While we may argue with some of the information,  this doctor cannot be faulted for his intention to ensure that his patients were fully informed before consenting to treatment. This is more than can be said of some doctors even today. Note that this article precedes the publication of Dr Robert Wilson's book Feminine Forever which thrust ERT into the limelight. However, some of his work is included in the references.

An increasing number of physicians are of the opinion it is physiologically sound and therapeutically practical to provide hormone replacement for most, if not all women with ovarian failure, whether their castration followed surgery or was a natural involution.

This aggressive therapeutic attitude received prominence in the teachings of Dr. Fuller Albright, Harvard Medical School, more than 20 years ago. He focused on the crippling consequences of menopausal osteoporosis and believed estrogen therapy would prevent this disorder which had previously been attributed to aging. Subsequent studies (1,7) have supported the value of estrogens in preventing osteoporosis even though Dr. Albright's theories about the mechanism of the osteoporotic process have had to be revised. In spite of his great influence his radical recommendation was generally ignored for a variety of reasons, some of which are listed in Table I.

Table I: REASONS AGAINST INTERVENTION 

1. Philosophic reluctance to interfere with nature.
2. Paucity of convincing clinical reports.
3. Fear of causing breast cancer.
4. Expense and inconvenience.
5. Inertia and lack of education (both lay and professional) .
6. Undesirable side-effects of therapy such as:

(a) Uterine bleeding-planned and unplanned.
(b) Breast tenderness or growth.
(c) Nausea and gastrointestinal upset.
(d) Malaise.*
(e) Excessive libido-pelvic congestion.*
(f) Hyperpigmentation.
(g) Spiders.
(h) Restlessness and irritability.*
(i) Saline retention.*

In recent years the attitude toward treatment has gradually changed. Five possible reasons for this change are noted in Table II.

Table II NEW REASONS FOR ACTIVE INTERVENTION

1. Population explosion of menopausal women.

The magnitude of the problem has grown markedly with the great and continuing increase in the number of menopausal women. Only 30 years ago the number of men over the age of 60 equalled the number of women. In 1975, these women will outnumber the men by 40% and a woman's life expectancy will have risen from its present 75 years to 80.2 It will become usual for the menopause to mark the mid-point of a woman's life, not the impending end.

2. Cancer not caused but prevented.

The fear that estrogen treatment might cause breast cancer, as it does in a special strain of mice, has not only failed to be confirmed, but to the contrary, a growing body of data supports the possibility that the incidence of both uterine and breast cancer is significantly reduced by long-term estrogen replacement therapy. Table III summarizes five such studies.(3-9) In addition it has been noted that the incidence of these cancers has not generally increased since the introduction of estrogen therapy in 1929, although in 1954 it was estimated that 7 million women were receiving such therapy each year (10) and now this figure has probably doubled.
 

Table III TREATMENT PREVENTS CANCER

Observer	patient yrs.	patient nos	Duration (yrs)	cancer expected	cancer found
Gordan 3,4	1200	120	14	12-15	0
Wilson 5,6	2604	304	17	20	0
Wallach 7	1480	292	25	(22)*	0
Warfield-Williams 8	........	500	15	(30)*	5**
Geist 9	........	206	55	(12)*	0
TOTALS		1422		96	5**
* Parentheses indicate author's estimate ** All uterine cancer. Only one of the five occured after 1945, when oral intermittent estrogens were substituted for continuously active injectable estrogen

3. Oral progestins available.

The recent availability of oral progestins makes it practicable to replace both chemical components of the normal woman's hormonal environment. Although there is virtually no information on the role progestins will play in treating the menopause, millions of women will be using them for contraception and, as a consequence, will find themselves in the fifth decade without any hormonal deficiency. It may be tlilat the best and simplest course will be to continue therapy indefinitely.

4. New published reports.

Considering the growing magnitude of the population concerned and the practical and philosophic challenge, it is surprising how little clinical research has been devoted to this problem, especially in this day of such generous support for medical research. However, there have been a few reports 3-8 and each supports aggressive therapeutic intervention.

5. Accumulating physiologic arguments.

Arguments for the physiologic rationale for treating the menopausal woman have been accumulating and are summarized in Table IV.

