Ruth Armstrong: Paring back

I WAS a young GP in the 1990s when the successful marketing of hormone replacement therapy was in its heyday.

Seemingly all of a sudden, therapeutic products I had learned very little about in my training became widely available in various doses and formulations.

The pharmaceutical representatives furnished us with information and offered ongoing support and sample packs. Women with troublesome menopausal symptoms had never been better served.

Then began the indication creep. We were encouraged to consider the likely benefits of long-term therapy in asymptomatic women at risk of osteoporosis and cardiovascular disease, and the possibility that HRT could benefit most women by staving off age-related problems such as cognitive decline and wrinkles — even in those who had been postmenopausal for years.

The sales reps were not alone in these assertions. They were backed by journal articles and expert opinion delivered by local and international speakers at educational events. The messaging was so effective that, by the end of the decade, some estimates indicated that up to two-thirds of women aged 55‒64 years were using HRT, many for “primary prevention”.

Somewhere along the line, in our enthusiasm for improving women’s health, the basic bioethical principle of doing no harm was not given enough consideration. With the subsequent publication of numerous studies showing few benefits of long-term HRT and some harms, dawned the realisation that at least some degree of disease mongering (emphasising benefits, minimising harms and extending indications) had been going on.

The current debate about testosterone use in ageing men is reminiscent of this situation, albeit without such wholesale expert support. Instead of primarily targeting doctors, vested interests have used disease awareness campaigns to inform men about “low T” creating unprecedented demand, especially in countries that allow direct-to-consumer advertising of pharmaceutical products.

A recent editorial in the Journal of the American Geriatric Society, coauthored by Australia’s Professor David Handelsman, which labelled the rise in testosterone prescribing as disease mongering, stimulated one of our news stories this week.

GP Justin Coleman told MJA InSight that the announcement in Australia of more stringent Pharmaceutical Benefits Scheme testosterone prescribing guidelines from 1 April, including a requirement for GPs to consult with a specialist before initiating treatment and a lowered threshold for deficiency, were “a step in the right direction”.

It will be interesting to see if this change results in more appropriate testosterone prescribing by GPs or whether it will just add to the bureaucratic load, while those committed to addressing “andropause” find creative ways to bypass it. If all else fails, there is a thriving online community for well-heeled patients who wish to try their luck.

However, moves to restrict testosterone prescribing indicate that our regulators take the problems of overdiagnosis and overtreatment seriously, in line with the current sustained research and professional effort to pare back medicine and revisit the balance of benefit and harm in much of what we do.

Other contributions along these lines in this week’s MJA InSight include a news story about the problem of false-positive gonorrhoea test results, and a report based on a randomised controlled trial that examined the safety of withdrawing statin therapy from patients with limited life expectancy.

Some reassuring news on the benefits side of the equation comes in the form of a comment from eminent lipidologist Leon Simons, who brings expert perspective to concerns about increased diabetes incidence in patients taking statins.

These considerations go to the heart of what medicine is all about. Reporting on the mixed reaction to the changes to testosterone prescribing restrictions, Australian Doctor quoted one reader as saying, “the increase in prescription rates suggests to me that the hormone has found its market and the consumers are happy. What more can one ask of the helping profession?”

It’s an interesting question and not as rhetorical as the writer believed it to be. History shows that consumer demand and even expert opinion can be distorted and manipulated in ways that do not improve health.

If doctors become slaves to “market demand” who are we helping?

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight