http://www.thestar.com/NASApp/cs/ContentServer?pagename...381&col=969048872038

How low can you go?
Dec. 30, 2005. 08:49 AM
NANCY J. WHITE
TORONTO STAR


In the annals of medicine, it was a bombshell. A landmark study in 2002 revealed that hormone therapy at menopause increased the risk of breast cancer, strokes and coronary heart disease. The conventional medical wisdom had dried up.

Three years later, what has taken its place? Confusion and controversy.

Drug companies are now marketing low-dose hormones and doctors now advise the smallest dose for the shortest time to treat severe symptoms.

"That's the party line," says Judith Manson, a certified menopause educator at Sunnybrook and Women's College Health Sciences Centre. "The problem is it's vague. No one is willing to commit to exactly what that means."

Women's health advocates worry about the safety of low-dose hormones and about a potential swing back, however slight, to the idea of hormone therapy as the magic bullet.

Other treatments — herbal remedies, soy products, anti-depressants, and exercises — seem to help some people but not others. Few studies have been done. Even a blue-ribbon panel of menopause experts convened by the U.S. National Institutes of Health last March couldn't identify a best treatment. Their advice? Talk to your doctor.

But not all doctors have the time or expertise to sort through the options, opening a niche market for private care. At the Menopause Health Clinic, which opened earlier this year, clients go through an hour-and-a-half wellness assessment, then doctors offer personalized approaches for $200. To become a member of the clinic, patients pay an annual $1,000 fee that includes consultations with an acupuncturist, dietitian, psychologist, fitness trainer and naturopath.

About 15 per cent of women breeze through menopause, barely a bead of perspiration on their foreheads. Most women, approximately 70 per cent, experience mild to moderate symptoms. And the remaining 15 per cent descend into a middle-aged purgatory, plagued by symptoms worthy of the Old Testament — heavy bleeding, joint aches, night sweats, memory impairment, mood swings and intense hot flashes. The symptoms add stress to already taut lives. "Menopausal women today often have careers, young children, aging parents," says obstetrician-gynecologist Caroline Huh, co-founder of the Menopause Health Clinic. "They face more demands than ever before in their lives. It's not your grandmother's menopause."

For decades, doctors prescribed hormone therapy as a panacea for menopausal symptoms, such as hot flashes and night sweats, and as a preventive measure against heart attack, bone loss and dementia. Then in 2002, the mammoth Women's Health Initiative revealed that estrogen and progestin therapy actually increased the risk of breast cancer, strokes and coronary heart disease. Another study showed possible increases in dementia.

Women fled from hormone therapy in a flash. Sales of the drugs plummeted, from more than 12.5 million Canadian prescriptions in 2001 to about 6 million this year, according to IMS Health, a company that tracks drug sales.

But some with severe symptoms found they couldn't go cold turkey. Doctors estimate about 25 per cent of those who stopped hormone therapy have restarted.

For lawyer Tracey Lloyd, a client at the Menopause Health Centre, the mood swings were unbearable. "One time I was arguing a case and tears started streaming down my face. I was completely mortified," says Lloyd, 57. "Some days I'd drive home and start crying for no reason."

During the night, she'd wake up several times dripping wet and need to change the sheets. She was tired during the day. Her thinking grew fuzzy; she forgot names and phone numbers.

She went on hormone therapy, and the symptoms improved. But after the WHI announcement, her doctor took her off.

"All the symptoms came back. I was so miserable I wanted to die," says Lloyd, who tried herbal remedies to no avail. "I was no longer the woman I knew myself to be."

She researched the hormone controversy and decided to try again. But rather than popping pills, she's getting progestin through an intrauterine device and estrogen through an estradiol gel that she rubs on her skin.

"I feel like a million dollars," says Lloyd, who has her blood pressure and hormone levels monitored every three months.

"It's a wellness approach," she says.

