What's A Woman To Do?

No doubt you're confused about hormone-replacement therapy. And, like thousands of women who bombarded their doctors' offices and sent help! messages to Internet bulletin boards last week, you're probably wondering what to do. Sammy Stevens, 60, started Prempro seven years ago to protect herself "for the future" against heart disease, stroke, maybe even Alzheimer's. But now that future seems more muddled than ever, and Stevens has decided to quit the drug. Taking it is like playing Russian roulette, she says. As Stevens ages, she will never know if Prempro did any good--or any harm. "I think there should be clear, definitive answers, but of course there aren't," she says. "I hate these studies."

Millions of American women feel exactly the same way. Despite those very precise statistics ("seven more heart attacks per 10,000 women"), last week's announcement did not suggest any specific alternative treatments. Marcia Stefanick, chair of the Women's Health Initiative's steering committee, says the group may draw up recommendations based on the new data, but it would take at least several months. In the meantime women and their doctors are on their own. Some have decided to accept the risks and stick with hormone treatment. For the many other women who choose to stop HRT, a host of encouraging options--from diet and exercise changes to herbs and medications--are available to treat symptoms and help ward off disease.

The era of one-stop shopping may be over, but a new, tailored approach to treatment could be even better for women's health in the long run. That's because, amid all the hand-wringing and question marks, one clear message emerged: every woman experiences menopause differently--some sail through, while others spiral into a sweaty, moody exhaustion. "We can never look for one golden scientific truth," says gynecologist Christiane Northrup. "One size does not fit all and it never will."

The first step in this new era is figuring out how to go off HRT. Dr. Nananda Col, of Boston's Brigham and Women's Hospital, says slowly tapering down by cutting the daily dose in half for two weeks, then taking it every other day for a couple of weeks, may help ease the transition. Wyeth Pharmaceuticals, maker of Prempro, says weaning offers no added benefit and women can simply stop taking the drug. Some who do may have a resurgence of hot flashes and other symptoms; if so, doctors say, they can go back on and cut down more slowly. We may know more soon: WHI investigators are now watching study participants, who were told to quit cold, to see how they fare.

There are few, if any, long-term conclusive studies on HRT alternatives to combat the acute symptoms of menopause, like hot flashes and night sweats, which seem to be triggered by fluctuating estrogen levels. Researchers say hormone therapy really is the most effective treatment. But some women have noticed improvements after trying other options, some of them quite simple. Cutting back on spicy foods, caffeine and alcohol, and increasing aerobic exercise, the intake of vitamin E and soy (through foods like tofu and soy milk) may reduce hot flashes. Preliminary studies of antidepressants such as Prozac and Paxil suggest that they may turn down the heat as well. Blood-pressure-lowering drugs may have some positive effects, too, but they can cause fatigue and dizziness. And antidepressants may induce sexual dysfunction--a symptom many menopausal women are fighting in the first place.

Women have been using herbs for hot flashes and night sweats for years and some swear by them. The National Institutes of Health is now supporting a trial to test two: black cohosh, a buttercup plant, and red clover, which contains isoflavones, or plant estrogens. So far, researchers have found no side effects, but they will continue to monitor women for changes in the breast, endometrial tissue and bones. There's no data yet on how well the herbs work--if at all. But smaller trials have persuaded some women to try them. One 46-year-old says cohosh got rid of her hot flashes: "I got back to being myself."

Vaginal dryness, another major menopausal complaint caused by loss of estrogen, can make intercourse painful and wreck a woman's libido. Most doctors still recommend localized estrogen, which comes in suppositories, rings and creams, to promote lubrication. Because the hormone is delivered directly to vaginal tissue (rather than through the bloodstream) and the dose is low, doctors believe it's safe. Nonhormonal over-the-counter vaginal lubricants may also help, though they can be messy. There's one very natural way to help ward off dryness: spend extra time in bed. "The more frequently you have sex," says Col, "the better off you are."

It's important to distinguish between the acute symptoms of menopause, which decline over time, and the long-term effects of aging. You can treat both by eliminating nasty habits like smoking and excessive drinking and by taking diet and exercise seriously. "A brisk walk 30 minutes a day is much closer to a magic bullet for health than popping estrogen-progestin pills," says WHI investigator Dr. JoAnn Manson. Exercise helps protect against osteoporosis, heart disease and possibly breast cancer. For bones, weight-bearing activities like walking, running and weight lifting are especially important. A good workout can also zap stress, improve mood and make you sleep better. Stress reducers like meditation may also help, simply by making you feel more calm. Foods rich in calcium--milk, nuts and dark leafy vegetables like spinach--build bone density. And a diet low in saturated fats lowers the risk of cancer and helps reduce cholesterol levels, protecting against heart disease. Quitting smoking is a no-brainer: tobacco thins bones, leads to heart disease, stroke and cancer, and can even trigger an earlier menopause.

Sometimes lifestyle changes alone aren't enough to control high cholesterol and the bone loss that worsens at menopause. That's when nonhormonal medications can help. Cholesterol-lowering drugs, known as statins, can dramatically reduce the risk of heart attack and stroke. Bone-building remedies called biphosphonates improve density, and the drug raloxifene helps prevent fractures. Doctors are awaiting results, still years away, of two large studies to see whether raloxifene protects against heart disease and breast cancer. The drug's downside: it acts through estrogen receptors so it can worsen hot flashes, and, like estrogen, increases the risk of blood clots.

Now that menopause treatment has entered a new phase, women need to discuss their next moves with their doctors and be wary of quacks and miracle cures. Menopause has become an enormous medical market. In an atmosphere of confusion and anxiety, the vulnerable could well be targets. "Every snake-oil salesman is going to be out there advertising beyond belief for every kind of concoction," says Dr. Wulf Utian, head of the North American Menopause Society.

Now might also be the time to take a new look at menopause itself. Susun Weed, an herbalist, says "menopause is a natural event in women's lives that has no more need to be treated than puberty." And, doctors say, it should not necessarily be isolated from the enormity of other issues affecting women at midlife. Many baby boomers work full time, have children at home and care for aging parents. Those responsibilities can add emotional stress to the physical changes and may even exacerbate symptoms. In this context, menopause is not an entity on its own, but part of the complexity of women's lives.

For many women, the most important reason to spotlight menopause is to better understand it. New research should help. In addition to its HRT trial, the WHI is studying vitamin D and calcium and also a low-fat diet in postmenopausal women, data that should be released in 2006. And the National Institute on Aging is observing 3,300 ethnically diverse women through menopause. Their findings should contribute to a deeper appreciation of menopause both generally and individually, and how--if at all--to treat it.

Kay Tamagni, 66, is satisfied with the choice she made. She took part in the WHI study to contribute to women's health. "I did it for future generations," she says. She and the 16,608 other women in the trial may have achieved that goal, not by providing an easy prescription, but by turning up the volume on women's health--and, in turn, prompting their daughters and granddaughters to demand more solid answers as they march forward in their lives.