Table IV REPLACEMENT THERAPY APPEARS TO PREVENT OR RETARD
1. Psychologic involution, apathy, negativism.
2.Cancer of the breast and uterus.
3. Osteoporosis.
4. Atherosclerosis.
5. Skin atrophy (wrinkling, bruising, itching)
6. Mucous membrane atrophy (eye, nose, urethra, vagina, rectum)
7. Menopausal diabetes? Menopausal thyrotoxicosis?

References

1. Reifenstein. E. C. Jr.. Osteporosis. in Harrison. T. R.: Principles of Internal Medicine. 3rd Ed.. The Blakiston Division. McGraw Hill Book Co.. Inc.. New York. 1958. pp. 664-671.

2. Tarver J.D. : Life Expectancy Projections., New Medical Materia 2:49 1960

3. Gordan. G. S. : Osteoporosis Diagnosis and Treatment. Texas J . Med.. 57:740. 1961.

4. Gordan. G. S. : Round Table Conference: The Menopause and the Roles of Estrogens. Excerpts Medica Foundation. May 1962.

5. Wilson. R. A. et al. : Specific Procedures for the Elimination of the Menopause. 'Western J. Surg.. Obst. & Gynec.. 71:110-121.May-June. 1963.

6. Wilson R.A. :The Roles of Estrogen and Progesterone in Breast and Genital Cancer. J.A.M.A. 182:327. 1962.

7. Wallach. S. and Henneman, P. H. : Prolonged Estrogen Therapy in Postmenopausal Women. J.A.M.A.. 171:1637. 1959.

8. 'Varfield-Williams. E. : The Management of the Menopause. Med. Press. CCXLIV:337. 1960.

9. Geist. S. H. et al. : Are Estrogens Carcinogenic in Human Female? Atypical Endometrial Proliferation in Patients Treated with Estrogens. Am. J. Obst. & Gynec., 42 :242, 1941.

10. Larson. J. A. : Estrogens and Endometrial Carcinoma. Obst. & Gynec. . 3 :551. 1954.

The ovary performs two independent functions; the production of the ovum ( egg) and the secretion of estrogen and progestins { the ovarian hormones) . These hormones not only cause menstruation, but have many important effects on other parts of the body. When the ovaries are removed surgically or wither naturally during the fourth decade in what is called the "menopause" or "climacteric" the woman becomes sterile (loss of ova) and becomes deficient in ovarian hormones. Treatment can replace this hormone deficiency but does nothing to return fertility.

The human ovary is an amazing example of an important organ that dies years before its owner. In virtually all lower animals, ovarian activity continues until death. In prehistoric days women probably rarely lived much beyond the menopause. When they did it was important in those primitive and fierce times for the onset of natural contraception (by means of the menopause) to prevent children when it was likely that the parents would die before the children could survive on their own. (This may be the "reason" for the menopause in the evolution of the human species.) Because the menopause happens to every woman it has generally been thought to be normal and not a disease. As long as there was no remedy this was a comforting idea. However, the universality of a bodily change does not necessarily mean that it is desirable for good health. Because we all lose the ability to read smaller print as we grow older we do not say, "Middle-age nearsightedness (presbyopia) is universal; it happens to everyone, therefore I shall not treat it by wearing glasses." Death is universal, yet we struggle against it. Nature did not give us glasses, false teeth, anesthesia, nor the means to fly, yet we do not hesitate to take advantage of the benefits of anything useful that we are ingenious enough to discover.

Similarly, chemical discoveries make it possible to substitute for hormone deficiencies whenever an endocrine gland fails within the body. In some cases the lack of a hormone causes death, as when the insulin-producing cells fail and cause diabetes, or the adrenal glands fail and cause Addison's disease. Specific chemical treatment is essential to maintain life in these cases of glandular failure. However, not all glands are necessary for life. Thyroid failure usually does not shorten life markedly and gonad ( sex gland) failure in either sex is compatible with a long life. But continued existence is not the same as good health.

During the menopause most women develop various symptoms and one study reported the following: 

nervousness, 96.3%; 

hot flashes, 92.1%; 

depression, 61.8%; 

decreased memory, 53.3% ;

fatigability and lassitude, 76.5%; 

disturbed sleep, 61.9%; 

irritability, 64.4%; 

excitability, 76.5%; 

occipitocervical (head and neck) aching, 43.8%; 

numbness and tingling, 27.1%; 

vertigo, 70.9%; 

constipation, 72.2%; 

palpitations, 60.2%; 

weeping, 61.8%; 

cold hands and feet, 39.7%;

and formication (crawling of skin), 23.2%.

