Special Feature
The Word Replacement’ Is Not Appropriate
By Leon Speroff, MD
I am on a small (and somewhat lonely) campaign to replace the word "replacement" as used with postmenopausal hormone therapy. "Hormone replacement therapy" contains the not so subtle message that we are replacing something missing or that we are restoring the hormonal state to that of the earlier reproductive years. It seems to me that the use of replacement is tied to the notion that menopause and the postmenopause are disease states, specifically estrogen deficiency disease states.
Modern data do not support the concept of menopause and the postmenopause as disease states, and furthermore, the notion of hormone therapy as treatment of a disease is an obstacle to good patient continuation rates (compliance is another word that I try not to use.)
Data from longitudinal studies uniformly indicate that most women experience menopause without difficulty as a normal physiologic event in their lives. The view that menopause has a deleterious effect on mental health is not supported in the psychiatric literature, or in surveys of the general population.1-4 The concept of a specific psychiatric disorder (involutional melancholia) has been abandoned. Indeed, depression is less common, not more common, among middle-aged women, and menopause cannot be linked to negative mental health changes. 5-12 A negative view of mental health at the time of the menopause is not justified; many of the problems reported at the menopause are due to the vicissitudes of life.13,14 Men and women at this stage of life both express a multitude of complaints that do not reveal a gender difference that can be explained by a hormonal cause.15
Part of the reason for our negative stereotypical views of menopause is that the initial characterization of menopause was derived from women presenting with physical and psychological difficulties. A study of 2001 Australian women aged 45-55 focused on the use of the health care system by women in the perimenopausal period of life.16 Users of the health care system in this age group were frequent previous users of health care, less healthy, and had more psychosomatic symptoms and vasomotor reactions. These women were more likely to have had a significant previous adverse health history, including a past history of premenstrual complaints. This study emphasized that perimenopausal women who seek health care help are different from those who do not seek help, and they often embrace hormone therapy in the hope it will solve their problems. Similar findings have been reported in a cohort of British women.17 It is this population that is seen most often by clinicians, producing biased opinions regarding the menopause among physicians. We must be careful not to generalize to the entire female population the behavior experienced by this relatively small group of women.
In my view, it is time to stress the normalcy of this life event. It is important to educate women and clinicians about the normal events of this time period. Changes in menstrual function are not symbols of some ominous "change." There are good physiologic reasons for changing menstrual function, and understanding the physiology will do much to reinforce a healthy, normal attitude. Menopausal women do not suffer from a disease (specifically a hormone deficiency disease). Hormone therapy should be viewed as specific treatment for symptoms in the short term and preventive pharmacology in the long term.
It is well-recognized that continuation rates with postmenopausal hormone therapy are low. The proponents of the "menopause is a disease" concept argue that this approach yields better motivation and continuation. Unencumbered by data, I challenge that argument, and offer an explanation that is at least a contributing factor for the low continuation rates with hormonal treatment. Postmenopausal hormone therapy is a preventive health care decision. It is a decision to undergo daily long-term treatment in order to gain the long-term benefits at a time when an individual is feeling well and in good health. There is an absence of the powerful motivating forces of pain, sickness, and the threat of disability or death. To make such a strong, long-term decision when the clinician insists an estrogen-deficiency disease is present, when the patient herself (as the longitudinal data tell us) believes menopause is a normal physiologic event, viewed without negative connotations, is very difficult because of the inherent conflict between the clinician’s and the patient’s views on menopause.
I believe that I have learned this from the women who have revealed what they believe and what they know in the longitudinal studies of the last decade. It only makes sense that trying to convince a woman she has a disease, when she does not believe it, will have a negative effect on the clinician-patient relationship. Postmenopausal hormone therapy is an option that should be offered to most women as they consider their paths for successful aging, but the attitude and beliefs of the clinician have a major influence on the decisions made by patients.
A willful, strong preventive health care decision must originate from an understanding derived from education regarding physiology and health. A clinician who provides such education and who promotes hormone therapy as preventive pharmacologic therapy will help patients generate lasting and firm preventive health care decisions. I believe this approach and attitude will ultimately yield better continuation rates with hormone therapy.
Thus, I believe the use of the word "replacement" is not consistent with a preventive health care approach. I believe the word replacement is rooted in the notion that menopause and postmenopause are disease states. Even the word therapy is not totally satisfactory, denoting treatment of a condition or problem. Nevertheless, "postmenopausal hormone therapy" is a step forward and an improvement over replacement therapy, and the word "replacement" never appears in my textbook. Other possibilities include "substitution, normalization, replenishment, or supplementation." I believe it is time to find a new phrase that appropriately and accurately represents postmenopausal hormone use in the 21st century.
References
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5. Hallström T, Samuelsson S. Acta Obstet Gynecol Scand (Suppl) 1985;130:13-18.
6. Gath D, et al. BMJ 1987;294:213-218.
7. McKinlay SM, McKinlay JB. The impact of menopause and social factors on health. In: Hammond CB, Haseltine FP, Schiff I, eds. Menopause: Evaluation, Treatment, and Health Concerns. New York: Alan R. Liss, 1989.
8. Matthews KA, et al. J Consult Clin Psychol 1990;58:345-351.
9. Koster A. Health Care Women Int 1991;12:1-13.
10. Holte A. Maturitas 1992;14:127-141.
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12. Dennerstein L, et al. Med J Aust 1993;159:232-236.
13. Dennerstein L, et al. Maturitas 1994;20:1-11.
14. Mitchell ES, Woods NF. Maturitas 1996;25:1-10.
15. Van Hall EV, et al. J Womens Health 1994;3:45-49.
16. Morse CA, et al. Maturitas 1994;18:161-173.
17. Kuh DL, et al. Br J Obstet Gynaecol 1997;104:923-933.
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