Hormone users take the chance
After hearing last summer that hormone replacement therapy may do more harm than good, Donna Hayden tossed her supply of estrogen and progestin. That was the easy part.
Within five days, the 56-year-old Costa Mesa woman developed hot flashes. Soon after, she began losing sleep and having trouble concentrating. Six weeks later, Hayden was on her way to the pharmacy to pick up a new supply of pills.
“I felt like a junkie,” she said. “But I had to go back on them.”
Like Hayden, thousands of women across the nation stopped taking hormones based on results from the massive Women’s Health Initiative study. In the first wave of media reports, researchers announced in July that taking estrogen and progestin for several years slightly increases a woman’s risk of heart attack, stroke and breast cancer. This month, investigators reported that post-menopausal women taking hormones had no improvements in cognition, depression, insomnia or sexual function compared to women who did not take hormones.
Now, the subsequent experiences of women who went cold turkey have driven home a key point -- for some individuals, hormone therapy may be worth the risk. An estimated 10% to 20% of menopausal women are tormented by severe symptoms, particularly hot flashes, and alternatives to hormones often prove inadequate. For them, life without hormones can be miserable.
“We hear from women who have these severe, flaming hot flashes who can’t get through the day the way they need to,” said Cynthia Pearson, executive director of the National Women’s Health Network, a consumer advocacy organization in Washington, D.C. “Hormone replacement therapy is the only real alternative.”
The complaints have also uncovered what may be a new medical syndrome, one in which estrogen withdrawal actually causes hot flashes. The possible connection, some physicians say, may shed light on how and why hot flashes occur naturally in menopause. Not only do doctors know little about what causes hot flashes, they don’t understand why some women have them and some don’t, nor why some cases are severe and others mild.
Serious hot flashes can cause drenching night sweats that require women to change clothing and sheets several times during the night, leaving them exhausted the next day. The daytime bursts of body heat embarrass many women and disrupt their work.
While doctors no longer advocate hormone replacement therapy for almost all menopausal women, many say they believe that a few years of hormone use in younger menopausal women with serious symptoms carries little risk. Some advise women to use hormones for severe hot flashes or to return to hormones temporarily and then taper off slowly instead of stopping them abruptly.
“I think women are being overly frightened, almost intimidated, by data that doesn’t quite justify the level of fear,” said Dr. Wulf Utian, executive director of the North American Menopause Society, an organization of menopause specialists. “For the younger, peri-menopausal or early menopausal women, who are most likely to have severe hot flashes, the level of risk is much less.”
The Women’s Health Initiative, a 15-year study headed by the federal government, was designed to explore the major causes of death, disability and frailty in post-menopausal women and how to prevent health problems linked to aging. It found that older women taking estrogen and progestin for five years have a 1-in-100 chance of suffering a serious side effect, such as a heart attack, from hormone use. But 50-year-old women probably have only a 1-in-1,000 chance of having such a side effect after one year of hormone use.
The study, so far, has reported on women who take estrogen and progestin -- the latter to guard against the development of uterine cancer. Another arm of the study, still ongoing, will explore the risks and benefits of taking estrogen alone among women who have had hysterectomies.Based on the current data, study leaders say that women should not take hormones if they don’t have menopausal symptoms, that those who do have symptoms should consider alternatives to hormones and that women who choose to take hormones should take the lowest possible doses for the shortest possible time.
Still, it may not be easy for some women with severe menopausal symptoms to limit hormone use to a year or two. Doctors can’t predict how long hot flashes and other symptoms will persist, says Utian. Nor can they predict the length or likelihood of estrogen-withdrawal hot flashes.
“I’ve seen 70- and 80-year-old women still having hot flashes,” Utian says. “Women go on hormones, and they are extremely effective. And when they stop, a large number have a recurrence of hot flashes. They go on the medication with every good intention of using it short term and it becomes long term.”
Since women stopped taking hormones in droves -- sales of the popular hormone product Prempro are down 50% since last summer, according to its manufacturer, Wyeth Pharmaceuticals -- many have experienced hot flashes, even women who did not have hot flashes before going on hormones. The emergence of hot flashes, especially in older, post-menopausal women, may be a temporary withdrawal from estrogen, says Dr. Gail Greendale, a professor of medicine at the David Geffen School of Medicine at UCLA.
“I think, and many others think, women are getting hot flashes from the abrupt discontinuation of [hormone replacement therapy] rather than the fact that taking them off the hormone is allowing their own hot flashes to [reemerge],” says Greendale. “It has made a new syndrome come to light.”
Still, said Greendale, the lack of research on the phenomenon leaves both doctors and women guessing about what to do.
Paula Golden, a Century City woman in her 50s, said she experienced profound hot flashes after stopping hormones abruptly last summer. However, she was resolved to stay off hormones and instead increased her exercise levels and improved her diet. Whether it was those lifestyle changes or simply time, Golden’s symptoms faded away.
“I sweated buckets of water for a month,” says Golden. “I was so fearful this was going to be my life. But then I decided to get real about exercise and nutrition. It has taken me six months, but I’ve never felt better in my life.”
The withdrawal syndrome suggests that hot flashes may be related to abrupt changes in estrogen levels, Greendale says.
More information on menopausal symptoms, including research on why certain women get hot flashes and how hot flashes are linked to estrogen levels, will be released later this year as part of another major women’s health study, the Study of Women’s Health Across the Nation. The SWAN study, a $17.5-million study led by the federal National Institute on Aging, follows women from pre-menopause through the menopausal transition.
“What the hormone debacle has ended up doing is shining the light on the fact that we need to know a heck of a lot more on menopausal symptoms,” says Greendale, a SWAN investigator. “Having hormone therapy around made the need to develop alternatives very much of a back-burner issue. But now the need and motivation to develop alternatives will be greater.”
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Other treatments for the symptoms of menopause
Many women are exploring alternative therapies for relief of hot flashes and other menopausal symptoms. Little research exists, but doctors say some therapies seem to help more than others.
Black cohosh: This herb is a key ingredient in the over-the-counter menopausal remedy Remifemin. Studies show it may be helpful for six months or less.
Isoflavones: These estrogen-like plant compounds are found in certain nuts, beans and soy and are available in supplement form.
Also, some studies have shown a 40% to 45% reduction of symptoms from soy protein.
Flaxseed oil: A few studies suggest modest relief, but the data is unconvincing overall.
Other herbs: Dong quai, evening primrose, wild yam, valerian root and chasteberry are often used to combat hot flashes, but the actual benefit is unknown because adequate studies have not been done.
SSRI antidepressants: Small studies show that SSRIs can reduce hot flashes in many women. The drugs cause side effects in some patients.
Lifestyle changes: Dressing in layers to cool off quickly or sleeping in a cool room may have a modest effect in lessening the severity of hot flashes.
Diet: Avoiding spicy foods and alcohol may help reduce the number of night sweats.
Exercise: Normal body mass index (neither too thin nor too heavy) was associated with fewer night sweats in one study.
Stopping smoking: Smoking is linked to more severe hot flashes.