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Hormone decision is all about risk

Osteoporosis is the disease the women in my family fear. So I decided long ago that I would turn to hormone replacement therapy, which has been found to combat bone loss, when I reached "that age." Then, last week, the results of the Women's Health Initiative HRT study provided convincing evidence that overall harm from the therapy outweighs the benefits it provides.

Regardless of the study, whether or not a woman will accept hormone replacement therapy is an individual decision. It's a decision that involves the best medical information possible _ and we are increasingly aware that medical information is often as ambiguous as are ethics in the financial world _ but also, importantly, one that requires women to think through what they value and fear and how they respond to risk. The news about the HRT study says as much about how we think about risk and medicine as it does about women's health.

In the prevention paradigm current in medicine, doing nothing is seldom the right answer. Letting nature take its course is not on the agenda. Identifying a dizzying array of risk factors and manufacturing ways to reduce them, is. This is one face of what sociologists now call the risk society; the world we live in is permeated with risk, awareness of uncertainty and dependence upon experts.

The risks we face with preventive approaches are double-edged. The prevention paradigm dictates that we do something to ensure a healthy future. But increasingly, betting on a cancer- or heart-disease-free future means taking on some other health risk. We can't count on data to tell us straightforward truths, so making our way through the maze of risks and benefits requires expert guides. And our expert guides are not always the infallible dispensers of absolute truths we wish they would be.

In the 1980s and early 1990s, women with advanced breast cancer faced a terrible dilemma. A risky, patently dangerous and expensive treatment _ high-dose chemotherapy _ was being touted by the medical profession as the best hope for those with certain types of the disease. A combination of fear, medical hype and the need to "do something" complicated the assessment of the treatment through clinical trials. Physicians attempting to conduct such trials in the early 1990s were frustrated by women who refused to participate, on the possibility that they might be randomly assigned to a control group _ standard therapy for breast cancer. To date, it is still not clear that high-dose chemotherapy is superior to conventional treatment.

The "do something" prevention paradigm is a profitable approach for the medical industry. Nothing beats carving out whole sectors of the population for fear and treatment, and we, as health care consumers, find ourselves caught in an ever expanding web of common diseases, risk factors and therapies. High-dose chemotherapy for breast cancer is an example of experimental technologies that are widely adopted to treat desperately ill patients while their safety and effectiveness are still in question. The hormone therapy under scrutiny by the Women's Health Initiative, on the other hand, is an example of a preventive treatment given to healthy women before the risks were carefully examined. Ironically, the long-awaited HRT trial has now convincingly linked that treatment to breast cancer.

The HRT story thus far should serve as a cautionary tale for another women's health issue currently being discovered _ or invented, depending on your perspective. Perimenopause, based on the notion that the changes in hormone levels that result in menopause begin at least 10 years before the cessation of menstruation, is now being "diagnosed" in women in their 30s and 40s.

While I have not seen estimates of how many women are prescribed HRT for relief of perimenopausal symptoms, surfing through women's health Web sites for a few minutes makes it clear that such prescriptions are not rare. Replacement regimens include the hormone combination found to increase risks of breast cancer and heart disease in the Women's Health Initiative trial.

Whether we continue the deficiency disease way of thinking about women's aging and hormones remains to be seen. But we should be grateful that the Women's Health Initiative has, in this instance, supported both skepticism about what we are told about our bodies and, perhaps, clearer thinking about risk.

Susan E. Kelly is an assistant professor of medical sociology at the University of Louisville.