Woman

by Natalie Angier

  Girls, poor girls, are in the thick of our intolerance and vacillation. Girls put on body fat as they pass into adulthood. They put on fat more easily than boys do, thank you very much, Lady Estradiol. And then they are subject to the creed of total control, the idea that we can subdue and discipline our bodies if we work very very hard at it. The message of self-control is amplified by the pubescent brain, which is flailing about for the tools to control and soothe itself and to find what works, how to gather personal and sexual power. Dieting becomes a proxy for power, not simply because girls are exposed through the media to a smothering assemblage of slender, beautiful models, but because adolescent girls today are laying down a bit of fat in an era when fat is creeping up everywhere and is everywhere despised. How is a girl to know that her first blush of fatness will ever stop, when we're tearing our hair out over how the national fat index keeps on rising and we must wrestle it to the ground right now?

  There are other, obvious reasons that a girl's brain might decide that a fixation on appearance is the swiftest route to power. There are too many of these Beauty '‹' You, Beast magazines around, far more than when I was a prepubescent girl circa 1970. (There were too many of them back then.) Supermarkets now offer no-candy checkout aisles for parents who don't want their children screaming for Mars bars as they wait in line. Where are the no-women's-magazine aisles? Where are the aisles to escape from the fascism of the Face? Any sane and observant girl is bound to conclude that her looks matter and that she can control her face as she controls her body, through makeup and the proper skin care regimen and parsing her facial features and staying on guard and paying attention and thinking about it, really thinking about it. No wonder a girl loses confidence. If she is smart, she knows that it is foolish to obsess over her appearance. It is depressing and disappointing; for this she learned to read, speak passable Spanish, and do calculus? But if she is smart, she has observed the ubiquitous Face and knows of its staggering power and wants that power. A girl wants to learn the possible powers. By all indications, a controlled body and a beautiful face practically guarantee a powerful womanhood.

  I'm not saying anything new here, but I argue that people should see adolescence as an opportunity, a fresh coat of paint on the clapboards of the brain. Girls learn from women: fake women, amalgamated women, real women. The Face is inescapable, but it can be raspberried, sabotaged, emotionally exfoliated. Repetition helps. Reassuring a girl that she is great and strong and gorgeous helps. The exhilarating, indoctrinating rah-rah spirit of the new girl-power movement helps. Girls helping each other helps, because girls take cues from other girls as well as from women. Ritual helps, and antiritual helps. We can denude totemic objects and reinfuse them with arbitrary mania. Girls can use lipstick to draw scarification patterns on each other's backs or faces, or a line of supernumerary nipples from armpit to pelvis. Build a hammock with brassieres and fill it with doughnuts and Diet Coke. Combine the covers of women's magazines with cutout parts from nature magazines to make human-animal chimerical masks: Ellephant MacPherson, Naomi Camel. Glue rubber insects and Monopoly hotels onto the top of a bathroom scale. Girls can imagine futures for each other, with outrageous careers and a string of extraordinary lovers, because it is easier to be generous to another than to yourself, but imagining greatness for a friend makes it thinkable for yourself. Sports help. Karate helps. Sticking by your girlfriends helps. Writing atonal songs with meaningless lyrics helps more than you might think. Learn to play the drums. The world needs more girl drummers. The world needs your wild, pounding, dreaming heart.

  12. MINDFUL MENOPAUSE

  CAN WE LIVE WITHOUT ESTROGEN?

  I RECENTLY HEARD Suzzy Roche, one of the three sisters who make up the clever-mellow folk group the Roches, perform a song in which she groans wryly about being over forty and listening to her friends talk about middle-aged things like wrinkles and estrogen. Not estrogen replacement therapy, mind you, just estrogen. When I wrote an article for the New York Times about estrogen receptor-beta and the complexity of the body's indigenous estrogen network, a number of readers thanked me for having clarified their thoughts on estrogen replacement therapy, although I'd barely mentioned the subject in my article. What we take seems stronger than what we have. Physiology is invisible and forgettable. Pills are tangible and melodramatic. They make grand promises and they raise grand hopes. And estrogen replacement tablets, being a nostrum for women, inevitably raise hackles as well.

