Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, December 21, 1993 TAG: 9312210108
SECTION: EXTRA PAGE: 3 EDITION: METRO
SOURCE: jane brody
DATELINE: LENGTH: Long
The average age at menopause for American women is now 51, and those who reach this age will live on average 30 more years, or 10 years longer than women of the same age lived at the turn of the century.
Thus, unless she receives hormone replacement therapy, the typical American woman spends more than a third of her life without the considerable benefits of estrogen to her heart, bones, skin and other tissues. Yet only about one menopausal woman in seven chooses to take replacement hormones. Critics often cite these objections to this therapy:
Some women consider it unnatural to tamper with the body's chemistry. But as Dr. Rogerio Lobo, an expert in the field, pointed out, "Neither is it natural from an evolutionary standpoint for a woman to live to 80." Lobo, of the University of Southern California School of Medicine, was co-chairman of an international conference on hormone replacement held last week in Bethesda, Md.
Hormone replacement often sets off cyclical or irregular bleeding, which postmenopausal women often find distressing and occasionally frightening.
Many women fear that hormone therapy will increase their risk of developing breast or uterine cancer or will promote the growth of a pre-existing cancer.
And when progestin is given to prevent cancerous changes in the uterus, some women react adversely to this synthetic hormone, with side effects like bloating, depression and irritability that prompt them to abandon hormone treatment.
When hormone replacement first became popular three decades ago, women were given rather large doses of estrogen every day, an approach later found to result in a ninefold increase in the risk of uterine cancer.
To protect the uterus against cancer, the regimen was changed in the last decade to lower doses of estrogen for 25 days a month, progestin for the last 10 of those 25 days and nothing for 5 days. This approach, known as cyclical hormone therapy, usually results in a continuation of menstrual-type bleeding for years beyond menopause.
Bleeding is the main reason women who begin replacement therapy often drop it after they have passed through menopause and no longer have disturbing menopausal symptoms. Many women have been reluctant to continue taking the replacement hormones for seven or more years to achieve the known benefits to the heart and bones.
Now there is a veritable cafeteria of choices: different dosages, different hormone combinations and different methods of administering them, so replacement therapy can be better tailored to individual needs.
As Dr. Leon Speroff, of the Oregon Health Sciences University in Portland, the other chairman of last week's conference, put it, "If a woman has an undesirable response to one approach, there is often a choice that could improve the therapy." He advises women not to abandon hormone therapy with the first problem but seek an alternative regimen.
For example, women who experience bad reactions while on larger cyclical doses of Provera, the most commonly prescribed progestin, might switch to its continuous use in a lower dose of 2.5 milligrams daily or substitute 0.35 milligrams of norethindrone, the mini birth control pill.
Women who, despite hormone therapy, experience an undesirable decline in their sex drive at menopause can have their libido enhanced by the addition of small doses of an androgen, like testosterone, which is naturally produced by premenopausal ovaries.
For those who are uncomfortable taken a pill each day or who respond poorly to Premarin, the leading menopausal estrogen product, another estrogen drug, Estinyl (ethinyl estradiol) could be substituted in the form of a skin patch on the lower abdomen and replaced twice a week, to provide a steady dose of estrogen.
But Speroff and Lobo, who are both reproductive endocrinologists, pointed out that all the needed facts about the various options were not yet available. None of the regimens, including the now-standard cyclical therapy, have yet been tested adequately for long-term benefits to the heart, blood vessels and bones and for long-term complications.
It is still uncertain whether adding progestin to the regimen to protect the uterus will also protect the breast against cancer or perhaps blunt the benefits of estrogen to the heart or is whether the estrogen patch will confer the cardiovascular benefits of a 50 percent reduction in coronary mortality associated with oral estrogens.
As for breast cancer, studies have had conflicting results, with some showing no increased risk associated with hormone replacement and others showing a small rise of about 35 percent in the risk.
Speroff of the Oregon Health Sciences University in Portland, among others, noted that heart disease is a far more common killer of postmenopausal women than is breast cancer, and hormone replacement appears to cut the risk of a fatal heart attack in half. So even if the hormone therapy slightly increases the risk of breast cancer, there would still be a substantial overall benefit.
In weighing the various options, a woman and her doctor should consider her personal and family medical history. If heart disease or osteoporosis is common in a woman's family or if she herself has a high risk of either, hormone replacement might be more strongly recommended than for a woman without such risks.
On the other hand, for a woman with a family or personal history of breast cancer, doctors are reluctant to prescribe estrogen and may instead emphasize the importance of healthful living habits like a low-fat diet and regular exercise.
Speroff said a treatment alternative for such women might be tamoxifen, a estrogen-like drug that has favorable effects on cholesterol levels and prevents bone loss at the same time that it protects the breasts against cancer.
But tamoxifen does increase the risk of uterine cancer, and women taking it would be wise to undergo periodic examinations to check for uterine changes that could herald this cancer, which is highly curable when detected early.
Properly designed studies are now under way to answer the various questions about the long-term risks and benefits of hormone replacement, but results will not be available for about 10 years, by which time another 20 million women of the baby-boom generation will have entered menopause and grappled with a decision about whether and how to treat it.
The best approach, experts agree, is for the woman and her doctor to review her risk factors, concerns and therapeutic options and together come to an informed decision.
A comprehensive and up-to-date reference for those seeking detailed information on menopause and hormone replacement therapy is the newly revised edition of "Menopause: A Guide for Women and Those Who Love Them" by Dr. Winnifred Cutler and Celso-Ramon Garcia (in paperback by W.W. Norton, $12.95).
Another helpful book is "Estrogen Replacement Therapy: the Johns Hopkins Guide to Making an Informed Decision," by Dr. Howard Zacur and Dr. Roger Blumenthal (Johns Hopkins University Press, 1993).
To order the book, a check payable to Johns Hopkins University for $4.95, which includes postage and handling, should be sent to Johns Hopkins University Women's Health Center, 550 North Broadway, Suite 1100, Baltimore, Md., 21205.
by CNB