Before the 20th century, most women didn't live long enough to experience menopause. Today, the average woman may live one-third of her life after the onset. Each year, 1.3 million American women enter menopause, and for many, this phase of life is marred by years of hot flashes, mood swings, and insomnia. It's not just the women who suffer: Spouses and children share the distress. Doctors still have questions about what causes these symptoms and why menopause seems to be linked with greater risks of heart disease and some cancers.
Options for treatment have followed a strange course. Since the mid-1960s, millions of women have used hormone replacement therapy (HRT) to ease symptoms. In the 1990s, several studies suggested that HRT could help prevent heart attacks, osteoporosis, colon cancer, and even Alzheimer's disease. "It was believed to be almost malpractice to not offer women estrogen for menopause," says Dr. Isaac Schiff, chief of gynecology at Massachusetts General Hospital in Boston.
Then in July, 2002, the pendulum swung. Results from the Women's Health Initiative, a large, eight-year study funded by the National Institutes of Health, found that HRT didn't prevent heart disease or breast cancer -- in fact, it raised the risk slightly. Estrogen is still a standard treatment for hot flashes and mood disorders. But now many doctors try to individualize treatment with a variety of formulations in pills, patches, and creams. Some also recommend alternative therapies. Here is what every middle-aged woman and her family need to know about menopause:
When does it begin?
Menopause actually happens in three phases. The first, called perimenopause, can last for two to eight years as the ovaries gradually decrease estrogen production. At this time women may have irregular menstrual periods, hot flashes, night sweats, and some mood swings. Actual menopause begins after a woman's periods have stopped for 12 consecutive months. The average age for that is 51, but some women are affected in their early 40s. The final phase, called postmenopause, refers to the 25 or so years that most women live after their periods stop.
What are the quality-of-life issues and long-term health risks?
Hot flashes are the most common symptom, affecting up to 75% of perimenopausal and recently menopausal women. One-third of them report more than 10 hot flashes a day. Sleep disruption, mood disturbance, and memory problems are other common complaints, along with vaginal dryness, headaches, and heart palpitations. About a third of all menopausal women have either mild or no symptoms, a third have moderate ones, and for another third, they're serious. Some 25% of women continue experiencing them for 10 years or more.
When estrogen levels drop, the rate of bone loss accelerates rapidly. The average woman loses 2% to 3% of bone mass a year for the first three years after menopause. As a result, osteoporosis is much more common in the decades after menopause. A woman's risk of heart disease also increases sharply after menopause, but estrogen's role is still under study.
What are the lessons from the Women's Health Initiative study?
It was conducted mainly to learn if HRT could prevent heart disease. It involved 16,600 women -- average age 63 -- who were taking Prempro, a combination of estrogen and progestin made by Wyeth. Although the study was supposed to have run for eight years, it was halted early, in 2002, because the risk of breast cancer appeared to exceed any benefits of HRT. In fact, in the population studied, HRT carried a small but significant risk of breast cancer, heart attack, stroke, and blood clots. Results from another part of the study showed no benefit from HRT in preventing Alzheimer's or other memory loss, and it did not improve the quality of life in postmenopausal women.
The study did find that HRT helped lessen the risk of hip fractures and colon cancer.
How should we interpret these results?
The study is important because it challenged the practice of prescribing estrogen for all menopausal women -- symptomatic or not. As for risks, especially for osteoporosis, there are effective alternatives. The point to take home: If you are not suffering from serious hot flashes, insomnia, or debilitating mood disorders, you shouldn't consider HRT.
The study was limited to older, postmenopausal women who were given HRT mainly as a preventative and who took it for 10 or more years. But the average age of women seeking HRT in a clinical practice is 45 to 55, says Dr. Wulf H. Utian, a gynecologist at the Cleveland Clinic and head of the North American Menopause Society. Experts suspect that risks are far less for younger women actively going through menopause who use HRT in the short term to help deal with symptoms like hot flashes. The risks of breast cancer and heart disease in the WHI study, for example, didn't become apparent until hormones were used for an average 5.2 years. That risk was not overwhelming -- increasing from 30 cases per 10,000 women to 38 cases.
So HRT is still a valid option?
About 28% of women age 50 to 74 are on it. That's because, despite the WHI findings, nothing seems to works better. The consensus among doctors is that short-term HRT is probably safe for healthy menopausal women who take the lowest effective dose to ease symptoms. The idea, says Utian, is to try to discontinue treatment after two years to see if symptoms have subsided. Ultimately, women should aim to limit HRT use to five years, and women with a history of breast cancer, blood clots, or liver disease should avoid it entirely.
What other drugs can treat menopause symptoms?
Evidence from studies on women with breast cancer found that antidepressants such as Effexor (WYE) and Paxil (GSK) can help reduce hot flashes by 50% or more in a majority of patients. But these come with their own set of side effects -- such as decreased libido and sleep disruption -- and some women have trouble getting off them. Clonidine, a blood pressure medicine, is also sometimes prescribed for hot flashes. Used in patch form, it can reduce symptoms by up to 50%, but at the most effective dose it can also cause dizziness and fatigue.
What about osteoporosis?
Raloxifene (LLY) -- known by its trade name, Evista -- is one of a new class of drugs called selective estrogen receptor modulators (SERMS) that are approved for the prevention of osteoporosis in postmenopausal women. Evista and similar drugs raise the risk of blood clots, so women who are prone to them -- and also need special insurance against osteoporosis -- should consider other nonhormonal drugs such as Fosamax (MRK).
Can certain diets and exercise help?
There's no evidence that they can completely replace drugs for women who experience symptoms. But no one disputes that a healthy lifestyle is important, especially for preventing osteoporosis. To maintain bone density, women over age 50 should get 1,200 milligrams of calcium per day and 400 international units of vitamin D from food, supplements, or both.
Salty foods can deplete calcium, experts warn. Spicy foods, caffeine, and alcohol seem to aggravate hot flashes for some women. Exercise, on the other hand, can relieve them, while improving bone density. What's most effective are so-called weight-bearing exercises -- anything that requires your feet and legs to carry your body weight -- such as walking, jogging, and dancing.
How do natural remedies stack up?
It's a mixed picture. Literally hundreds of products are sold in supermarkets, health food stores, and pharmacies claiming to relieve menopause symptoms. Most contain phytoestrogens, weak forms of estrogen derived from plants, which have some of the same problems as estrogen. None of these products has been shown definitively to reduce hot flashes or build bone, says the American College of Obstetricians and Gynecologists. Soybeans and black cohosh have a better track record. Herbal creams containing progesterone may help with hot flashes, but since they are not regulated by the FDA, it's hard to know what you're getting.
For the future, watch developments with SERMs, which could ease symptoms of menopause and protect bone and heart health without adding to the risk of breast cancer.
By Naomi Freundlich