  What is it about women's "health" issues that turns people malign? Hysterectomies, cesarean sections, abortions, mammograms, hormone therapy: our bodies, our hells. Men are so serene by comparison, indifferent even to the brouhaha among doctors over the proper monitoring of the prostate gland. But here we are, saddled with another gynecrisis, another source of anguish over the cantankerous merchandise the female body, this crisis perhaps the biggest one ever. By the year 2000 there will be about 50 million women in the United States over the age of fifty, all of them potential candidates for hormone therapy. If every one of them were to take hormone pills for the next thirty years—to the age of eighty, which is close to the current female life expectancy—that amounts to 1.5 billion woman-years of drug consumption. What an absurdly huge number. Never before has a drug regimen been proposed on such a scale. Can we expect unity and revelation from the teeming ranks of womankind? Can we expect a simple yes-or-no answer to the question "Should I take hormone replacement therapy?"

  Does the pope howl at the moon? Has your hysteria been wandering?

  There is no simple answer. You already know that, but still you hope for a simple answer, if not now, then later, in the twenty-first century, when the results of bigger and better clinical studies come in. Unbate your breath. Whatever results emerge, from the massive Women's Health Initiative in the United States or similar trials in Europe, they almost surely will be complicated. Hormones have much to offer, but still they smirk ever so slightly. They're a little dangerous, a little threatening. They're not Flintstone Vitamins; they're hormones, strong messengers, and their shoes are cockily winged.

  At menopause, the ovaries stop producing estradiol. Hormone therapy starts talking where the follicles fall silent. But does our body appreciate the perpetuation of noise? Or is midlife finally the time to throw the teenagers out of the house, blastocas-ters and all? Most gynecologists and internists today think that hormones are the right choice for most postmenopausal women. Yet they concur that the therapy is not without risks. The Women's Health Initiative will clarify the risks, but it won't make them disappear. Individual variation will not disappear. The so-called designer estrogens that pharmaceutical companies are racing to develop and perfect, which in theory will offer the benefits of tissue specificity, of protecting the parts that need protecting while ignoring the tissues, like the breast, that don't want the stimulus, are a grand hope. But designer estrogens such as tamoxifen and raloxifene are still hormones, and each one must be extensively tested, and hormones are never risk-free. Women must decide for themselves. Women do decide, but then, fie fie, they turn fickle, and run the other way. We love estrogen, we fear estrogen. Everybody wants to take it. Why do so few women take it?

  We can't be blamed for our volatility. The scientific literature is volatile, and it is vast. We are chased and torn. We jump through all four carbon hoops of our exasperating steroid, and hop right back again. We live in the age of mindful menopause, forced to dwell on the change and its aftermath as our foremothers never did. My grandmother was proud of the fact that she hardly noticed her menopause—no insomnia or hot flashes to speak of, and good riddance to the monthlies. Undoubtedly she took disproportionate credit for the easy transition, attributing it to her stalwart will rather than her lucky phenotype, but still, the change came and went and that was that. If she were alive today, her doctor would raise the subject of hormone replacement therapy. There's no escaping the drone of menopause consciousness. I'm not advocating a return to the days when women were ashamed to talk ab
out menopause and the discomforts they felt, just as they were ashamed of everything else having to do with the female body and with getting older. Yet in becoming a topic fit for public discussion, menopause has exposed itself to homily, reductionism, and medical sharecropping. You say middle-aged woman, they say HRT. "Counseling about hormone replacement therapy should be given to all postmenopausal women," a 1996 medical review from the University of Utah said. Over the past few years, the medical juggernaut in favor of hormone therapy has barreled ahead with spectacular determination. "Based on evidence that hormone replacement therapy is cardioprotective, enthusiasm for universal hormone replacement therapy in postmenopausal women has grown," wrote doctors from the University of Texas Southwestern Medical Center in Dallas.

