Menopause: Easing The Transition

Drug therapies and food supplements can help relieve the symptoms

Menopause is coming out of the shadows, and with good reason. An unprecedented number of female baby boomers will be undergoing this inevitable physical change. Given today's longer lifespans, many will be post-menopausal for a third of their lives.

But menopause remains little studied, and myths and magic potions still abound. While national studies are under way to better understand menopause, "it's still something of a moving target," says Pam Boggs, a spokeswoman for the North American Menopause Society. Nowhere is debate more intense than on the correct use of estrogen in treatments.

REPLACING HORMONES. Menopause is defined as the cessation of menstruation for at least 12 months, which occurs on average at age 51. Perimenopause, the time surrounding this event, can last anywhere from 2 to 10 years, ending about a year after a woman's last period. In perimenopause, ovaries begin shutting down, causing a drop in estrogen hormones and resulting in such symptoms as irregular periods, hot flashes, night sweats, and vaginal dryness. While these symptoms may seem more annoying than harmful, the estrogen decline also can lead to osteoporosis, cardiovascular disease, and perhaps Alzheimer's.

The standard treatment of the symptoms of menopause is the hormone estrogen. Perimenopausal women can start with birth control pills in their 40s. Then, at menopause, they switch to hormone replacement therapy, which involves lower doses of estrogen and progesterone.

Both treatments involve a varying mix of hormones. During perimenopause, progesterone in birth control pills mainly functions to prevent pregnancy, while estrogen can help even out perimenopausal symptoms. The main component of hormone replacement therapy after menopause is estrogen; progesterone is thrown in only to reduce the risk of uterine cancer. That's because estrogen alone increases the risk of uterine cancer. As a result, it is only recommended for women who have had hysterectomies. If a woman suffers from severe loss of energy or libido, a third hormone--testosterone, which is produced by the ovaries in small amounts--can be added to the brew.

While contraceptives and hormone replacement therapy are known to ease the mood swings, insomnia, and memory loss associated with menopause, there's growing evidence that estrogen may also have long-term effects on neurotransmitters and memory centers in the brain. Doctors at Yale University have found that estrogen can even interfere with the formation of Alzheimer's disease plaque in animals' brains. Estrogen also prevents the debilitating fractures and bone loss that accompany osteoporosis, and it appears to reduce the bad cholesterol that causes heart disease.

But many women shy away from hormone therapy because they're concerned that estrogen causes breast cancer. But this link hasn't been proven. "Most data don't support the estrogen connection," says Dr. Trudy Bush, professor of epidemiology and preventive medicine at the University of Maryland College of Medicine in Baltimore. "Most physicians who treat women of this age believe the benefits of hormone therapy outweigh the risks." For example, many more women over 50 die of heart disease than of breast cancer. Women in general have a 23% chance of dying from heart disease, vs. a 4% chance of dying from breast cancer, according to NAMS. And since early detection has proven successful in beating breast cancer, one strategy is to combine hormone therapy with frequent breast exams.

SOY OPTIONS. Nevertheless, if you and your doctor deem estrogen to be unsafe because of your individual risk of breast cancer, a promising alternative is phytoestrogens, which are found in soy foods and flaxseed oil. These weak, estrogen-like substances appear to confer similar benefits, but it's still unclear how much you need to eat to get them. One 8-ounce glass of soy milk a day appears to ease symptoms such as hot flashes and may even help protect heart and bones. So do products such as tempeh and tofu. New drugs, such as Evista, are designed to prevent bone loss and help lower cholesterol without affecting breast tissues.

Alternative treatments derived from plants such as red clover, marketed as Promensil, black cohosh (Remifemin), and the Chinese plant Dong Quai call for a dose of skepticism. Manufacturers claim they alleviate perimenopausal symptoms more naturally, but evidence for their benefits is scant. "Just because something's natural doesn't mean it's safe or effective," says Dr. Donna Stewart, chair of women's health at the University of Toronto, who has reviewed much of the scientific literature on alternatives. She says that only the use of phytoestrogens, or soy, is backed by scientific evidence. Moreover, other herbs and concoctions may vary wildly in strength, or could be contaminated with foreign substances.

Whatever drug or food supplement you decide on, experts stress that the experience of menopause varies tremendously and that treatment should be based on the wishes, health, and family history of each woman. Tests may help determine if you are in perimenopause. Levels of follicle-stimulating hormone rise as the ovaries stop performing, but since the ovaries' output fluctuates for years, this isn't always a reliable indicator of perimenopause. A signpost of how you may fare in menopause is how prone you are to premenstrual syndrome (PMS). "Studies show that women who suffered the most with PMS will have the most trouble with perimenopause and menopause," says Dr. Christiane Northrup at University of Vermont College of Medicine and author of Women's Bodies, Women's Wisdom (Bantam Doubleday Dell, $17.95) If you fall in this category, you might want to start taking birth control pills early.

In the meantime, there are some tried-and-true measures that women can use to protect themselves against the temporary and long-term effects of menopause. Exercise and diet can protect the heart and bones as well as help to relieve symptoms. Avoiding caffeine and alcohol can ward off hot flashes. Women should receive bone density scans and start taking 1,500 mg of calcium daily in their late 30s.

And new treatments are in the pipeline. Researchers at Massachusetts General Hospital have succeeded in preventing menopause in mice. "We've collected eggs from mice at ages comparable to 100-year-old women," says Jonathan Tilly, an instructor at Harvard Medical School. While such a breakthrough for humans is still far away, the choices of remedies and treatments for women reaching the age of menopause are growing.