A Win, Win for Women?

To some of us, it's the M word. If you're between 40 and 55, you know exactly what we mean. While many women sail through menopause without much trouble, others are felled by hot flashes, sleep problems and mood swings. But relief could be on the way for at least some of those women. As researchers distill the latest round of studies on the risk and benefits of hormone therapy, they are feeling more confident that it can help generally healthy women who begin taking it around the time their periods end. "There is more enthusiasm for estrogen as the most effective treatment for most menopausal symptoms," says Dr. Nanette Santoro, director of the division of reproductive endocrinology at the Albert Einstein School of Medicine in New York. But that doesn't mean estrogen is the answer for everyone. "The concept that women who are post-menopausal are a one-size-fits-all crowd is going to disappear soon," Santoro says.
 
First, a little history. Throughout the 1980s and 1990s, doctors routinely prescribed estrogen to millions of midlife women to ease symptoms and also to prevent heart disease even if they had no symptoms. Doctors were reassured by long-term observational studies that showed women who took estrogen after menopause were less likely to have heart disease.
 
But in 2002, a massive federal study called the Women's Health Initiative (WHI) was halted early because researchers reported that taking estrogen actually increased the risk of breast cancer and stroke. The WHI was a more scientifically reliable clinical study (with a control group) and it contradicted the results of earlier observational studies, which simply followed women over the years. Within weeks of the report, estrogen sales plummeted. But since then, the WHI results have been criticized by some researchers who think that the average age of women in the study (63) was so far beyond the average age of menopause in this country (51) that the results really were not applicable to younger women who need symptom relief for a relatively short period.
 
After the WHI information scared women away from conventional hormone therapy, some turned to so-called "bio-identical" hormones, which are individually prepared in compounding pharmacies. Although these are touted as natural, they have not been proven to be any safer or more effective than estrogen produced by major drug companies. Women also tried other alternative therapies, including soy or taking herbs like black cohosh, neither of which has been proven to be significantly more effective than a placebo.
 
Now, new research indicates that starting estrogen close to the time of menopause may minimize the risks highlighted in the WHI and increase the benefits. For most women who are troubled by symptoms, this is the period when hot flashes are most acute. These newer studies, along with ongoing analyses of the WHI results, have prompted the North American Menopause Society (NAMS) to revise its recommendations. In a position paper issued this summer, NAMS, whose members are clinicians and researchers, concluded that there is increasing evidence to suggest that estrogen is a reasonable choice for younger post-menopausal women with severe symptoms.
 
The position paper, which has been endorsed by other major medical groups including the American Medical Women's Association and the Endocrine Society, also points out that there is growing reason to believe that estrogen, when initiated around the time of menopause, may protect against heart disease. 
 
 "Things were so adverse a few years ago that symptomatic women would not entertain the possibility of taking hormones at all, no matter how miserable they were from their symptoms," says Santoro. "That was just not right." Now, says Santoro, "Women can often do the math for themselves when this is discussed and then balance against the benefit that symptom relief provides."
 
In a study published this week in the online version of the British Medical Journal, Australian researchers found that taking estrogen improved sleep, joint pain and sexuality (generally because of increased libido and less vaginal dryness) for older women. The study involved 3,721 post-menopausal women in the United Kingdom, Australia and New Zealand. On average, they were 13 years past menopause--although researchers say the study alone does not justify starting hormone therapy in women long past menopause who do not have symptoms.
 
Most importantly, this is not a one-time decision. The risks and benefits change as you get older and it is critical to regularly re-evaluate with your doctor whether taking estrogen is still the best choice. Some doctors think that women should not be taking estrogen for more than five years, but others see potential long-term benefits. Professor Alastair MacLennan of the University of Adelaide in Australia, the lead researcher on the BMJ study, thinks a woman can stay on estrogen "for as long as she feels she needs it for quality of life and she feels the advantages to her outweigh the informed risks that have been individualized for her and her regimen."
 
If you're entering the menopausal transition and are thinking about taking estrogen, here are five questions to consider:
 
1.      Are your symptoms so bad that non-pharmaceutical solutions won't help? Triggers, like too much caffeine or stress can often set off hot flashes. Keep a diary to identify your triggers and then eliminate them. Women who exercise regularly also report fewer hot flashes, so try walking briskly at least half an hour a day. Losing weight may also help since heavier women have more hot flashes than slender women. Smokers are more likely to have problems as well, so this is another reason to quit.
 
2.      What is your personal health history? Estrogen can be a problem if your mother or sister was diagnosed with breast cancer before menopause (the risk increases after three years of taking estrogen) or if you have a family or personal history of heart disease or blood clots. However, if none of these are in your background and you are just reaching menopause, then your risk may be acceptable if you take estrogen for just a few years. If you are vulnerable to osteoporosis, estrogen could be an effective therapy for this disorder, which is characterized by increasingly fragile bones. Since the WHI, drug companies have been making estrogen available in much lower doses than the dose examined in that study. Lower doses are presumed to carry less risk, although no one knows for sure.
 
3.      Do you still have your uterus? There's good evidence that giving estrogen to women who've had a hysterectomy (with their ovaries also removed) may protect against heart disease and osteoporosis, especially if the hysterectomy occurred many years before the natural age of menopause. In such a case, the estrogen is essentially replacing the hormone that would have been produced by their ovaries. Women who still have their uteruses must also take progesterone to prevent potentially risky thickening of the uterine lining caused by estrogen. Some researchers suspect that the progesterone might be the culprit in increasing the risk of breast cancer, but that has not been proven.
 
4.      How close are you to menopause? One of the controversial aspects of the WHI study is the average age of the participants: 63. Many researchers say that makes it an unreliable indicator of the effects of estrogen on a woman who starts taking it many years earlier when symptoms are most severe.
 
5.      Is your doctor a menopause specialist?  The constant influx of new data over past few years has demonstrated the importance of keeping up on the latest research. A growing number of gynecologists are specializing in health issues of midlife women. You might consider going to one if there are aspects of your health history that could complicate your suitability for taking estrogen. A good place to start looking is an academic medical center. The NAMS web site++www.menopause.org++<http://www.menopause.org/> contains a list of physicians who specialize in menopause, as well as other useful information.
 
Although the NAMS position statement draws on the latest thinking, some of the current recommendations are certain to change as research continues. There are still many unanswered questions. No one really knows how long an individual woman can safely continue taking estrogen. However, many women find that a year is enough to get through the worst of their symptoms.
 
There is at least a 50 percent chance that symptoms will recur when estrogen is stopped. For that reason, some doctors recommend tapering off gradually, although there is no evidence this works any better than going cold turkey. Santoro says women taking estrogen should regularly reevaluate that decision with their doctors.

The bottom line on the M word? The more information you have, the easier it will be to make the right choice.

Barbara Kantrowitz and Pat Wingert are the authors of "Is it Hot in Here?  Or is it Me? The Complete Guide to Menopause." (Workman Publishing, 2006)