyes. I sat back, hoping for a compliment. Redemption. “But, you know…” Her eyes darted from one picture to the next like sparrows looking for a roost. “…They don’t seem to illustrate any particular theme. Nothing connects one to another…” She focused her attention on a large photograph of a man holding a baby and indicated her target with a nod of her head. “I mean, you have a man with a baby in this one –nice photograph, I suppose- but then, on the wall behind me, there’s the coloured line drawing of a peasant woman leading a horse…”

I’d never experienced a critique of my art before and I didn’t know whether to feel honoured, amused, or embarrassed. I chose embarrassed. “I…ahh… Well, they just seem to accumulate over the years. I mean, I didn’t choose them to illustrate a particular theme, or anything…”

Her face believed me, and her smile tried to plaster over any unpleasant criticism. It tried to exculpate me from my tasteless choices. Her eyes, however, no longer sparrows, were birds of prey and I could see her fighting with her need to be honest and yet not cast aspersions on me. On my world. On my ability to be her doctor.

“Maybe move the Woman with the Horse to the examining room and the…” She suddenly had second thoughts. “No, I don’t think the IUD picture would be suitable in here…” She closed her eyes for a moment, trying to reconfigure things in her head. “I like the smiling woman –it’s a Rosamund isn’t it?”

The drawing was on a far wall and I had to squint to see the signature. I couldn’t quite make it out, so I was forced to shrug. I mean, who looks at signatures?

“What about that green apple picture hanging in the hall..?” It was amazing how much she’d noticed. “No, actually it adds a light touch to the corridor –sets a mood, as it were.” Her eyes alighted briefly on one of my diplomas, flitted to me, then on to her lap when she saw me watching. I could see her trying to disguise a sigh. She was not successful.

She’d told me she’d come for a consultation on the menopause and yet she was aggressively adamant that she was coping perfectly well with The Change  -and she continued to insist this even under what I thought was careful questioning. Apart from a recent and bitter divorce, things were completely under control -better than they’d ever been, in fact. I glanced at my computer screen again, and then accidentally refreshed it, for some reason. There was now a note that my secretary had just added to the referral letter section -her doctor had faxed the information to me a few minutes before before. Janet had requested a second opinion when her GP had suggested she might need to go on hormone replacement therapy for her menopausal symptoms. She’d become enraged at his lack of judgement and his inability to keep up with the current medical literature. She wanted –no, demanded– to see someone who wouldn’t judge her on insufficient evidence and wouldn’t assume that her every foible was attributable to insufficient hormones. Apparently she’d suggested that he needed them more than she did. And he’d assumed she would neither give me an accurate history nor deliver the note he’d written.

She saw me scrutinizing the screen as I started scrolling through it, and a mischievous smile captured her immediately. “Still can’t find his referral letter?” she asked, with what was another uncamouflaged smirk after one more quick look around the room. “He gave me a hand-written letter in a sealed envelope for you…” I studied her expectantly when she decided to prolong the suspense; she was not a happy woman and I fully expected her to unleash the eyes again. “I don’t think he has a computer; and anyway I threw the letter away,” she added in answer to my unspoken question. “I read it, of course, but it was all nonsense.” Her lips parted slightly in what was either a broken grin, or more likely, a sneer. I could see her hands tighten into fists in her lap. “Never trusted the man,” she said, looking again at the two little girls in the picture. “No taste.” She turned to look at the Woman and the Horse on the wall behind her and then sighed loudly.Theatrically -no attempt at a disguise…“Unlike you…”

We both laughed, but I’m not sure at what. Or at whom…

The Uber-obvious in Medicine

I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! http://www.cbc.ca/news/canada/montreal/quebec-doctors-can-now-prescribe-exercise-1.3215821 And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”

 

Risk Perception

Risk is something we all need to assess from time to time. The problem lies in how we do it. If there are factors we fail to take into account that affect our risk perception then our evaluation may as likely be wildly unrealistic, as appropriate. Emotion tends to skew things in one direction or other, as does as the degree of perceived asymmetry between the benefits and dangers –if we really desire or enjoy something, we might be less risk averse than if we were not keen on it in the first place. The status or acceptance acquired from smoking for a teenager, say, might counterbalance the long-term dangers; it might not be seen that way by an older, more confident adult. And immediately experienced risk –driving a car with faulty brakes- may be more influential than future risk such as lifestyle changes for cardiac disease prevention. And then, of course, there are cognitive biases –our own subjective mythologies, expectations and intuitions- not to mention cultural biases, all contributing to the overall assessment of the acceptability or not of the risk.

