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by R. Nagarajah

As a Sri Lankan living in Canada, it was an intriguing to read some of the current discussions in the medical community in Sri Lanka about recent revelations on Hormone Replacement Therapy that has rocked the western world. I hope the following will help to weigh the pros and cons on this important issue.

Recently, the media in North America and the Western World bemoaned about the harmful effects of long-term use of hormones. It was revealed that women who take these hormones faced an increased risk of breast cancer, stroke, heart attacks and blood clots. The Women's Health Initiative (WHI), a trial overseen by the U.S. National Institute of Health and involving 16,608 women between 50 and 80 found that long-term use increased the risk of coronary heart disease, one of the very illnesses the synthetic hormones were meant to reduce. Interestingly, the follow up study which was intended to be completed by 2005, was halted abruptly in May because even at that point the increased risk of breast cancer among those receiving the hormones was deemed higher than ethically acceptable. Even the recent study aimed at damage control, suggesting that HRT for ten years can reduce the risk of Alzheimer's disease is shaky. The study is said to have been on observation, not rigorous and randomized research with placebo that could yield indisputable evidence as did in the WHI. Study.

HRT fever began in 1966 when an American doctor named Robert Wilson wrote a best seller called Feminine forever. He called the disappearance of estrogen at menopause a "catastrophe". He said replacing it is like replacing insulin in a diabetic. "Breasts and genitals will not shrivel, and women will be much more pleasant to live and will not become dull and unattractive". In the 1970s researchers found that estrogen therapy alone increased the risk of uterine cancer, so the drug companies added progestin, which causes the uterus to slough its lining and negates the risk. Soon HRT became the anti-aging panacea for women, and the world sales now surpass 2 billion a year.

For the most part HRT is a fodder to western dogma and its weird philosophy about aging. HRT has been cast as an instrument of female liberation and sexuality. The western world wants to spread its concept of medicalization of natural life transition processes and finding cures for so called syndromes. The western medical system's automatic response to hot flashes and night sweats has been to pull out the prescription pad instead of educating and encouraging alternatives such as physical fitness, balanced diet and spirituality.

After the shocking revelation about adverse effects of these hormones, the American Medical Association has now recommended its doctors to "stop prescribing this combination for long-term use ...do not use estrogen/progestin to prevent chronic disease". Surely this has brought despair to pharmaceutical companies depending on HRT for huge profits. As usual the drug manufacturers determined to support the cash cow of HRT, would naturally want to tap into the unsuspecting, acquiescent third world market. They know that patient awareness and 'informed consent' ethics are low in the third world and they could exploit this in every way as they did with the Depo-provera in the seventies and eighties.

They would aggressively increase their 'professional education' and promotional programs in order to persuade doctors to prescribe. They will find more creative and subtle ways to downplay the risk and hint at unproven benefits of hormone replacement therapy, and to convince the women and doctors about the need for it.

As a rural medical practitioner in Sri Lanka in the 70s and 80s, I can regrettably attest to the fact how western drug companies influenced Sri Lanka into using contraceptive pills with higher amounts of hormones, contraceptive injections (Depo provera) and implants.

This was the time when our rural women neither had the knowledge nor the wherewithal to do breast self-examination or get mammograms. Information about contraindications and long-term adverse effects were downplayed by sales promotion and propaganda sponsored by the drug companies.

Even when low-dose pills were introduced to reduce adverse effects and the use of Depo-provera stopped in the western world in the 1990s, the use of these drugs lingered unabated in Sri Lanka. Pills (Mithuri) was available in village stores as non-prescription item while in the western world these were prescribed after careful screening and tests. Given the conditions prevailing, it wasn't any body's agenda to carry out comprehensive studies to find out how many people suffered from cancer or cardiovascular disease due to such indiscriminate hormone use.

The longevity and health of men and women is partly mental, social, cultural, philosophical and spiritual rather than hormones alone. Some in the western world are now beginning to think about this seriously. Japanese women with the highest life span and many other countries including Sri Lanka where our mothers and grand mothers aged healthily and gracefully did not depend on synthetic hormones. The problem with modern life is that everyone wants to feel and look the same forever by manipulating their hormones, and the recent revelations about the adverse effects of hormone therapy are just one dangerous result of this mind set. How far can we go against nature?

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