Illustration. Yael Bogen
Opinion

Between Truth and Bullshit: The Actual Link Between Hormones and Women's Health

Telling the scientific truth involves a long and winding road, and sometimes laziness and anxiety conspire to conceal it

Relying on the truth – adherence to beliefs that are consistent with reality – enhances our ability to make the right choices, survive and fulfill our goals. Full revelation of the truth forms the basis for mutual trust, which is essential for the existence of the institutions that are the foundations of human society.

The truth, namely the recognition of reality, does not fall into our hands like ripe fruit. Arriving at it entails imagination, reflection, perseverance, steadfastness and consistency. Striving for the truth is a never-ending process. Discovering new evidence, or casting doubt on existing evidence, can alter one’s perception of reality.

Upon being asked what he would reply if, after dying, he were brought into the presence of God and asked why he had not been a believer, Bertrand Russell, the great British philosopher, replied “Not enough evidence, God! Not enough evidence!”

Science is a formal system of rules governing the process of uncovering the truth, allowing us to comprehend the world we live in. The scientific process has been very fruitful. Its contribution to the survival of the human species, and its becoming the dominant species in our world leaves little room for doubt. Despite this, science is not immune to errors or faulty interpretation. But, since the core of scientific endeavor involves casting doubt on existing information, and the meticulous gathering of evidence, advances are almost inevitable – even if great effort and much time are required to achieve them.

One example, among many, of the long and tortuous road taken to uncover a scientific truth involves the study of the influence of female sex hormones on women’s health during menopause.

First step: In 1963, a gynecologist from Brooklyn, Robert Wilson, and his wife, Thelma, co-authored an article in the Journal of the American Geriatrics Society. The article left a powerful impression, despite its paucity of empirical evidence. According to the authors, the cessation of the menstrual cycle in aging women is merely an evolutionary accident. In their view, menopausal women suffer from hormone-deficiency disease. Because the development of this disease is related to chronological age, many people tend to see the cessation of the menstrual cycle and the ensuing symptoms as an inevitable consequence of aging – but that, they explained, is a serious mistake. Ongoing treatment with female sex hormones could eliminate all the phenomena brought about by menopause.

The doubt: At the end of the 1960s, a group of scientists in Germany contended that although Wilson’s theory was impressive in terms of its logic, the supporting evidence for it was meager. In 1971 a meeting was held in Geneva, under the auspices of the World Health Organization, with the participation of physicians and scientists, and resulted in publication of a booklet entitled “Estrogens and Aging.” This publication and subsequent conferences encouraged funding for research on the influence of the female sex hormone on health and disease in menopausal women.

Bloomberg

Second step: Numerous studies conducted in the 1970s and ‘80s, based on the long-term follow-up of menopausal women, attained similar results, leading to the conclusion that estrogen treatment affects the risk of developing many types of disease, and in various directions. In some cases, the risk increased, in others it decreased, but mostly in small percentages. However, the most striking result was a sharp decline – of about 30 percent – in the risk of developing atherosclerotic heart disease (myocardial infarction), which was at the time the major cause of death in the Western world.

The doubt: In 1991, E. Barrett-Connor, an American epidemiologist, published an article in which she argued that the follow-up studies contained a fundamental error, as a result of which the exposed “truth” was flawed. Surveys conducted in the U.S. showed that women who took hormones were from a higher social class, better educated and led healthier lives – including physical activity and proper nutrition – compared with women who did not take them. The incidence of heart disease among that group would naturally be lower, irrespective of hormone consumption.

The only way to overcome this flaw, Barrett-Connor and colleagues maintained, was to conduct a controlled clinical trial. Using this methodology, the population of menopausal women would be divided randomly into two comparable groups. One group would receive hormones, the other a placebo. Thus, all the factors influencing women’s health aside from hormones would be represented equally in each of the two groups, and would not affect the differences between them regarding the various types of disease associated with menopause.

Third step: In the wake of the claims about the weakness of the evidence gathered by the above-mentioned follow-up studies, it was decided to conduct a large-scale controlled clinical trial. In 1993, recruitment began for the project known as the Women’s Health Initiative. More than 16,000 women took part in the clinical trial on hormones and menopause, which ended after five years, three years earlier than originally planned, because of a higher incidence of disease among the women receiving the hormones. The researchers reported that this group was at greater risk of atherosclerotic heart disease, stroke, pulmonary embolism and breast cancer, although it was at lower risk for large-bowel cancer and femoral neck fractures.

The doubt: Francine Grodstein, a Harvard epidemiologist, and her colleagues compared the results of the follow-up studies conducted in the 1970s and 1980s with those of the controlled clinical trial. They found considerable similarity between the studies with regard to the relative risk for most types of disease. However, there was a dramatic difference in the risk for atherosclerotic heart disease – a risk decrease of 30 percent among the women who participated in the earlier follow-up studies, and a risk increase of 30 percent among the women who were part of the controlled study. Based on currently existing knowledge, they argued, it was unreasonable to think that a healthy way of life or any other factor would alter the risk of myocardial infarction exclusively and not all the other types of disease.

