A Guide to Making the Right Choices for Menopause

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WHETHER YOU'RE just entering menopause or have been postmenopausal for years, there are essentially two major diseases that various treatment options can help you avoid: osteoporosis and heart disease.

But two other important considerations have to go into the mix. One is your risk for developing breast cancer, since certain treatments raise the chance that you'll develop that disease. The other consideration--if you are still in the first few years of menopause--is how strongly you're affected by short-term symptoms like hot flashes, mood swings, vaginal dryness, and headaches. Once you and your doctor determine which are the most pressing factors in your particular case, you can make a more informed choice.

One strategy gaining favor is to use hormone replacement therapy (HRT) in order to relieve the symptoms of menopause during the first 2 to 3 years and then to evaluate specific risk factors in designing a long-term treatment program. But if you feel your menopause symptoms are bearable without the help of hormones and you are not found to be at particular risk for osteoporosis or heart disease, you probably won't need any drug treatment whatsoever--and won't need to reconsider until you reach your 60s. In general, it's at that point that the risk of bone fractures and heart disease begins to rise more sharply.

Whatever you decide, it's important to keep an open dialogue with your doctor and to remember that you can always change your mind. The best option is often to try something and see how it goes. There really is no risk in taking a drug for a short time and then reconsidering your options if the side effects become intolerable or you reprioritize your long-term strategy. You don't have to make an immediate decision concerning lifelong therapy and then be stuck with it.

If you are at high risk for osteoporosis...
Certain women are at much higher risk than others for developing osteoporosis: those with a family history of the disease; those who have reached menopause before age 45; women who have a petite, thin build; smokers; women who don't participate in weight-bearing exercises like walking or jogging, which strengthen bones; those who have a history of not getting enough calcium; and anyone taking corticosteroids such as prednisone.

But the only way to know for sure the extent of your risk is for your doctor to order a bone mineral density scan. Ideally, if you're uncertain about hormone therapy, you'd want to have one within a couple of years of entering menopause. If your score shows you are at high risk, you might seriously want to consider bone-saving drug treatment. If, on the other hand, your bones test well in a bone density scan, you can probably wait until you are 65 or so to retest and reassess your need for treatment measures. Keep in mind that once you do decide to take a drug to prevent further bone loss, if you stop taking it at any point, your bone density will gradually decrease unless you switch to another drug; the effects of the treatments don't last indefinitely.

Bone-saving options available
If bone deterioration is the only risk you are concerned with, any of the treatments mentioned at the top of page I can benefit you. They're all effective at preventing osteoporosis. Beyond maintaining bone, however, each treatment comes with its own particular set of benefits and problems.

Hormone Replacement Therapy A woman who chooses HRT to protect her bones may get the added benefit of protection from heart disease. HRT lowers "bad" LDL-cholesterol and raises "good" HDL-cholesterol. For a woman in the early years of menopause, HRT will also relieve symptoms such as hot flashes, vaginal dryness, irritability, and sleep disturbances.

But HRT creates other menopause symptoms in some women: spotting and breast tenderness. HRT also comes with a small increased risk for clots in the deep veins of the legs, which can cause a life-threatening pulmonary embolism if a clot travels to the lungs. But such an occurrence is rare. Of much more concern to most women is the fact that estrogen can increase the risk for breast cancer. On one hand, that seems like a scary prospect; breast cancer is the most common form of cancer among women in the United States. On the other hand, a woman is many times mere likely to die from heart disease as from breast cancer.

Consider that for every 100,000 women in the 65-to-74 age category, there are about 100 breast cancer deaths a year, but more than 500 heart disease deaths. For every 100,000 women in the 75-to-84 category, 140 women will die from breast cancer in a given year, while more than 1,700 will die from heart disease. Thus, the fact that HRT increases breast cancer risk is not always of overriding concern, especially when you consider the magnitude of the increased risk. The chance of dying from breast cancer for ..... a woman who opts for HRT goes up only 3 to 4 percent, on average.

Of course, for a woman who is at high risk for breast cancer to begin with, any increased risk could be too much. That's why a woman with increased odds of getting breast cancer should carefully consider the HRT decision with her doctor. Your odds for developing breast cancer are increased if you have already had it; you have a mother or sister who was diagnosed with breast cancer; you never had children or had your first pregnancy after 30; you started menstruating before age 12; you reached menopause after age 55; you have at least one alcoholic drink a day; or you are overweight.

One bone-saving option a doctor' might suggest, even for a woman at high risk for breast cancer but who has debilitating menopausal symptoms, is to take a little less than half the typical estrogen dose. Researchers at Creighton University in Omaha have discovered that women who took 0.3 milligrams daily of estrogen as opposed to the usual 0.625 milligrams still had significant improvements in bone density. And the smaller dosage may not raise the risk for breast cancer as much. "The increased risk of breast cancer related to HRT appears to be dose-dependent," says Harvard's Dr. Manson.

