Dr. Nancy Milliken

Imagine a future in which every doctor who cares for you understands your unique female biology and values your preferences. Imagine a future in which health care providers work in teams and share information with each other -- and you -- via the internet. Imagine a brand new state of the art hospital in San Francisco devoted entirely to providing women a lifetime of reproductive health, where a woman can have a baby in a birthing center, receive the latest in breast cancer care, uterine fibroid treatment or incontinence all in a woman-centered environment.

That future is closer than you think thanks to the vision of lifelong women’s healthcare advocate and expert Dr. Nancy Milliken. Dr. Milliken, who for decades has pioneered efforts to change the medical system from within, helped create the UCSF National Center for Excellence in Women’s Health in 1996. Now a decade later she is a force behind the planned new UCSF Women’s Specialty Hospital at Mission Bay. The Women’s Hospital is part of a new $1.5 billion UCSF medical complex scheduled to break ground in 2011.

As a young undergraduate at Harvard during the 70s, Dr. Milliken was caught up in the counter-cultural changes sweeping through college campuses. Cambridge was ground zero for the women’s self-help health movement, an offshoot of the era’s bold push for women’s rights.

The Boston Women’s Health Collective urged women to take charge of their health in a new way that combined women’s innate wisdom about their bodies with modern medical information. They published the landmark book, “Our Bodies, Ourselves” and as a witness to this achievement, Dr. Milliken discovered her true calling.

A history major near graduation at the time, switching to pre-med meant almost going back to square one. But once Dr. Milliken sets her mind to something, she seems unstoppable. Before too long she was taking premed courses at Stanford before entering Duke Medical School.

The long and distinguished career which followed is one of persistent victories that have furthered the cause of optimal healthcare for women. While she has advanced to the top rungs of her profession, Dr. Milliken has stayed true to her passion and her dream. She lives in San Francisco with her husband and their two teenage sons.

Women are the major health care decision makers in this country. They make 70 to 90 percent of the decisions for their health, their parents’ health, their in-laws’ health and their children’s health. By truly respecting women and giving them information they need to make those decisions, we can have a major positive impact on communities. – Dr. Nancy Milliken

BAWJ:  What is one of the biggest changes you have seen in women’s healthcare?

Dr. Milliken: The biggest change is the recognition that by excluding women from clinical research trials we might be providing ineffective or unsafe care to women.

Women were excluded as subjects because we are more difficult and thus more costly to study, due for example, to daily hormone fluctuations. Historically, the solution was to study only men and then assume the findings applied to women. That reasoning was scientifically flawed. We need to study women to know what works in women.

This began to change in the 1990s; Congresswomen in office at that time really helped bring about change. Another driving force was Bernadine Healy, the first female head of NIH. Studies are no longer funded unless women are represented in numbers large enough to be valid.

Another major change in women’s lives is that we are living longer. Just think, at the beginning of the 20th century the average lifespan for women was 48 years, by the end it was 85. This means women are living a full third of their lives past menopause and we have known very little about health in those added years.

Knowing how women are different from men is essential to understanding prevention strategies, screening and diagnostic testing as well as medical and surgical treatments. This is essential if those added years are going to be long and healthful.

Once we have the new knowledge we must put it into action.  There are two great routes to accomplish this. One is to make sure that the curricula in our health professional schools are up to date so we train our doctors, nurses and pharmacists to be able to take care of the unique needs of both women and men.

Secondly we need to put this new info into the hands of women. This is a most effective strategy because women are extraordinarily thoughtful and savvy consumers of health care.

BAWJ: As we saw with the movement for home births instead of hospital births during the 1970s?

Dr. Milliken:  Exactly. When women were dissatisfied with the delivery of care and lack of options, they voted with their feet. Home births replaced hospital births and hospitals paid attention! As a result there is no hospital now that doesn’t have a birth center. No one should underestimate the power of informed women.

