And Now For A Hot Flash

Want to clear a crowded room? Try starting a discussion about menopause. I know; I did it several times before I got the message to sit down and shut up. Or, as one friend finally leaned in at lunch to say, sotto voce, "Just take the Premarin." Now the whole world knows that that mantra simply will not do. Since the news broke of a government study showing that hormone-replacement therapy does more harm than good, there's been discussion aplenty. Will those women who took hormones find other remedies? Will they stick with the combination of estrogen and progestin that the women in a federal test were urged to abandon? Will they sell their stock in Wyeth, the drug company whose shares tumbled on the news that its biggest-selling product might cause breast cancer, heart attack and strokes?

But if the discussion merely concerns menopause and hormones, it will have been a huge missed opportunity. Instead this is the ideal time to confront the issue of one-size-fits-all health care, which has been the standard for far too long.

Here is where the expected attack on the medical establishment would normally begin. Not this time. As an editor once told me, "Cherchez le contract." By deciding to willy-nilly prescribe hormones to every female patient, from those who had dry skin to those tormented by hot flashes from hell, doctors were just doing what was easiest. By deciding to sell that medication by overstating its benefits and understating its risks, pharmaceutical companies were just doing what was most profitable.

Both groups are culpable, but so are patients, who need to take responsibility for their decisions, or for deciding not to decide and letting doctors and the marketplace decide for them. The case of hormone therapy is particularly glaring in this regard. How could the most ostentatiously self-aware generation of women in the history of this country allow themselves to be led like lemmings to a "cure" for a condition that is not a disease and a "remedy" for symptoms that were originally described largely in terms of how they inconvenienced men?

That is how hormone therapy was first foisted wholesale on American females. A doctor whose own son says he was in the tank for the estrogen industry wrote a book called "Feminine Forever" about ways to alleviate the symptoms of menopause. But many of the symptoms described in his book tended to fall into the "criticizes the way I chew and doesn't fix up her hair" school of husbandry.

Nevertheless, within a decade millions of women were taking hormones as a matter of course, even as one study after another emerged suggesting links with various cancers. Everybody did it, just like everybody with reproductive problems had hysterectomies and everybody with breast cancer had mastectomies. Some of this treatment was appropriate and helpful; some was unnecessary and even harmful.

Doctors got a lot of the blame, and patients were portrayed as a victim class. That has become ridiculous. Publishing houses keep churning out more and more books on health. Newspapers and magazines run stories constantly. Holistic medicine and herbal remedies are finally getting the respect and attention they deserve. The Internet is not just a shopping channel for linens and things, but a boundless source of information on issues from nutrition to transplant surgery. When you type in the key words "hormone replacement therapy," you get almost 100,000 sites.

Fifty years ago a doctor said to my mother, in effect, "Just take the DES." Probably he didn't even name the stuff, just prescribed it, in a case that has become the poster child for bad medicine. DES is a synthetic estrogen that was said to prevent miscarriage, but didn't. What it did was cause cancer, infertility and perhaps autoimmune problems in the daughters of those women who took it. As a result of my in utero DES exposure, the product of my mother's well-meaning ingestion of a hormone that her doctor automatically prescribed, I look at a prescription scrip the way some people look at a loaded gun.

But rationally I also learned to bring the same set of questions I bring to my work to my health: What is this? Why is it needed? What are the downsides? Where do I go for another opinion? In the drama of my body, I have become both the story and the reporter.

It is easier to simply take the pill, whatever it is, instead of studying up on diet, exercise, alternatives, the risk-benefit equation of surgery or drugs. What an orderly world it would be if the pill always did what it ought to, with no ill effects, no downside. But that's sci-fi, not reality. "I understand that medicine is not an exact science," it says on one surgical consent form. Where does that admission leave us? With choices, preferably informed ones, not the "yes, doctor" of years past. The day of the MDeity should be over; doctors have acted like little gods because patients have treated them as though they were. The woman who looks to a doctor to dictate rather than advise may wind up with treatment that she lives to regret. Or perhaps doesn't.