PERSONAL HEALTH
The Search for Alternatives to Hormone Replacement Therapy
By JANE
E. BRODY
 any
women worried about the latest findings on the possible health risks
of long-term hormone replacement are ready to abandon the therapy or
have decided not to start it. But how? How can a woman stop hormones
without suffering the menopausal symptoms that may have prompted her
to start in the first place? What can a woman do instead to protect
her bones, her heart or any other part of her that estrogen was
supposed to help?
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The Women's Health Initiative findings of increased risks of
heart disease, breast cancer, strokes and gallbladder disease
unleashed all kinds of advice about alternatives to the popular
hormone combination known as Prempro. But many of the alternatives
have undergone far less testing for safety and effectiveness than
the drug they seek to replace.
One critical piece of advice is rarely mentioned: substituting
one hormone product for another is not the answer, since there is
now no way to know whether any hormone product is safer than Prempro.
For those who choose to remain on hormone replacement by mouth or
patch, most experts believe that the safest approach is to use the
lowest possible dose needed to relieve symptoms.
Dr. Roger Lobo, an obstetrician-gynecologist at the
Columbia-Presbyterian Medical Center in New York, suggests using at
most 0.3 milligrams of an estrogen-only product daily and, for women
with a uterus, using progesterone (natural or synthetic) for several
days two or three times a year to reduce the risk of endometrial
cancer.
Getting Off Hormones
For those now using hormones to control menopausal symptoms like
hot flashes, mood swings or sleep disturbances, quitting cold turkey
is not the best way to become hormone-free. Dr. Sally McNagny, a
former investigator for the Women's Health Initiative study of
hormone replacement, suggests gradual weaning over many months.
Start by cutting out one pill during the week, then several weeks
later eliminate another, then another, until you are down to one
pill every other day. Then try cutting the dose in half. Finally,
try eliminating each of those pills one at a time.
If at any point disruptive symptoms reappear, return to the last
eliminated dose. Continue at that level for some months before
trying again to cut back further. For most women, the acute symptoms
of menopause are relatively short-lived, lasting only a year or two,
although some women continue to experience hot flashes of varying
intensity for a decade or more.
Finding Substitutes
HOT FLASHES Testimonials abound as to which
products are safe and likely to do the most good in countering this
common symptom of menopause. But few of these many substances have
been tested in well-designed clinical trials, and virtually none
have been tested for long-term safety. Also, their ability to
relieve hot flashes and night sweats seems to vary greatly from
woman to woman.
Some women swear by one soy product or another. Soy contains weak
plant-based estrogens. But to obtain enough of these estrogens to
counter a severe case of hot flashes or night sweats may require
doses that are as strong, or nearly so, as pharmaceutical estrogen
products and may present comparable risks.
For women concerned about estrogen's effects on the breast,
oncologists caution against using soy extracts like isoflavones
formulated into pills or powders, since these may be no safer than
Premarin or Prempro.
Others have found relief in an herbal remedy called black cohosh.
German researchers who have tested this (using the product Remifemin)
in placebo-controlled trials report that many women will achieve
significant relief after taking the herb twice a day for at least a
month, with an 80 percent reduction in hot flashes after 12 weeks.
As for other herbal remedies, research evidence of their
effectiveness is scarce, and some like kava kava and dong quai can
be hazardous.
Another possibility is a half dose of an antidepressant in the
Prozac family like Effexor or Paxil, which helps about 70 percent of
women, although the long-term effects of these drugs is also
unknown.
Simple changes can help, too. Avoid high necks, and dress in
layers so that outer garments can be shed easily when the internal
temperature rises. Install ceiling fans and use portable fans where
you work and cook. Sleep in a cool room wearing as little as
possible. Avoid foods that aggravate hot flashes, including
caffeinated beverages, chocolate, spicy foods, alcohol and hot foods
and drinks, and add soy-based foods to your daily diet.
VAGINAL DRYNESS Contrary to common belief,
estrogen is not what sustains a woman's libido — testosterone is.
But vaginal atrophy, dryness and itching that often follows the loss
of estrogen can result in painful sexual intercourse, an increase in
vaginal infections and even discomfort during activities like
jogging or biking.
Vaginal applications of estrogen are effective and considered
safe, because little of the hormone is absorbed into the
bloodstream. A popular remedy is vaginal insertion of an estrogen
cream one to three times a week or use of an estrogen-containing
vaginal ring. Vaginally applied estrogen can also counter recurrent
urinary tract infections in postmenopausal women.
Nonhormonal options for temporary relief of vaginal dryness
include gels or creams like Replens, Vagisil, Astroglide and K-Y
jelly.
BONE LOSS The rapid acceleration of bone loss at
menopause is most effectively countered by estrogen. One relatively
new drug, raloxifene (Evista) acts like estrogen on bone but lacks
estrogen's harmful effects on the breast and uterus. In fact, a
large national study still in progress strongly suggests that
raloxifene protects against breast cancer, much like tamoxifen. But
in about 20 percent of users, raloxifene causes hot flashes, which
may diminish with time.
For older women experiencing significant bone loss, tablets of
biphosphonates (Fosamax or Actonel) taken weekly are effective at
staving off and treating osteoporosis. Their main side effect is
esophageal and gastric irritation, which may preclude their use by
women with chronic reflux.
Also crucial is to provide your bones with enough building
materials — calcium and vitamin D — and to create the mechanical
stresses needed to rebuild bone through weight-bearing activities
like walking or jogging or strength-training exercise like lifting
weights.
> HEART HEALTH The very disappointing finding
that hormone replacement failed to prevent heart disease and may
instead cause it has sent women back to the basics to maintain
cardiovascular well-being. Start with a heart-healthy routine — a
diet low in saturated fats and rich in vegetables, fruits, unrefined
(fiber-rich) carbohydrates and adequate calcium. Avoid cigarette
smoking and engage in daily (or nearly so) moderately intense
aerobic exercise like brisk walking, cycling and lap swimming.
If other measures are needed to control cardiac risks, take
medicines daily to normalize blood pressure or blood sugar or lower
high cholesterol, and adopt a balanced diet and exercise program
that can help you achieve and maintain a normal weight.
BRAIN FUNCTION "Use it or lose it" seems to be
as apt a motto for the brain as it is for muscles. Remaining
intellectually and socially involved may not prevent Alzheimer's
disease, but it can help to maintain a sharp mind. Experts on aging
recommend doing crossword puzzles, playing bridge, attending
lectures, reading books and joining discussion groups.
Women seeking more information on hormone alternatives might
consult "The Truth About Hormone Replacement Therapy" by the
National Women's Health Network (Prima Publishing, 2002, $15.95).
Forum: Join a Discussion on Women's Health
Scientists Question Hormone Therapies For Menopause Ills (April
18, 2002)
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Gender Specifics: Why Women Aren't Men (June 21, 1998)
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Company Sends Letter to Retain Hormone Sales (July 11, 2002)
$
Hormone Replacement Study A Shock to the Medical System (July
10, 2002)
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