But I suspect that a major obstacle in risk perception lies in its probabilistic nature. People have enough difficulty in understanding the simple Bell Curve distribution of likelihood let alone the mathematical Baye’s theorem which ‘describes the probability of an event based on conditions that might be related to the event.’ Our estimates are more intuitively driven than statistically. Understandable, to be sure, but unreliable in most appraisals. Misleading. Dangerous, even.

It’s hard to grasp the concept that even doubling a risk when it is almost imperceptably low already, still leaves it almost imperceptable. So, at what stage does it become unacceptable, if it wasn’t really perceived to be that in the first place? Is any risk acceptable if we know about it, no matter how small and unlikely? What about the background risks that are inherent in most things –be they visible and published or not? Riding a bicycle, for example, or running on a treadmill, walking to work… At what point do we merely turn off and get on with life?

The problem is certainly manifest in Medicine. Most of us invest health –especially our own- with an appropriately significant amount of concern. But it is more of an emotional than intellectual process, and we tend to interpret the concept ‘improbable’ as the much more personal ‘but possible’. Shadows, despite their insubstantiality, hide ‘what-ifs’ –or worse still, unrealistic fears that favourable probability cannot disguise.

Martha was one of those. I would never have guessed it to look at her, though. She sat relaxed and confident in the waiting room, surveying her adopted realm like a tall queen. Crowned with long brown hair, the curls danced from her shoulders as she stooped to pick up a child’s toy, then returned it to him with a smile that would have melted an older stranger. Fifty-ish and surprisingly thin, she was dressed in loose, faded jeans, orange sneakers and a light blue designer tee shirt that said ‘Dare Me, eh?’ She was in control of all she surveyed: monarch of the room.

She stood when she saw me approaching and extended her hand before I was half way across the floor. “I’m so glad to meet you, doctor,” she said loud enough for all to hear, and squeezed my hand like she was doing an exercise in the gym. A full head taller than me, I had to look up to see her face. For a moment, I felt like that little boy whose toy she had rescued, and as I led her back down the corridor to my office I had the distinct impression that, despite her being behind me, nonetheless it was me being taken for a walk like a small dog on a leash.

She sat down on the chair opposite my desk and waited for me to settle into mine before starting the interview. That’s how it felt: she was interviewing me like a reporter hot on a story.

“I’m here,” she said without the usual preliminary pleasantries, “because of a disagreement with my family doctor…” She left her thought unfinished so she could study my face for its reaction, and when she saw nothing but curiosity written on it, continued. “She seemed to feel that my worries about hormone replacement therapies were unfounded.”

She immediately folded her arms across her chest to -as her tee shirt invited me to do- dare her to defend herself. I wondered if she’d chosen it specifically for the visit. I smiled to diffuse her arms, but her body had hardened into place; everything remained on guard, and her eyes perched on her face like a pair of eagles watching me from their aerie in a tree.

I thought I’d keep it simple. Basic. “She felt you needed hormones?” A regal, no-nonsense nod. “And why was that?”

“Hot flushes.”

I duly typed this on my laptop, although I sensed it might be only the tip of a rather unpredictable iceburg. So I waited.

I could sense she was testing me, and the eagles shifted impatiently on their branches. “I don’t need hormones, doctor. I was just going in for my pap smear and she asked me about hot flushes.” A smile passed across her face like a shadow crossing a stage. “I think she just wanted to compare notes with me…”

I tried to concentrate on her mouth, her eyebrows, hair –anything but those unnerving eyes that seemed constantly on the verge of attack. “So you’re not bothered by them?”

She shrugged, but if I hadn’t been staring at her, I might have missed it. I sat back in my chair, wondering where the thread-bare conversation was taking us.