  What a vociferous, clanking tank the medical consensus can be. It has so much work to do, so many millions of women to persuade, that it becomes unyielding and intolerant of dissent. We're not allowed to have our fears and our irritations. We are scolded. The finger wags in our face. If we worry about the increased risk of breast cancer that hormone therapy can bring, we're told, Why are you worrying about breast cancer? Heart disease kills far more women than breast cancer does! You're swayed by sensational and inaccurate reporting in the popular press. Get your demography straight. Repeat it to yourself each night: heart disease is the number-one killer of women. Whenever a new study comes out suggesting an increased risk from hormone therapy of breast cancer, uterine cancer, or ovarian cancer, defenders of the universal solution storm in to put the results "in perspective," to remind us that heart disease, not cancer, is the biggest killer of women, and that the risk of osteoporosis is greater for a woman than her risk of breast, ovarian, and uterine cancer combined. When Susan Love, a renowned breast surgeon, wrote a book critical of hormone replacement therapy, and when she summarized her arguments on the op-ed page of the New York Times, many of her colleagues rallied with their blowtorches, attributing her exaggerated emphasis on breast cancer risk to her bias as a surgeon who sees a lot of breast cancer patients. Malcolm Gladwell parodied her in The New Yorker and accused Dr. Love of doing a disservice to womankind by scaring them away from one of the best proactive health measures yet devised. Dr. Love's statistics may be debatable and she may embrace some suspect alternative therapies such as homeopathy, but her basic message is valid. Hormone therapy is powerful, she says; it is meant as a prophylactic measure, to be taken in perpetuity by healthy women rather than as a medication to treat the sick. Shouldn't the bar of acceptable risk be higher for a preventive regimen, she asks, than for a therapeutic one? Absolutely, her critics respond, and hormone therapy clears the bar with an Olympian's might. Hormone therapy helps cut the risk of heart disease, osteoporosis, and possibly Alzheimer's, and the benefits of hormone therapy are large and incontrovertible and supported by scores of clinical studies. And they are. The benefits are real, but so are the risks. It's perfectly respectable to dither. The facts do it all the time. Here are a few of the more salient ones.

  Considered broadly, hormone therapy "works"—that is, it reduces mortality by a fairly impressive margin. According to a 1997 report from the Nurses' Health Study, for example, the women on hormones had a 40 percent lower risk of dying during a given year than women who had never taken hormones, mostly as a result of a decline in heart disease. That's the big picture; the statistical miniatures are worth examining as well. In the nurses' study, hormone therapy helped best those who needed it most. For women who smoked, were overweight, had high blood pressure, high cholesterol levels, or other known risk factors for heart disease, hormones slashed their admittedly elevated risk of mortality by more than half. But for women who were in good shape and free of harbingers of heart disease, hormone use showed no statistical benefit in reducing mortality; it did not help those who helped themselves. Moreover, the survival benefits of hormone therapy for any subgroup declined with duration of use, as the rate of death from breast cancer began canceling out the reduction in coronary disease. The results jibe with other studies showing that long-term HRT use—ten years or more—is associated with a 50 percent hike in the risk of breast cancer.

  Of course, there is more to life than dodging death. Hormone therapy can improve the tone of life. It inhibits the dissolution of bone, that gradual regression to the bog collective. Women who take hormones have a 50 percent lower risk of fracturing a hip than noncompliers, and the older you get, the less you want to crack a hip. Hip fractures are the primary reason that people over seventy end up in nursing homes. Hormone therapy maintains the pliancy of the bladder's sphincter and thus helps prevent incontinence, and it prevents the vaginal wall from getting thin and dry and prone to bleeding during intercourse. The performance of the urogenital tract is no small matter on the quality-of-life front. And then we have the brain, our beloved brain. Several studies have indicated that estrogen therapy may reduce the risk of Alzheimer's disease by about 50 percent. Many women who take estrogen replacement therapy like how they feel on the drug. They find that estrogen helps stabilize their mood and that it improves their memory. They had been growing forgetful in their middle years, and they hated that. They felt neuronally fragmented, as if there were too many skips, nicks, and blank spots on the hard drive. Estrogen tablets gave them back their fine minds, they said, and made them smart again. It's true that a number of studies have shown some improvement in memory in postmenopausal women when they are given estrogen replacement. Whereas before hormone supplementation they could remember only seven out of ten words in a list, for example, after estrogen they were able to recollect all ten. Experiments with brain cells and brain slices cultivated in laboratory dishes have demonstrated that applications of estrogen can nourish dendritic and synaptic complexity. If you look at pictures of rodent nerve cells before and after treatment with estrogen, it's like looking at images of a tree in winter versus in summer, or the mammary gland before or during lactation: how wild and weedy do the lines of life become! Yet it bears mentioning that estrogen is not a universal clever pill. It doesn't improve IQ scores. And in some studies of rodents, females who have had their ovaries, their biggest source of estradiol, surgically removed do better on certain maze tests than females with ordinary stores of estrogen.