Women are the major health care decision makers in this country. They make 70 to 90 percent of the decisions for their health, their parents’ health, their in-laws’ health and their children’s health. By truly respecting women and giving them information they need to make those decisions, we can have a major positive impact on communities.

BAWJ: What is the latest thinking on Hormone Replacement Therapy?

Dr. Milliken:  There’s been a huge sea change in our understanding of HRT. In fact we don’t call it HRT anymore. We call it HT for hormone therapy to emphasize that it is a therapy with risks and benefits that should be used to treat symptoms. Menopause is not a deficiency state that needs to be corrected.

In the recent past we routinely recommended HT to women without menopausal symptoms as good prevention. Now we know HT (which most commonly is estrogen combined with a progestin) may put an older woman at risk of heart disease, stroke and pulmonary embolus.

The lesson of this story is the importance of good clinical trials to good health care. The earlier hypothesis that estrogen must be good was based on the fact that women don’t get heart attacks as early as men. Heart disease is the number one killer of women, but not until later in life, after menopause.

At first, most but not all, observational studies seemed to confirm the common sense notion that hormones might have a protective effect against heart disease. Unfortunately observational studies can mislead, as they did in these studies, in which women who choose to take hormones were compared with women who hadn’t taken them. Given the new findings, we think there may be something about women who choose to take a pill for prevention that is different from those who don’t. Perhaps those women are more health conscious and do more beneficial things for their health. Perhaps they have better access to health care and more money to pay for medications.

To control for those factors, we needed a good randomized controlled study. We finally got that with the Women’s Health Initiative (a major 15-year research program launched in 1991 to address the most common causes of death, disability and poor quality of life in postmenopausal women -- cardiovascular disease, cancer, and osteoporosis). This study showed that traditional HRT is not helpful for heart disease and can increase the risk of blood clotting and stroke. Plus after a period of time on HRT, risk of breast cancer goes up. I think we can clearly say that hormone therapy for prevention is contraindicated.

However, hormones remain one of the most effective treatments for hot flashes and other menopausal symptoms. Its benefits may out weigh the risks in younger women having symptoms. I would advise these women to use hormones at the lowest dosage and for the shortest period of time as necessary.

The good news is that there are ongoing studies and data analysis. We know more and more each year. The information is so much better than before. So we need to weigh the pros and cons for each woman. It’s not one size fits all.

BAWJ:  What about the current concern about cosmetics?

Dr. Milliken: We are starting a new research and policy program on women’s reproductive health and the environment. There are a number of potential toxins in the environment that we will be looking at and we don’t know what the results are going to be.
It is possible that some cosmetics may be found to be harmful to reproductive health – they have not yet been rigorously tested. The European Union has already restricted over 1,000 chemicals found in personal care products. It is something for women to pay attention to and to go with the safest alternatives.

BAWJ: Are you seeing an increase in women going into medicine?

Dr. Milliken:  The shift has been dramatic since I was in Medical School.  This year’s entering class at UCSF was 59% women; nationally the percentage is now over 50%.    In ob-gyn the gender mix has changed even more significantly over the past 20 years.

It is healthy to have diversity within the healthcare community. Diversity is essential to excellence in research and health care. Our workforce should mirror the people we are treating so we hope to attract students of diverse gender, racial and ethnic backgrounds, LGBT identity and those who are differently-abled.

BAWJ: You have accomplished, and continue to accomplish, tremendous achievements in advancing the state of healthcare for women. How has that dedication and focus affected your personal life? Do you feel you have a work life balance?

Dr. Milliken:  When there is so much to improve, it is an enormous challenge to find the right balance. I feel fortunate to have a community at work where my colleagues are my friends. As professional women with young children and aging parents, we are often juggling the same family/work issues; we support each other in finding solutions and covering for each other when time is needed at home. I have always lived close to the hospital so my husband and sons could visit when I was on call, which was great for them and me. I have a wonderful family and my time with them is a great balance to my time at work. 

I feel incredibly blessed by having found a passion that I continue to care about and a profession that has allowed me to make a difference in people’s lives. I am thankful about that every day.