She could see my confusion, although I had tried to hide it behind an Oslerian mask of Aequanamitas. I sometimes find it doesn’t quite cover everything, no matter how I wear it. “Look, she’s a nice woman and I think she was just trying to be kind.” She hooded the eagles and looked over my shoulder at something for a moment. “It was a girl thing, I suspect –you know, an attempt at empathy, wearing my shoes, or something.” One of my eyebrows started to move before I could rein it in and she noticed it and grinned sheepishly. “After I left her office, it dawned on me that she’s probably on hormones herself. An example of the play within the play of Hamlet: The lady doth protest too much, methinks.”

Martha was obviously not your average patient –she even put the ‘methinks’ at the end, where its supposed to be. I was impressed. “You think she was trying to convince herself that hormones were safe?” Might as well cut right to the chase.

She nodded. “I made the mistake of arguing with her and it rolled downhill from there. I shouldn’t have been so righteous, but from my reading, I felt she was mistaken.”

I could tell being a referee in a contest where one party has done extensive research on the subject, and the other was speaking to the contrary out of vested interests would not be easy. Martha had probably read more Shakespeare than me as well. I approached the issue carefully. “What did you find troubling about her opinion?”

She smiled; her trap was laid. “Well,” she started equally carefully, “for a start, the risk of phlebitis is increased by about three hundred per cent on hormone replacement therapy…”

I inclined my head slightly –it was meant to acknowledge the number, but not succumb to it. “Well, in fact the exact incidence of DVT” –I used the acronym for deep vein thrombophlebitis, to show her I had some trifling knowledge of the subject- “is unknown because of the inaccuracy of clinical diagnosis, but if you want to look at another way, its incidence is up to six hundred per cent higher in the first year of use…”

Her smile broadened –she’d been validated. She had been right to worry.

“But,” I added when her smile looked as if it was going to split her face in two, “Six hundred per cent of what?” I let it sink in; I didn’t expect an answer.

“Well, six hundred per cent higher than in non-users…” Her eyes were hunters again –hawks this time, I think. The tone of her voice said that it was obvious. “Six hundred per cent higher, doctor! Six hundred…”

I briefly flirted with some sort of aerial fight, our eyes meeting each other somewhere over the desk in a dominance combat . But I’m not like that. “So, six hundred per cent higher than in non-users in the first year? Otherwise, -what did you quote, three hundred per cent higher?- after the first year of use, I guess you mean?” She nodded impatiently, as if she was being patronized. “And the rate in non-users?”

This time I did expect and answer… Or did I? Three times anything seems like an awful lot more. And six times…? She shrugged as if it were not that important. The relative increase was what mattered. “Well, given that I said that the exact incidence was hard to determine, the figure in many studies has been estimated at around 80 cases…” -I stretched it out for effect- “ 80 cases per 100,000 people. Give or take.” I paused for a moment again. “So, even six times that is –what?- 480 people per one hundred thousand. That’s…uhmm… 0.48 cases per hundred people per year?” It sounded about right… But I have trouble with decimals sometimes.

“Whether I’ve got the numbers exactly right is not the issue, really. The point is more that six times very little, is still very little.”

I could see her mulling it over in her head; doubt lingered on her face, but at least she’d put the hawks away for the day. “An interesting way of looking at it, I have to say… but certainly not intuitive at all, is it?”

I allowed myself a smile that I hoped was non patronizing. “Probability –statistics- is not very intuitive.” Her face stayed neutral. “If I told you I had a way of increasing your chances of winning the lottery by 100% would you be interested?” She nodded, as I knew she would. “It’s simple, really…” She rolled her eyes –no eagles there anymore. “Just buy two tickets.”

She sat back, but I couldn’t tell from her expression whether or not I’d convinced her –or even held her interest. “So tell me, doctor, if I were your sister, would you suggest I go on hormone replacement?”

I sighed; she’d asked for honesty, not medical rhetoric. I locked eyes with her. “If you were my sister?” She nodded –earnestly, I think. “No.”

She seemed surprised after my attempt at explaining probability and risk. “Why not?”

“You’d argue with me every time we met…”

Hormone Replacement Therapy

Do you remember those Once-upon-a-time stories from when you were a child? They seemed to promise so much and yet, when considered in the light of the next day, offered so little. Sometimes I think that the story of hormone replacement therapy (HRT) has a lot in common with those faerie tales. I mean it all seemed to make so much sense: replace what is no longer there. I even remember likening estrogen lack -menopause- to diabetes with its relative or absolute insulin lack: a disease for which good health mandates a replacement.

