When menopause symptoms strike, what is a woman to do?

“Everyone should take estrogen!” “No one should take estrogen!”

Charles Hammond, MD, chair emeritus of Duke’s Department of Obstetrics and Gynecology, says that in the course of his career, he’s seen the medical opinion on estrogen replacement swing from one extreme to the other, and back again -- at least twice. And frankly, he doesn’t expect the debate to end anytime soon.

That doesn’t do much to comfort women who are facing menopause and its often life-altering, sometimes debilitating symptoms.

Women quit hormone replacement therapy in droves following the July 2002 closing of the Women’s Health Initiative (WHI) studies -- the largest study to date of estrogen replacement in postmenopausal women -- which showed that the therapy created a small but measurable increase in breast cancer risk, and did not provide any protection against heart disease or dementia.

Nearly a decade later, the tainted reputation of estrogen therapy has left a gaping hole in the therapeutic options for women struggling with symptoms of menopause. But HRT (hormone replacement therapy) still has a place in helping some women, Duke experts say -- as long as it is prescribed appropriately.

Why? Why Not?

For women whose menopausal symptoms are mild, the question of taking estrogen is not much of a question these days -- according to the best scientific evidence available, the benefits are not compelling enough to offset the risks.

But for women whose symptoms interfere with their normal daily life and diminish their quality of life, Hammond says physicians must walk the fine line between the risks of action and the consequences of inaction.

“The primary reason to prescribe estrogen for a woman is menopausal symptoms,” says Hammond -- hot flashes, vaginal and urinary changes, and psychological or mental effects ranging from depression to a frustratingly nondescript haze that is usually labeled “cognitive dysfunction.”

None of these symptoms are life-threatening, but they can have a long-term -- and really unpleasant -- impact on a woman’s quality of life. Some women experience vaginal changes that make sexual intercourse quite painful -- sometimes impossible, even with lubricants.

As for hot flashes, Hammond says, “people tend to chuckle about hot flashes, with this image of Aunt Fannie sitting on the porch with her hand fanning.” But they’re not funny at all for women who experience such strong and frequent flushing that they can’t get restful sleep, can’t concentrate at work, and avoid social activities.

Sexual and urinary dysfunction affect as many as 50 percent of menopausal women, says Hammond, and without treatment these symptoms can get worse over time. About 75 percent of women have hot flashes -- among those women, two thirds will see a lessening of their symptoms after a few years. But a quarter of all women experience severe, persistent hot flashes that can go on for decades.

Although every natural remedy under the sun has been touted at one point or another for soothing hot flashes, nothing’s been proven to have more than about a 20 percent effectiveness rate -- in other words, not much more than a placebo effect.

For these symptoms, estrogen remains the hands-down most effective way to diminish or even reverse both hot flashes and vaginal symptoms.

Think Little and Brief

But what if estrogen might increase a woman’s chances of developing cancer later on?

Hammond says that while researchers will continue to debate the role and risks ascribed to estrogen in women’s health and disease, most physicians and health organizations recommend prescribing estrogen at the lowest possible effective dose to women whose symptoms are significant, and to keep them on the hormone for as brief a time as possible.

“There are two forces at work in this debate,” Hammond says. “One is a population of symptomatic women, whose quality of life is suffering. The other is the fact that we all want a treatment that doesn’t have any side effects or any risk. And in terms of hormone replacement therapies, that just doesn’t exist right now. And quality of life is important, so trying to bring these two things together is the goal.”

Life After Estrogen

For now, while HRT may still be prescribed for women with severe menopausal symptoms, long-term use of the therapy is no longer the norm.

“We now recommend that women take HRT for only a few years, then stop and see whether symptoms return,” says Duke internal medicine physician Lori Bastian, MD. “If that happens, we’ll try other interventions.”

Because a “cold turkey” approach may aggravate symptoms, Bastian suggests that women taper off HRT gradually. In the post-HRT world order, what other means can women use to ease their path through “the change”?

Antidepressants such as Paxil and Effexor have shown benefit in some women for easing psychological effects and even hot flashes.

Soy, with its wealth of estrogen-like substances called isoflavones, continues to earn kudos for its proven power to ease menopausal symptoms. Even though it’s a natural product, soy should be taken in moderate amounts -- excessive use of soy may stimulate diseases such as fibrocystic breast disease, breast cancer, uterine fibroids, or endometriosis.

Regular exercise, including weight-bearing, resistance, and aerobic components, can be especially important to maintain (or begin, if you aren’t exercising already) during menopause and beyond. Exercise helps protect bone mass, lowers the risk of cardiovascular disease, and releases endorphins that help ease mood swings.

Calcium and vitamin D are key to help prevent bone loss. Aim for about 1,000 to 1,500 milligrams of calcium a day from all sources, including calcium supplements; excess amounts (more than 2,500 milligrams per day) can cause harmful effects. Because the body requires vitamin D to metabolize calcium, 15 minutes of sunlight daily or vitamin D supplements (at least 1,000 milligrams) are also recommended.

Bastian also recommends that women coping with menopausal symptoms avoid alcohol, which may trigger hot flashes, and give up smoking -- the nicotine in tobacco suppresses estrogen metabolism and can worsen menopausal symptoms.

For easing stress, time-honored techniques such as deep breathing and yoga can be very effective indeed -- and blissfully free of side effects.