Menopause-Related Problems, One Therapy No Longer Fits All
by Dr. Gary Farr on 20 July 2003
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Menopause: one condition, with at least 32 million ways to experience it. That's how many women in the United States are between the ages of 45 and 64–the years when, for most women, menopause becomes keenly felt. In every one of these people, the nagging issues associated with menopause vary.
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Does her hot flash shoot up her arms or cause a mild flush? Do night sweats keep her awake? Does she forget her ATM password? What are her odds of developing heart disease? Unfortunately, despite this wide spectrum of symptoms and risks, the traditional reaction has often been to reach for a one-size-fits-all therapy–a prescription for Prempro, a standard, two-hormone pill. "Maybe we've been a little 'hormone positive,' " concedes Kenneth Muhlendorf, a gynecologist in Norfolk, Va.
Today, the medical community is changing its thinking in light of a large study, the Women's Health Initiative (WHI). It showed long-term hormone replacement therapy (HRT) can foster more problems–a small risk of heart attacks, stroke, and breast cancer–than it does solutions–a slight decrease in bone fractures and in colon cancer. Now, "rather than automatically start on HRT, we are individualizing the care more," says Muhlendorf, noting that a quarter of his patients who were on standard hormone therapy stopped when they heard the bad news. "There are lots of ways for women to maintain their health. The study brought the options to the forefront."
Mix and match. One 62-year-old patient seeing Georgia gynecologist Don Robinson had been taking oral estrogen for vaginal dryness but was frightened off when she heard about the potential breast cancer risk. So now she's using Vagifem, a suppository that supplies estrogen locally rather than to the whole body. Robinson also finds he's prescribing more medicines specifically for the prevention of bone loss. Instead of running to the cabinet for the usual hormone pills, he says, "we need to specifically analyze each patient and come up with the best package for her."
There's actually a rainbow of tweaked and modified therapies, with or without hormones, to fit each woman based on her personal and family medical history, health goals, and lifestyle as she passes through and beyond menopause. "The message should be hopeful," says Karen Matthews, director of the Cardiovascular Behavioral Medicine Research Training Program at the University of Pittsburgh. "We still have lots of good things that can be done."
And the universe of treatment options is expanding. There are tiny hormone dosages that can provide similar benefits to HRT but with fewer risks. Different ways to take hormones, such as skin patches or inserted vaginal tablets, may cut down on side effects. Researchers are testing new hormone sequences and combinations, shorter courses of treatment, and drugs to help build bone in women with osteoporosis. To deal with hot flashes, women are trying out herbal options such as black cohosh and plant chemicals called phytoestrogens, like those in soy.
Women should always remember, however, that some of the "alternatives are often less well tested," says Nanette Santoro, director of the Division of Reproductive Endocrinology and Infertility at the Albert Einstein College of Medicine.
Plus, not all women should go cold turkey off hormones–many with excruciating hot flashes often find estrogen is the only thing that brings relief, Santoro says. A one- or two-year course of hormones to deal with temporary symptoms is reasonable. "There is no evidence that you must stay on something for the rest of your life," says Nancy Avis, associate director of research at the Women's Health Center of Excellence at Wake Forest University. Women should touch base with their doctors as their symptoms change and subside, she says.
Lifestyle changes. Expect to hear a lot more from those doctors about the tried-and-true tips for healthy living–lowering cholesterol, exercising, maintaining a proper weight, not smoking, and controlling stress. These approaches may be low-tech, but they can stave off menopause-related complications such as cardiovascular disease, osteoporosis, and depression. "These are well-worked-out techniques, but people have to be motivated," says Matthews. "It takes a lot of change, but they do work. The real trick is to make them last."
The best results, and better health, will emerge for women who do some homework: thinking about why they are or are not taking hormones, making a list of questions about alternative options, and reviewing their decisions with their doctors. "Because we understand little about symptoms attached to menopause, it's not always clear what the treatment should be," says Santoro, who worked on the WHI. "Don't be shy if the treatment isn't working." Just keep talking and consulting, because finding the right solution will be, like menopause itself, an ongoing affair.
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