Her gel is made from bioidentical hormones, ones produced in a lab to resemble the body's estrogen. The traditionally prescribed estrogen hormone, Premarin, is derived from pregnant mare's urine.

The bioidentical hormones got a pop culture push in 2004 from actress Suzanne Somers in her book The Sexy Years — Discover the Hormone Connection. Some doctors prefer them, some call them a marketing ploy.

"There's the impression they're safer, but we have no basis to say they are," says Dr. Jennifer Blake, chief of obstetrics and gynecology at Sunnybrook and Women's.

Blake sees a bit of a pendulum swing back toward hormone use. But many women find it a difficult, even embarrassing decision. "They tell me that it's their little secret," says the doctor. "They don't tell anyone for fear of hearing `How can you do that?' There's the expectation you should tough it out."

She prescribes low-dose hormones to control severe hot flashes and other problems for as long as is needed. "There's no cookie-cutter formula," says Blake. "Some women's symptoms last longer than others." In most cases, they go on for two to five years, but can continue much longer.

Some symptoms, such as vaginal dryness, don't get better. Sexual intercourse can become painful. That's bad timing if a male partner has discovered erectile dysfunction drugs.

"Viagra is a big problem," says Dr. Wendy Wolfman, director of the menopause unit at Mount Sinai Hospital. Non-prescription vaginal moisturizers may help. Or some doctors recommend a local estrogen, often a cream or a ring, that's low dose with small absorption into the body.

When dealing with overall symptoms, Dr. Donna Stewart, chair of women's health at the University Health Network, calls herself cautious. She doesn't prescribe low-dose hormones until all other avenues have failed, and she'll try taking patients off after about six months. While she feels the smaller doses are "pretty safe," she thinks more rigorous studies are needed. Stewart worries about efforts by the drug companies to debunk the WHI findings. "It was so bad for their bottom line," she says. "Medical speakers are funded by the industry to discredit the WHI results. You can't go anywhere without hearing it."

The WHI study wasn't perfect. The biggest criticism, she and other doctors point out, is that the participants tended to be older, so more inclined to health problems and many had already gone through menopause. The average age was 63 years old.

But the study's size and scope were phenomenal, says Stewart. "Anyone who isn't swayed has their head in the sand," she says.

Women who do not experience severe problems should exercise caution around this new notion of low-dose, tailor-made hormone therapy, says Kathleen O'Grady, communications director of the Canadian Women's Health Network, a non-profit umbrella group. "A lot think they need medical attention," says O'Grady, "but menopause is just a natural part of aging."

Many women are experimenting with alternatives, including naturopathic remedies. Toronto resident Helen Meschino takes a menopause formula — a mix of five herbs made by her naturopath — for hot flashes, gingko for her memory, and a hormone balancer to steady her emotions. "Menopause is just part of attending to my health and well being, " says the artist.

Some people swear by the herbal remedy black cohosh for hot flashes, but others get no relief from it.

"I look at a person's symptoms and individualize the formulas," says Cheryl Proctor, head of women's health at the Canadian College of Naturopathic Medicine. "I use a lot of tinctures and things in combinations."

Soy in your diet may ease hot flashes, she says. Although the isoflavones in soy products aren't hormones, she explains, they can have a mild estrogenic effect. She recommends about 30 to 40 milligrams of isoflavones a day.

"We're very open to alternative treatments," says Huh, co-founder of the Menopause Health Clinic, "but you have to be realistic — how much will they help and how motivated are you? There are very few studies on herbal treatments."

Opinions differ on the effect of exercise on hot flashes, but its overall benefits are indisputable. Experts also advise avoiding caffeine, alcohol, spicy foods, and stress — often hot flash triggers.

"I have to be really strict with myself or I feel the effects," says Jan Lancaster, 54, a Toronto public health manager. She's devised a regimen — no coffee or chocolate, no refined sugars, daily exercise — that keeps her hot flashes and nightly wake-ups in check.

"It's become an all encompassing life change."