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November 2001 Issue
The Postmenopausal Hormone Questions: Whether, which, when, how long?
by Michael Fick
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Ignore that rumbling sound, ladies; it's just all the guys running for the exits with strained looks on their faces. Geez, you'd think I said "menstruation" or something. Oh, well ... let's get on with one of the biggest midlife decisions all women must make: whether and how to take estrogen supplements when menopause approaches. Unfortunately, we can't even make a dent on the topic here, but you'll see my real purpose shortly.

Postmenopausal hormones -- including estrogen -- have significant, proven, well-defined benefits and risks, plus many lingering questions. Estrogen alone dramatically affects the cells of blood vessels, skin, bones, brain, liver, and all the delightful and functional parts that make women women. The lesser effects of waning estrogen production include raging hot flashes, aching joints, insomnia, and meteoric mood swings. (You do know why they called it "menopause", don't you? Because Mad Cow Disease was already taken.) Its more serious, yet common, effects include sexual dysfunction, heart attacks, and terminal hip fractures. Name your poison.

Synthetic estrogen was welcomed in the 1920s as a cure for most of those problems, until a decade later it was discovered to lead to endometrial cancer. In the '70s, the addition of progestin solved that problem, and the combination of estrogen and progestin remains the "cure" of choice for the effects of declining estrogen production. But estrogen still dramatically impacts the risks of other very serious diseases, some positively and some negatively. You must analyze and evaluate the tradeoffs according to your own circumstances, based on much more information than we can cover here.

The benefits of estrogen include relief of menopausal symptoms (big cheer from both the guys and the gals), lower risk of osteoporosis and its crippling effects, improved cholesterol profile and cardiovascular health, improved blood flow via several different mechanisms, probable lower risk of colon cancer, and maybe lower risk of Alzheimer's disease. That's all big stuff!

But estrogen also increases the risks of endometrial cancer, breast cancer, gallbladder disease, deep vein thrombosis with pulmonary embolism, ovarian cancer, and maybe asthma and lupus. The conflicts between estrogen's life-prolonging benefits and ultimately life-threatening risks mean that estrogen has a clear near-term benefit for many women but more murky long-term effects. As more data emerge from the relatively recent addition of progestin to estrogen therapy, the long-term picture will tend to clear up.

There are charts, chapters, and even whole books on the various types of estrogens, progestogens (such as progestin), and their combinations. You and your physician will need to apply that data to your own medical history and profile in the process of deciding your own hormone regimen. For example, a woman with a family or personal breast cancer history may want to avoid estrogen, but if the skeleton in her family or personal closet is colon cancer, estrogen will reduce her odds of getting it by 35 percent. Science is already exploring the means of tailoring your personal postmenopausal hormone therapy cocktail - or your cancer chemotherapy cocktail -- to your individual DNA profile to maximize the ratio of benefits to risks for your individual situation, but for now it's just not that "simple".

Doctors say the postmenopausal hormone question - whether, which, what form, how long - is one of the most complex, challenging, and overwhelming decisions their middle-aged female patients must make (outside the shoe store). Debates over obvious existing medical quandaries such as open heart surgery, amputation, chemo, or nursing home time almost resolve themselves at some point, as the patient's circumstances reach a critical stage. But letting the postmenopausal hormone therapy questions solve themselves is asking for an unnecessarily detrimental outcome. Most of the symptoms and effects of declining estrogen can be preempted or greatly mitigated through medical science. For now, the bottom line seems to be to read, study, ask, consult, decide, and act ... then revise your decision adaptively as your body responds and medical data keep rolling in.

An obvious copout? Of course. The decision should involve reading several books, consulting at length with at least one or two specialist physicians, discussing with your family its affects on your longevity and vitality, and a great deal of thinking ... not a three-minute read in an e-zine.

Fortunately -- and here is the real message of this month's column - a new, groundbreaking, authoritative, and still-evolving study and book have shed new light on this and many other life-affecting women's health issues. Every female old enough to comprehend the book should read it cover to cover. I recommend buying it for your near-adolescent daughters and literally home-schooling them in it if they need a push or aren't quite capable yet of understanding it unassisted. Why the rush? Because many health problems start in childhood, especially with dietary and exercise habits.

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