Another strategy for preventing osteoporosis, Dr. Manson says, is to take HRT for the first 2 to 3 years of menopause, when bone loss is relatively dramatic, and then restart it (or some other bone-saving treatment) after age 60. "The risk of breast cancer is not significantly increased with HRT that lasts fewer than 5 years," she says.

Raloxifene (Evista) An estrogen-like drug that mimics some of that hormone's effects, the "designer estrogen" raloxifene is a good choice for women who have fragile bones but are highly concerned about breast cancer. Raloxifene helps maintain bone without raising breast cancer risk, according to the evidence available thus far (no menopause treatment has been studied for as long or as thoroughly as HRT). Indeed, one study suggests that raloxifene can cut breast cancer risk by 76 percent. "I think the evidence is very promising that it may prevent breast cancer," Dr. Manson says. It even lowers LDL-cholesterol and thereby may cut the risk for heart disease (but this remains unproven).

However, raloxifene, unlike HRT, does not reduce the unpleasant initial symptoms of menopause. Indeed, it increases hot flashes in an estimated 20 percent of women who take it. (The drug probably will not cause hot flashes in somebody who entered menopause at least 5 years before she started using it.) Furthermore, like HRT, it appears to come with a very small but nonetheless important risk of blood clots in the deep veins of the legs.

Alendronate (Fosamax) Fosamax is generally prescribed strictly for women who are at high risk for osteoporosis or who already have documented osteoporosis. "It is not a drug you take routinely to prevent osteoporosis," Dr. Manson says.

One reason is that administration of Fosamax requires special consideration. You have to take it on an empty stomach, and you can't lie down for an hour afterwards. You must also swallow the drug with 6 to 8 ounces of water to wash the pill completely from the esophagus into the stomach. If you don't follow all the rules, the bioavailability of Fosamax goes down to practically nil. Worse still, you also risk getting an esophageal ulcer.

The upside of Fosamax is that it is not a hormone or hormone-like drug, so it does not create any side effects like the breast tenderness or bleeding that can come with HRT or the hot flashes that raloxifene can cause. Also, it is slightly more efficient at restoring bone density than raloxifene--increasing it by as much as 7 percent rather than 2 to 5 percent.

If you are at high risk for heart disease...
If a woman is at high risk for heart disease and the goal of treatment is to prevent her from having a heart attack or some other cardiac problem in the future, HRT is probably the best choice. It not only improves blood cholesterol levels, it also improves the function of the cells that line the cardiovascular tissues as well as blood vessel tone. A doctor can help a woman determine if she's at high risk by checking her blood cholesterol, triglycerides, and blood pressure and also by going over her family history and lifestyle factors.

If a woman already has been diagnosed with heart disease, Dr. Manson suggests that she should not start taking HRT. A multi-center study called the HERS trial (Heart and Estrogen/ progestin Replacement Study) suggests, at least preliminarily, that women who have already had a heart attack or narrowing of the arteries (diagnosed by an angiogram) are more likely to have heart complications during the first year after starting treatment. That's not to say that women with a history of heart disease who have been taking HRT long-term should stop taking it. But someone with established heart disease who hasn't been on HRT should not add it to her treatment regimen.

Fortunately, HRT is only one of many treatments for heart disease. And raloxifene, while it lowers total blood cholesterol, isn't the only alternative. There is also a powerful class of drugs called statins that can lower cholesterol in both women and men. Losing excess weight, quitting smoking, taking brisk half-hour walks 5 days a week, cutting back on saturated fat, and eating more fruits, vegetables, whole grains, and other high-fiber foods can also greatly improve risk profile. In fact, many people who are willing to commit to a healthful lifestyle can avoid heart-protecting drugs altogether.

Whatever you decide...
Whether or not you choose to take hormones or other drugs, the best long-term prevention of heart disease and osteoporosis always includes proper nutrition, regular exercise, not smoking, and having no more than one alcoholic drink a day--less if you're at high risk for breast cancer. Another component of proper nutrition for a woman age 50 to 64 includes getting at least 1,000 milligrams of calcium a day, 1,500 milligrams if she's not on HRT. A women 65 or older should be getting 1,500 milligrams of calcium daily--whether she's on HRT or not. Women 51 to 70 should also be getting 400 International Units a day of vitamin D (provided by most multivitamin supplements). Women older than 70 should get 600 units of D daily. A cup of milk has 100 units of vitamin D, but other dairy products do not usually contain it.

In a future issue we will discuss tamoxifen, a drug that early evidence suggests might be able to prevent (not just treat) breast cancer.

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