Now, all that is about to change. For the next 14 years women over 50 will be the focus of an enormous federally funded project called the Women’s Health Initiative. Medical researchers around the country will be monitoring the health of more than 150,000 of them, exploring what really goes on during the last third of women’s lives and what hormones and nutrition do to their bodies and minds.
The study will help researchers understand better the incidence and precipitating factors for a number of major illnesses in postmenopausal women, including heart attacks, stroke, cancer and osteoporosis (rapid bone loss that can lead to multiple fractures). The relationship of disease and diet–particularly calcium and fat–will be examined. And various regimens of female hormones will be administered to quantify how much they help alleviate menopausal symptoms and prevent or cause serious diseases.
Although pieces of the puzzle are still missing, menopause is by no means a complete medical mystery. And although women’s experiences of this middle-age milestone vary enormously, there are certain universal elements.
The most obvious–and least mourned–is the cessation of menstrual bleeding, typically between the ages of 45 and 55. Periods often turn quirky and treacherous, arriving unannounced at odd moments. Eventually they disappear entirely because the ovaries stop churning out estrogen. If a woman undergoes chemotherapy or has her ovaries removed, her menopause is swift and sudden. If it’s a natural event, the average age at which she has her last period is 52. A small percentage–one woman in 10-undergoes menopause before 40.
Estrogen plays a major role in female physiology, affecting more than 300 body functions. So when it starts fluctuating or tapering off, the result is often a bumpy ride. While some women report that they scarcely noticed passing through menopause, most are aware of dramatic changes. As many as 75 percent experience embarrassing hot flashes, lasting from 15 seconds to an hour. These bursts of soaring internal temperature can cause profuse sweating and frequently strike during the night, contributing to insomnia.
As estrogen tapers off, both body and soul respond. Some women experience loss of libido, a complex condition that can have several causes. One is the melancholia and mood swings many menopausal women suffer; another is the very common problem of vaginal dryness that makes intercourse uncomfortable.
The most effective fix for almost all the woes of menopause is estrogen-replacement therapy (ERT). The estrogen given to menopausal women bears little resemblance to the far more potent hormone in oral contraceptives. And having spent years on the pill doesn’t put women at any special disadvantage for taking estrogen at menopause.
ERT almost always zaps hot flashes, soothes vaginal dryness, improves bladder problems, evens out mood swings and clears up short-term memory loss. It also combats the more serious effects of estrogen deficiency: osteoporosis and an elevated risk of heart attacks. The hormone retards bone loss (most dramatically if prescribed within three years of the last period) and cuts deaths from heart attacks in half.
Unfortunately, estrogen is not a magical anti-menopause potion. “There’s a lot going for it,” says Dr. Veronica Ravnikar, head of the menopause unit at Massachusetts General Hospital. “But there are a lot of holes in the data.” The biggest worry is that estrogen may increase the risk of breast cancer. Much of the research finds that it does not up the odds. Still, several recent reviews of all the best studies have concluded that the incidence of the disease rises from 1 case per 1,000 women per year in untreated women to 1.2 cases in women taking estrogen. The women who get breast cancer while on estrogen, however, often live longer than women who get it and don’t take hormones-probably because they are more closely monitored by their physicians and thus more likely to be diagnosed early.
One hazard of estrogen is undisputed. Given by itself, it can increase the risk of cancer of the endometrium (the uterine lining). To combat this effect, most women also take a synthetic form of a second female hormone, progesterone. Usually given orally for 10 days a month, progesterone isn’t risk-free either. It may detract from estrogen’s protection against heart attacks, and in about 25 percent of women it causes PMS-like bloating and irritability. Because it breaks down the uterine lining, it also brings on " withdrawal" bleeding for a few days each month.
A newer approach to progesterone, under development in Europe, would deliver the hormone directly and solely to the endometrium through an intrauterine device, which would eliminate the PMS symptoms and the bleeding. A form of progesterone called Megace, approved by the FDA for treating breast cancer, may also be useful in relieving menopausal symptoms of women who’ve had the disease and can’t take other forms of hormones.
Dr. Lila Nachtigall, a reproductive endocrinologist who heads New York University’s Women’s Wellness Center, estimates that 35 percent of women really need hormone-replacement therapy, and 60 percent could benefit. But in fact only about 15 percent of menopausal American women take hormones; most are educated, upper middle class and white. According to pharmaceutical research, most women don’t stay on them more than nine months. “That’s probably because doctors don’t explain the long-term benefits,” says Dr. Wulf Utian, chairman of obstetrics and gynecology at Cleveland’s University Hospitals. “And they don’t make themselves available to answer women’s questions and concerns.”
Listening helps, but the time for rejoicing won’t arrive until doctors actually learn more about what makes midlife women tick. That information will emerge gradually over the next decade, as the major new studies of women get underway and we find out, finally, exactly how the change of life really changes our lives.
Most women take estrogen in pill form, for three or four weeks of each month. The most common brand name is Premarin. The hormone should not be taken by women who’ve had breast cancer.
The hormone is sometimes administered as a cream to combat the common symptom of vaginal dryness. The drawback to this method is that the precise dosage is hard to regulate.
Thirty percent of women choose the newest form of estrogen: a transparent patch worn on the abdomen or buttocks and changed twice a week. The hormone is absorbed through the skin.