Fourth step: Grodstein and her colleagues examined several possibilities, in an effort to explain the discrepancy between the controlled study and the follow-up studies. They concluded that the likeliest explanation lay in the timing of the start of hormone treatment. The average age of the women recruited for the controlled study was 63 at the start of estrogen treatment, whereas the average age of the women in the follow-up studies was 51. The theory that the result was associated with the timing of the treatment was supported by laboratory studies, animal studies of monkeys whose ovaries were removed (artificial cessation of menstruation), and by lengthy follow-up research. According to these studies, female hormones prevent the formation of sclerosis in “healthy” arteries, which are more prevalent in younger women, but are liable to promote myocardial infarction by inducing the formation of blood clots in the arteries that are already sclerotic, as is the case in older women.

Fifth step: The results of a controlled study conducted in Denmark, involving 1,006 healthy women who had recently stopped menstruating, were published in 2012. After 10 years of follow-up, it had been found that women who received replacement hormones shortly after cessation of menstruation were at a significantly lower risk of developing atherosclerotic heart disease than women who did not receive hormones. There was no increased risk of cancer or stroke in this group.

Franka Bruns / AP

Aging and anxiety

In 1968, Robert Wilson published his ideas in a book, “Feminine Forever,” which, with media hype, became a worldwide best seller. Wilson maintained that estrogen taken by women during menopause would stop all aging-related phenomena, and help them realize the ancient dream of eternal youth and femininity. The findings that hormonal treatment not only could preserve youth but could prevent heart disease were widely reported widely. Women flocked to get prescriptions, which doctors assiduously provided. Estrogens were added to the list of medications that prevent heart disease. The number of prescriptions written for estrogens in the U.S. soared from 13.6 million in 1982 to almost 100 million by the beginning of the 21st century.

The Women’s Health Initiative study brought the euphoria to an end. Like other follow-up studies, it indicated a small but significant increase in the risk of breast cancer in menopausal women taking hormones. The media quickly played up this finding and published articles that raised women’s anxiety level. Anxiety is a powerful motive for modifying behavior, and reports relating to a large number of people attract large audiences, resulting in the expected change.

By the end of 2002, the number of hormone prescriptions issued in the U.S. had decreased by 30 percent compared to the second quarter of that year (before publication of the research findings in July of that year). The trend continued: In 2009, 70 percent fewer prescriptions for hormone substitutes were written compared with the numbers before the results of the research were published.

New evidence and the continuing discussion of the association between hormones and women’s health were not widely reflected in the popular media. In this pendulum swing – between the desire for eternal youth and existential anxiety – there was no room for a more complex perception of reality. Newspapers need to provide interesting material, preferably provocative and in real-time, and they usually avoid dealing with elaborate information. On the social networks, the demand for very short messages and the size of the screen dictates catchy content with no room for discussion. In such a situation, the public may easily lose its grip on reality.

Days of Bullshit

In 1986, Harry Frankfurt, a philosopher at Princeton University, published an article titled “On Bullshit,” which today, with the new president in the White House, looks like a self-fulfilling prophecy. Frankfurt distinguishes between a lie – defined as a focused action calculated to instill falsehood in the target audience, and “bullshit,” which reflects indifference to the truth and sometimes also hostility toward it.

In a complex, competitive and hedonistic world, the value of qualities like perseverance and consistency is declining constantly. The temptation to surrender to basic pleasures, the herd instinct (believing in what is accepted), and simple laziness (avoidance of making an effort without a guaranteed quid pro quo) are on the rise. A large public is sealing itself off from new evidence and does not critically examine the evidence provided. Many people adopt readily available and easily obtainable statements about reality without making the slightest effort to verify them.

One would have thought that in our day, the realm in which truth prevails would be expanding constantly. The internet, search engines and the social networks make it possible to obtain information easily, to exchange it openly, and to uncover evidence that will lead to the truth. But in practice, the dramatic change in the transmission of information posits numerous difficulties to proponents of the truth. The web is the modern version of the Greek “agora”, where there is room for every opinion and where every shred of evidence can be circulated. The status of the gatekeepers – those striving to expose lies – is waning. Moreover, the web is like a hall of mirrors: Every statement, whether truthful or false, is repeated endlessly.

Indifference to the truth abandons a large public to manipulators who shape an alternative reality, leading many people to act contrary to their own interests. The cynics subordinate the media to their needs and lash out angrily at devotees of truth, whose numbers are rapidly dwindling.

In the bullshit culture, consistency or conceptual coherence are no longer in great demand. The social dialogue becomes unproductive and sterile, and trust, which is one of the core precepts of the society we live in, disintegrates, threatening the very foundations of modern civilization.

Dr. Benjamin Mozes is an internist and clinical epidemiologist. He is the author of the books “The Truth of Scientific Medicine” and “On Being a Doctor in the Era of Knowledgeable Ignorance.”

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