However, much more important than these symptoms are subtle metabolic (chemical) changes in the body. Women differ in the extent of these changes but probably every woman eventually suffers from them to significant extent. Some of these metabolic changes are:

1. A loss of protein and calcium from the bones resulting in a thinning and weakening of the bone which is called "osteoporosis." Even if this fails to progress to the point of causing loss of height, "dowager's hump," backache or collapse fracture of the vertebrae it can never be considered a "normal" or "good" change. The 80-year-old woman who suffers a fractured hip in a minor fall can blame it on the fact that her ovaries ceased functioning 30 years before and substitution treatment was never given.

2. A loss of the normal female protection against atherosclerosis (the cause of heart attacks and strokes).

3. A tendency to gain weight and to develop diabetes in those who have the inherited trait.

4. A withdrawal of protein from the skin, thinning it and giving the fine wrinkles usually blamed on aging.

5. An increased irritability and vasomotor instability leading to some of the symptoms listed above, especially hot flushes.

6. The atrophy and drying of mucous membranes. This includes drying of the lining of the nose and throat, eyes and tear ducts, and of the neck of the urinary bladder and vagina. Individuals vary widely as to the degree of symptoms that result but many times the local irritation or itching is a cause of serious discomfort.

7. An increased tendency for the kidneys to waste salt in the urine leading to a decreased volume of blood which may cause weakness and dizziness.

8. An increased incidence of cancer of the breast and uterus.

In five separate studies involving a total of 1,422 women treated with estrogens for up to 25 years, there should have been 96 cases of cancer of the breast or uterus. In fact, only five cases of cancer occurred, instead of the expected 96. It would seem that 91 women who would ordinarily have gotten cancer had been saved from this disease by hormone treatment!

Of the physicians confronted with menopausal patients, some choose to treat only a small portion, and those only for a few months during their most severe symptoms. Many physicians (probably a majority) believe that any of the symptoms justify some treatment for a year or two. Some physicians are more concerned about the late dangers of the metabolic consequences of ovarian insufficiency and believe almost all women should be treated regardless of whether or not they have symptoms. The doctors with this opinion recommend that treatment must be continued for life because the ovarian failure is permanent. Twenty years ago, Dr. Fuller Albright, of Harvard Medical School, one of the world's leading endocrinologists, implied that every woman should receive hormone treatment to prevent the metabolic bone damage resulting from the menopause.

In an article published in June 1962, Dr. Allan Barnes, Professor and Chairman of the Department of Obstetrics and Gynecology of Johns Hopkins School of Medicine, said ". . . therefore, in my practice the menopause is a disease process requiring active intervention. The idea is not new, of course, and has been practised and advocated by many."

There are many similar articles, and the accumulating scientific evidence continues to add support to this position. An increasing number of doctors agree with this viewpoint, but there is not yet sufficient scientific proof to settle the matter and there is a natural reluctance to recommend treatment for such a large, diverse group.

There will be continued uncertainty and honest debate for many years because no one has set up the very expensive, prolonged human experiments necessary to remove all doubt. Additional reasons given by some doctors for not treating most women are the following:

1. Most women do not have severe or persistent symptoms.

2. Many of the problems occurring at this time of life are of psychologic origin and, being unrelated to ovarian failure, they are not specifically helped by hormone treatment.

3. Both physicians and patients tend to be wisely conservative about "tampering with nature" by giving pills to "normal" people.

4. The metabolic dangers of ovarian insufficiency listed above may proceed without symptoms for years-and when they do lead to trouble it can as easily be blamed on "old age."

5. The treatment requires some expense and some medical supervision.

6. It does sometimes lead to difficulties in some individuals.

I believe this is a fair analysis of both sides of the situation but you may have questions which you would like to ask me. Feel free to do so because I want you to understand the background of the treatment so you can make up your mind for yourself. Your understanding will greatly assist in the success of this treatment.

Although 17 practice guidelines on hormone replacement therapy (HRT)  have been developed and several  physician surveys and review articles have been published on the topic, there are few clearcut recommendations on  when to prescribe HRT, which pretreatment investigations to conduct, which regimens to prescribe, how long HRT should be prescribed or what schedule of surveillance should be followed.