While many women sail through menopause with mild symptoms or none at all, others find themselves trying to muddle through, sinking into a depression or suffering sleepless nights from never-ending hot flashes.Yet they’re too scared to consider hormone therapy — even though, experts agree, it’s still the most effective treatment.
Dr. Isaac Schiff, chair of gynecology at Massachusetts General Hospital, says he frequently sees patients with major menopause life disruptions refusing to consider hormone therapy. “The WHI results were almost like shock and awe, very frightening,” he says. “After peeling back the data, though, we see that those who start hormones relatively early after menopause don?t have an increased risk for heart disease and if they take hormones for a short time, probably don?t have an increased risk for breast cancer.”
No question, though, that potential breast cancer risk sounds scary: the WHI trial found that those who take hormones for at least five years have a 33 percent increased risk of breast cancer compared with those who don’t. and some recent evaluations of the WHI data indicate those hormone-induced breast cancers may be more life threatening.
But Schiff prefers to give his patients absolute risk numbers. “I tell my patients if you have 1,200 women ages 55 to 60, you would expect three of them to develop breast cancer every year. if you took those women and put them all on hormones for at least five years, four out of 1,200 will develop breast cancer” every year.
Another way of looking at it is via lifestyle choices that influence breast cancer risk. Women who are overweight probably have the same increased breast cancer risk as those who take hormone therapy; so too, those who consume more than one alcoholic drink per day. Those who exercise vigorously every day, on the other hand, have about a 30 percent lower risk.
Given all that, however, women are correct in being wary of hormones and should only take them if they really need them, Schiff says. Some women, for example, become extremely irritable or depressed when their periods become erratic during perimenopause, possibly due to rapidly fluctuating hormone levels. When this occurs, Schiff usually prescribes hormone therapy, not antidepressants, because it’s more effective at lifting moods.
There’s also a growing recognition that hot flashes can last a lifetime for a small percentage of women. “We used to think that hot flashes lasted a few years on average and that taking hormone therapy simply delayed them,” says Schiff. “Now we know that in some women, they may never go away.”
In this case, the hormone decision becomes more difficult. the WHI data suggest breast cancer risks accumulate with duration of use and that it’s best not to take hormones for more than five years. On the other hand, those added risks are still very small and may be acceptable for women having, say, 30 hot flashes a day.
While Schiff says he has some patients in their 70s and 80s who are still taking hormones, he won’t prescribe them to, say, women with hot flashes who are years past menopause and have never before taken hormone therapy. the WHI data indicates that women who initiate hormone therapy later in life have higher health risks than those who start at the time of menopause.
For these women, as well as those at increased risk of breast cancer due to a family history, Schiff recommends alternatives like soy — which contains compounds that mimic the effects of estrogen — in the form of soybeans, tofu or supplements. he also recommends the herbal remedy black cohosh, which some women swear provides hot flash relief even though studies haven’t found this to be the case.
“Neither is terribly effective,” he admits. Some prescription drugs like the antidepressant Paxil and the pain reliever/anti-seizure drug Neurontin also appear to help alleviate hot flashes, though neither is approved by the US Food and Drug Administration for that purpose and both have side effects.
Acupuncture, too, may be an effective menopause remedy, according to a study published last week comparing acupuncture with sham treatments in 53 postmenopausal women. Those who had the 20-minute real treatments twice a week for 10 weeks experienced more relief from their hot flashes and mood swings compared with women who had “fake” treatments where the needles didn’t puncture their skin.
Arya Nielsen, an acupuncturist who’s been treating menopausal patients for 30 years at Beth Israel Medical Center in new York, tells me the treatment really works — at least in some women. “What the study showed was this ancient therapy continues to prove itself relevant today,” she says, “an important drug free option that is safe.”