The enthusiasm for a hormonal direct-drive model for sexuality is reflected in many studies that imply benefits from estrogen replacement therapy (HRT). In biological models of menopause, sexual functioning should be closely associated with changes in reproductive hormones—estradiol (a form of estrogen), progestin, or androstenedione (a form of testosterone). Most, if not all, of the sanctioned scientific literature on menopause and sexuality mention the possible association between hormones, sexual interest, and sexual function. However, few actually collect empirical data on levels of circulating hormones that may confirm (or disconfirm) the supposition. Several published papers report a favorable association between estrogen replacement therapy and sexual function (Leiblum, 1990; Sarrel, 1990), but few actually present empirical data to confirm (or disconfirm) this hypothesis (Riley, 1991). Other articles promote the indirect value of estrogen replacement on sexual activity, because it can slow the progress of osteoporosis, which may discourage sexual activity (Reyniak,
Belief in the ubiquitous value of estrogen for women, despite inadequate data, is also reflected across cultures. For example, one Finnish author suggested that HRT could preserve brain and cognitive functions (Sour – ander, 1994), and a German author recommended that estrogen be prescribed for all women of menopausal age (Takacs, 1991). Alternatively, a Spanish language magazine, Buenhogar (good housekeeping), noted that if women had more frequent sex with their husbands, their natural estrogen levels would rise, providing benefits in the reduction of heart disease, maintain bone density, and reduce depression (Dennis, 1997).
In contrast to these claims, recent findings not only suggest that estrogen has little effect on sexual arousal or sexual activity (Lindgren, Berg, Hammar, & Zuccon, 1993; Nathorst-Boos, Wiklund, Mattsson, Sandin, & von Schoultz, 1993), but also implicate hormonal replacement therapy in increasing women’s breast cancer risk (Colditz et al., 1995). Yet, despite all the unanswered questions and inadequate data, wholesale endorsements by medical authorities abound in the print media, as illustrated by the following two quotes from The Detroit Free Press: “For every one woman who dies of breast or uterine cancer that might have been associated with the use of estrogen, there are 35 to 50 women dying of complications due to hip fracture or heart disease that could have been prevented with hormone replacement.” Another gynecologist is quoted in the same article querying, “Why would you want to live without a hormone that’s so vitally important to your well-being and to the prevention of disease?… Exercise and a good diet are a drop in the bucket compared to what estrogen does to the body” (Anstett, 1994). In contrast to these testimonial endorsements, research has found that benefits attributed to estrogen replacement, particularly protection against heart disease, instead may be due to the fact that women who take estrogen replacement therapy are initially more healthy than the cohort of women who do not. Women who opt for consistent and extended use of hormone replacement have initially better health than women who do not. Before beginning replacement therapy, users have better cholesterol profiles, triglyceride levels, and body mass index than non-users (Matthews, Kuller, Wing, &. Jansen-McWilliams, 1997). Most of the studies of the benefits of estrogen replacement have been cohort studies of more or less self-selected women, and cohort studies simply cannot substitute for good clinical trials (Matthews et al., 1997).
Conjugated estrogen is the most prescribed drug in America. A two- page color advertisement that we recently spotted in U. S. News and World Report pictured a thin, conventionally attractive woman with long blonde hair blowing in the wind as she walks along the beach with her two huge golden retrievers. She’s looking toward the camera and smiling. The lengthy text begins, “For more than 50 years, health care providers have prescribed Premarin. In fact, today more than 8,000,000 American women take Premarin.” Does this imply it is safe? The last sentence reads, “Premarin, earning your confidence generation after generation.” Then, on the reverse side of the ad, in minuscule print, is a daunting full-page list of dangers of estrogen, side effects, and risks. If one reads the fine print, it is less than confidence-inspiring.
In contrast to the emphasis on estrogen, the most consistent empirical data suggest that forms of androgen are more likely to underlie sexual interest or activity than estrogen (Bachmann & Leiblum, 1991; Sherwin & Gelfand, 1987). One may even surmise that a decline in estrogen in relation to testosterone may lead to increased sexual interest. However, some studies have suggested that the effects of androgens are related to sexual motivation rather than to sexual activity (Sherwin, Gelfand, & Brender, 1985), and other studies have reported no association at all (Bach – mann, Leiblum, Kemmann, Colburn, Swartzman, & Shelden, 1984). One study by James Frock and John Money (1992) recruited 20 postmenopausal women and elicited responses to a short questionnaire but collected no physiological measures at all. The study nevertheless concluded, with egregious errors of logic, that androgen maintains sexual functioning and can be administered with good therapeutic effect. A more thorough review of the literature indicates that androgen may affect sexual functioning for surgically menopausal women, but perhaps does not affect naturally menopausal women (Walling, Andersen, & Johnson, 1990).
In conclusion, examining sanctioned and lay literature on mid-life sexuality leads us to again wonder what larger stakes are involved in continuing to define menopause as a deficiency disease to which estrogen provides the obligatory and necessary answer. Writing on the 1970-1980 estrogen debates between the pharmaceutical industry, the scientific community, the government, the media, and the medical profession, Patricia Kaufert and Sonja McKinlay (1985) delineated “how the production of medical knowledge is determined by ideological and sociopolitical factors among which women’s own needs and interests have low priority (p. 113).” Certainly, there are economic incentives for having the majority of “meno – boomers” on hormone replacement therapy for years of their lives. Although we acknowledge that there are women for whom hormone therapy is appropriate and beneficial, as of this time there is an inadequate scientific basis for unequivocal blanket endorsements.
So far, we have noted how popular and scientific literature negatively portray menopause and aging. We now take a closer look at the medical model of menopause. First, we present a broad survey of the field of published literature to acquaint the reader with the lay of the land. Then we present examples of the methodological and conceptual problems that infest it.