And it made sense that those things which seemed uncommon during menstrual life -heart attacks, memory loss, dementia and so on- should be treatable, if not in fact preventable with a mere whiff of estrogen. But of course, it was quickly appreciated that estrogen, as powerful as it seemed, was only half the equation; it needed its partner Progesterone to prevent inadvertent over-stimulation of estrogen sensitive cells like those in the uterus -and maybe elsewhere. Who knew?

That of course led to a struggle between the two giants: some people developed mood changes, irritability, or even depression with progesterone. And some synthetic progesterones carried their own baggage: they changed cholesterol and sometimes even triglycerides to levels that might indicate an increased risk for heart attacks and maybe strokes.

It quickly became a delicate dance of two partners, both used to control -or at least being controlled. Like two teenagers constrained when at home, managed as they were growing up with recognizable top-down authority, they were noticeably different when their parents were away: no rules. Even their roles were vague. Should enough progesterone be given to inhibit bleeding? For years it was administered  cyclically in an attempt to mimic the normal monthly pattern of periods. Then it became apparent that cyclic bleeding was not only unnecessary, but also confusing: could the bleeding be a sign of something other than progesterone withdrawal -cancer, for example? So continuous administration of both hormones became the norm.

Then the breast cancer scare. Progesterone seemed to have the special task of inducing cellular growth in normal breasts, so could it go one step further and..? Well, the dance continued -and continues. It’s a kind of Three -make that two- Bears story now: Just right baby bear. Not too much progesterone -just enough to do the job without getting into any other mischief.

Several large prospective studies were done that sort of took the wind out of the hormonal sails and the prospect of eternal youth with cardiovascular and neurologic protection as a bonus seemed to evaporate like early morning fog. Not only did they not protect against the ravaging teeth of age or dementia, there seemed to be a higher risk of heart attacks and strokes for at least the first year of their use. Not what anybody wanted to hear.

More recent evidence suggests that if the hormones are started early enough, there may be some degree of protection for maybe five years or so, but are you beginning to see a pattern in the retrenchment? We are determined to salvage some degree of credibility for hormone replacement even where the evidence is underwhelming.

And yet, it’s perhaps not that HRT is not helpful, but merely that it is not helpful enough in the areas where we had our greatest hopes: prevention. The elixir of youth was never attainable, but it did seem reasonable to hope that those things that often accompany the withdrawal of hormones -or maybe just the age at which it occurs- could be forestalled. Eliminated. Conquered. Youth, when hormones are raging, is seldom bothered by heart attacks, Alzheimer’s or strokes. There is a different world-view, a different expectation…

But menopause can be a traumatic time both psychologically as well as physically. There is a realization, sometimes resisted, that a different era has begun. A different life, even: one without the prospect of pregnancy, or natural periods, or even comfortable sex in some cases. A life that some might be tempted to live in retrospect: what was, and not what is… The tripartite curses of hot flushes, memory loss, and sleepless nights are for many, significant and insufferable.

Fortunately, that’s an arena in which HRT plays comfortably. No, there’s no magic potion; Ponce de Leon never visited this country. But hormones are fairly efficient at relieving hot flushes and the other menopausal symptoms that make daily life so uncomfortable. There are bonuses with maintaining bone health, and perhaps skin health, and maybe even vaginal health. Everybody’s different -all doctors say that (just in case)- but one could certainly argue that HRT should only be used for symptom relief and not preventative therapy. Know the risks and balance them with the benefits -another truism.

HRT has its place as do alternative therapies. But obviously if the alternative therapy wishes to address an estrogen lack, it has to have an estrogen effect and therein lies the problem. A phytoestrogen (plant-derived), for example, can be just as dangerous, unopposed by progesterone, as another more mainstream form of estrogen. The piper has to be paid. There are risks to all hormones, whether estrogen-substitutes or the real thing. Some are helpful in the short-term, and some are probably placebos but there is at least a choice -none miraculous, none infallible, some of even questionable value, but all are available for the choosing. Or not.

One can choose not to choose. All choices come with pitfalls; I certainly cannot make the choice. I am reminded of  Hortensio in the beginning of that delightful Shakespearean play The Taming of the Shrew. The context is irrelevant, but his comment is not: There’s small choice in rotten apples. Well, maybe, but at least there are apples…