  Hormone therapy has much to recommend it, but then we are pulled back to the reality of the heightened risk of breast cancer that years—decades—of estrogen supplementation can bring. We may wonder, should we be on hormone therapy for our entire postmenopausal life, or should we be more circumspect in our use of it? We're waffling again, we women. Not just in this country, with its "inflammatory" press, but everywhere. Complain though American doctors will about the low compliance rate of their postmenopausal patients, American women lead the world in the use of hormone therapy, just as they do in the rate of hysterectomies. In the United States, 46 percent of postmenopausal women take or have taken hormone therapy. British, Australian, and Scandinavian women come next, with ever-used rates of around 30 percent. Continental Europeans are notably less enthusiastic about medication, the figures falling into the teens, while in Japan a mere 6 percent of postmenopausal women take hormone replacement therapy—perhaps because they import enough estrogen into their bodies through the foods they eat, notably that sink of phytoestrogens, soy.

  In reporting on the relative rate of hormone use among their nation's womanpool, researchers wring their hands and ask, Why, why aren't we better missionaries than we are? The researchers look for defining characteristics of the hormone faithful. In America, hormone use is positively correlated with educational level: the more formal schooling a woman has received, the likelier she is to be a hormone enthusiast and to agree with the statement "the benefits outweigh the risks." But in the Netherlands, a country of bright, bookish women, educational level has no impact on hormone use, while in Norway, the more educated the woman is, the more likely she is to reject hormone therapy. The researchers of the various studies conclude by offering suggestions on ways to improve patient
compliance, the most common being that doctors must learn to preach early and often. From a study in Rehovot, Israel: "We believe gynecologists should devote more effort to public education, in that those women who had discussed HRT with their physician were more likely to use it." From Copenhagen: "It is suggested that lack of knowledge of HRT may sometimes be the cause of rejecting it, or may influence the compliance regarding its use." From Scotland: "In conclusion, women around the menopause ... are often anxious about HRT use. Better health education might improve HRT uptake."

  Nobody will argue against patient enlightenment. Let's all talk ourselves hoarse. Yet a more interesting point emerges from the parade of studies on the psychological profile of the middle-aged woman. It turns out that one of the biggest reasons that many women reject hormone replacement therapy is that they have positive feelings about menopause. They don't think of it as an illness, so what's to treat? In two separate U.S. studies comparing black and white women, researchers found that "the African-American women had significantly more positive attitudes toward menopause" than white women did, and that though they had the same number of menopausal symptoms as whites did, the blacks "perceived them as not very bothersome." The African American women surveyed also had a fairly good understanding of the "proper" order of health risks an aging woman faces, placing heart disease at the top, yet still they were far less likely than whites to be on hormone therapy. After noting ruefully that among Dutch women, the "mean duration of HRT use is only seven months," investigators at Elkerliek Hospital in Helmond, the Netherlands, went on to say, "The positive attitude of most women towards the climacteric is an explanation for this very short duration of use." Comparing a group of forty-five-year-old women who expressed an intention to use hormone therapy after menopause with a group who planned not to, London researchers found that there were no significant differences in the women's health or socioeconomic status, but that "HRT intend-ers reported significantly lower self-esteem, higher levels of depressed mood, anxiety, and negative attitudes to the menopause. They also expressed stronger beliefs in their doctors' ability—as opposed to their own—to control their menopause experience."