Women’s Cycles Up for Sale

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Women's health activists have, for several decades, analyzed and criticized the process of medicalization. This process involves seeing and treating natural experiences and socially-created problems as biological diseases or illnesses that require medical surveillance or intervention. This process has been shown by many to be harmful to women's health.

In general, women's lives are more likely than men's are to be medicalized. This has, perhaps, been most common with regard to women's mental health and reproductive lives. These are two areas in which women's experiences differ greatly from men's and have for years been seen under a medical lens. For the most part, the medicalizing of events and experiences such as menstruation, pregnancy and menopause has involved providing a diagnostic label and then offering, if not imposing, some biomedical or surgical intervention to "treat" it.

Sadly, medicalization is not only a process from the past; in its "classic" forms, it continues today. However, our understanding of the process seems to warrant some updating and reassessment to take into account two more recent phenomena. One includes the ways in which disease-creation is today more likely to be done by pharmaceutical companies than by physicians; the other involves the framing of natural experiences less as diseases themselves, but as causes of future diseases.

These new twists on the old theme seem to warrant a new name, and neo-medicalization may fit the bill. Adding the prefix "neo" draws attention both to what we already understand of medicalization and to the contemporary economic forces that encourage this extended approach.

Pills For Prevention
Neo-medicalization fits seamlessly in the consumer-oriented society of North America today and to current views of disease -- if not "pre-disease" -- as a "market opportunity!" For example, this latest medicalization comes packaged as individual "choice" with the offer of multiple "options" to women. Thus, both neo-medicalization and consumerism construct health as a commodity, a resource needed for economic growth, and both emphasize increasing women's choices (via the creation of tests, screening exams, etc.). Further, by framing life experiences as "causes" of disease, neo-medicalization thereby generates a whole industry to create "pills for prevention."

To clarify this, let's consider the transitional state in women's lives known as menopause. In the 1950s, under the "old" medicalization, hormones (estrogen +/- progesterone) were prescribed for women mainly to treat what was labeled the (hormonal deficiency) "disorder" of menopause. Over the years, prescriptions for hormone replacement therapy (HRT) continued to be written for this "disease," but more recently these drugs also came to be recommended for their alleged ability to prevent the diseases that menopause was alleged to cause: heart disease, osteoporosis, even Alzheimer’s disease.

In other words, the story of HRT for midlife women is not only about how a natural life experience became a "disease" ("hormone deficiency") needing treatment, but also about how, when calling this experience a "disease" dropped from favour, it became framed as the cause of subsequent problems and, as such, still in need of treatment.

This could be seen in the recommendations made by a variety of organizations and individual health practitioners who believed that virtually all post-menopausal women should be on HRT to prevent heart disease and osteoporosis. That there was no solid information from randomized trials to support this recommendation didn't seem to matter, and the number of prescriptions for HRT for healthy women, many with no menopausal symptoms, mushroomed. (HRT remains an effective short-term option for those with severe menopausal symptoms).

Things changed drastically on July 17, 2002, when the Journal of the American Medical Association (JAMA) published the first sets of results from the study known as the Women's Health Initiative (WHI) showing that more harm than benefits occurred when women took HRT for its supposed preventive effects. In fact, women and their physicians have been rocked ever since, as one by one, the various myths about HRT as a "wonder drug" have been punctured.

The results of the WHI should put an end to the unfounded, but quite widespread treatment of all women over 50 with HRT, and we might count as a bit of "progress" that menopause is no longer universally declared to be a disorder itself. But, this "victory" may be short-lived.

Pharmaceutical companies have their shareholders to satisfy, and so not only are they already scurrying to find other hormonal combinations and/or ways of delivering them, but they are also turning attention to the other milestone in women's menstrual lives: the start of menses. This, too, is something that almost all women experience, and as such offers quite a vast "market opportunity" for neo-medicalization. Thus, quite opportunistically, when menstruation first begins, and how often it happens subsequently, are being framed as possible "causes" of future ill health and points of entry for pharmaceutical management.

For example, some are urging intervention when menstruation begins at a young age, arguing that hormonal manipulations of young girls to create "mock" pregnancy states might be a way of lowering some potential risks for the later development of breast cancer. Many others are arguing to eliminate periods altogether, pointing out that regular periods "cause" many women distress and might even "cause" cancers later in life. Suddenly, or maybe not so suddenly, having periods is -- or at least is made to seem -- not "natural" and a possible "cause" of later problems. And pills to "fix" women’s cycles are being marketed yet again.

Of most interest here is that these views of menstruation as a causal factor for disease only began to gain currency when drug companies had already prepared a pharmaceutical response. Thus, hormonal cocktails probably first developed to manage women's cycles when they were undergoing fertility treatment may be finding new uses to manipulate young pre-teens; birth control pills (e.g., Seasonale) developed in efforts to provide contraception at the lowest possible doses seem to be finding expanded use as a "period-free" pill.

Clearly, these are experimental uses of hormones and birth control pills, uses that lack any justification. There are no data to indicate the safety of exposing healthy girls to "hormonal pregnancies" or women to long-term menstrual suppression. Women who go these routes are, in fact, participating in uncontrolled experiments. Why offer to "fix" something that isn't broken? Women's cycles are NOT a problem, an illness, or a cause of disease no matter that framing them in this manner can be profitable for pharmaceutical companies.

There are many other ways in which the commercial base of neo-medicalization is expressed, and among the most problematic are when conditions are created specifically to match some drug already available. Contrary to the usual practice of developing a drug for a disease, the "cause/effect" situation is increasingly reversed and a "disease" is developed to expand the sales of a drug, either one already on the market or a somewhat repackaged version of it. In both cases, this can ensure a longer patent protection for a company.

Most recently, this has been seen in the search for a female market for Viagra -- or a similar compound -- and the creation of what has been labeled "female sexual disorder." As Leonore Teifer of the New View Campaign has written, "Some women do have sexual problems; this cannot be denied. But there is good research to show that these are most often not of the sort that interests the pharmaceutical industry. Rather than pills, patches and creams with Viagra-like drugs in them, potentially dangerous medications, women need good information, good sex partners, sexual safety and time for pleasure to have good sex lives."

Let me be clear: there are essential drugs both to treat and to prevent disease. But their use should be restricted to what are real, and not artificially-created, diseases. Yes, we do need safe immunizations against smallpox, measles and mumps. Yes, we do need companies that will add iodine to the salt we use, vitamin D to milk. We also want to ensure there is sufficient (and safe) heparin, an anticoagulant, available for the use of those facing surgery who need to prevent the formation of blood clots; safe insulin for those with Type 1 diabetes; effective anti-seizure medicines for those with epilepsy; and tamoxifen for women with a clear diagnosis of breast cancer.

What we do not need are "pills for prevention" that may cause, not protect us from, disease. In this context, drugs are clearly NOT the answer for promoting women’s health. And, it seems, neo-medicalization may continue to be the problem.

Abby Lippman is Professor of Epidemiology at McGill University and a member of Women and Health Protection, a coalition of community groups, researchers, journalists and activists concerned about the safety of pharmaceutical drugs, www.whp-apsf.ca/en

A version of this article first appeared in French in Sans préjudice, www.rqasf.qc.ca/publi_sp.html