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Hormone dilemma: still a hot topic

Five years ago, a landmark study dashed the belief that hormone treatment is the key to keeping women of a certain age sexy, healthy and young.

On the contrary, maintaining estrogen and progestin at abnormally high levels after menopause was shown to be risky for their hearts, brains, breasts and blood vessels.

The government study abruptly transformed the use of hormone therapy - and, in the ensuing years, has undermined the idea that women who don't get long-term treatment are doomed to decrepitude.

The notion that menopause is something to be permanently fixed has held sway for decades, rooted in the fact that estrogen acts on tissues throughout the female body and fertilized by such scientific fancy as "Feminine Forever." In that 1966 best-seller, physician Robert Wilson claimed the "staggering catastrophe" of menopause could be "cured" by replacing the estrogen that ebbs with age.

Ironically, it took rigorous research with wretchedly disappointing results to foster the idea that the "change of life" is a transition, not a tragedy.

"I view menopause not so much as a disease process, but more like puberty," said Stacy McCrosson, an obstetrician-gynecologist. "It's stressful for some, exciting for some."

The landmark research remains bitterly controversial, its findings incredibly complex. In recent months, re-analyses of the data have found that while hormones raise heart risks for women long past menopause, they pose no such danger - and may have cardiac benefits - for recently menopausal women.

Critics of the study - known as the Women's Health Initiative - have argued for five years that it overstated the heart risks for younger women.

While the science is still evolving, hormones have been firmly reestablished in a limited role: to relieve the passing discomforts of dwindling estrogen.

"More than a century after it was conceived," Harvard Women's Health Watch wrote just a year after the study came out, "hormone therapy appears to be back where it started."

Indeed, use has plummeted. The number of prescriptions dropped from nearly 100 million in 2002 to less than half as many last year, according to IMS Health, a health-care information company in Plymouth Meeting.

Many women are leery of using hormones even to ride out temporary discomfort, although, anecdotally, nothing else is as effective.

Ida Kern is such a woman.

She had her first hot flash - actually, more like a warm flash - four years ago, at age 42, earlier than most American women start to sweat the transition to period-free lives.

Kern was aware at the time that a big hormone study had just come out.

"I was like, `Whoa!'" she said. "Because 10 years earlier, they were saying hormones will protect your heart and memory and keep you young."

Her hot flashes - and sleep disturbances and low libido - have since become bothersome, but she's still refusing therapy.

Her attitude toward menopause: If it's not really broken, don't fix it. Especially if something else might break. That fits well with the new medical bottom line: Take hormones - as little as possible, as briefly as possible - only when you're really miserable.

"If the hot flashes get much worse, I may reconsider my stance," Kern said. "But I'm a cancerphobe."

Some physicians worry that women have been unnecessarily scared away from hormones by the initial overstatement of certain risks, and by sensational news coverage.

"Even if I go over everything objectively with them, as miserable as they are, many won't try anything," said Sherry Blumenthal, an ob-gyn.

Stoicism may be easier for some women than feeling reassured about drugs that, even now, have unanswered questions. The federal study, which followed more than 27,600 women, found that the risk-benefit trade-offs depended, among other factors, on the type of therapy (estrogen-progestin is standard, but women who have had hysterectomies take just estrogen), duration of use, and age.

For example:

Estrogen alone didn't increase breast-cancer risk, while estrogen-progestin did - beginning at about four years of therapy, with cumulative effects.

Stroke risk increased for older postmenopausal women - probably not for those closer to menopause.

Heart-attack risk increased in the first year of estrogen-progestin use for older women but not for younger ones. And estrogen alone reduced hardening of the arteries for women in their 50s.

All women, regardless of age, faced a tiny increase in the chance of life-threatening blood clots - in the first one to two years of therapy.

The research found that hormones did provide benefits to the bones and colon, but only with long-term use - which then raised risks.

"I call it `the study that ruined everything for women,'" said Blumenthal.

Her medical field was particularly rattled. Before the study, the American College of Obstetricians and Gynecologists fervently advocated hormone "replacement" therapy. Even now, the academy's literature refers to "the long-term health risks associated with menopause, such as osteoporosis."

This view, many experts say, is too simplistic.

"I personally do not believe menopause is a disease state or that the decline in estrogen contributes to disease, with maybe the exception of bones," said Stanford University researcher Marcia Stefanick, a leader of the federal study. "But osteoporosis is very complicated. Men lose bone with age, too."

At 61, Blumenthal has been on hormone therapy for a decade - twice as long as the ob-gyn academy recommends, and twice as long as she prescribes it for patients.

"I went on when I had symptoms. I was waking up six times a night, and I couldn't function," she said.

While she does not foresee hormone supplements again playing a role in preventive medicine, she is convinced that - for her, for now - hormones enhance an intangible: quality of life.

"I know that I feel better overall on hormones," Blumenthal said. "If I should get breast cancer in the next few years, I might kick myself. But I take responsibility for my decision. I'm not suing me."

After the Women's Health Initiative, Wyeth Pharmaceuticals, maker of leading hormone brands that it supplied for the study, was deluged with lawsuits from women who had developed breast cancer.

This is another complex issue. An individual's increase in risk is small, and breast cancer is common in women who never took hormones. The study estimated the number of new cases of breast cancer would rise from about 30 for every 10,000 women not on the drugs to 36 to 38 per 10,000 women who were on estrogen-progestin for five or more years.

The numbers add up when enough women are involved. In 2003, the year after millions quit hormones in a panic, newly diagnosed breast cancer dropped 7 percent - the first decline in almost seven decades. Since the rate did not rebound in 2004, researchers believe less hormone use is at least part of the explanation.

Of course, the Women's Health Initiative did not end the quest for youth elixirs. Fans of so-called "bioidentical" custom-made hormone preparations claim these can ward off illness, disability and weight gain, to which Wulf H. Utian, executive director of the North American Menopause Society, retorted: "What utter nonsense!"

Yet giving up on pills that once seemed like a sure bet is freeing for many women.

"I think overall women have relatively positive attitudes about menopause," said Joyce Bromberger, a University of Pittsburgh psychiatrist who has studied menopause and mental health.

"That's not to say they don't anecdotally report symptoms. But I don't think women perceive it as the terrible change that perhaps they once did - or we thought they did."

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