Menopause is the time in a woman's life when menstruation, the monthly menstrual periods, end (usually at about age 51). Following menopause, a woman's ovaries stop producing the sex hormones estrogen and progesterone. These sex hormones control menstruation and affect the body in many different ways.

As estrogen in particular drops to very low levels, your body may respond in several ways:

• You may experience hot flashes, which can make your face red and cause a sudden sensation of body warmth and then coldness as perspiration cools off.
• Your sleep may be interrupted.
• Your vaginal tissues may become thinner, which can cause vaginal dryness, itching, and pain during sexual intercourse.
• Your bones often become thinner and lose calcium, which can lead to spine fractures, a curved spine (dowager's hump), and hip fractures - a major cause of hospitalization in elderly women.
• Your brain may respond to a lack of estrogen with mood swings, some memory loss, irritability, a lack of well-being, or depression.
• The cholesterol level in your bloodstream may increase.

What the Latest Studies Are Telling Us
In 2002, the first part of the Women's Health Initiative (WHI) study showed that prolonged use of hormone therapy with estrogen plus progestin (a synthetic form of progesterone) caused a slight increase in the risk of breast cancer. In women in this age group (average age, 63 years) estrogen plus progestin also caused a slight increase in heart disease and strokes, and a slight decrease in the risk of fractures and colon cancer. In August 2003, The Million Women Study from the United Kingdom confirmed the initial WHI study.

The second part of the Women's Health Initiative Study examined the use of estrogen alone in women who had already had a hysterectomy. (Women without a uterus do not need progestin, which is usually given to lower the risk of uterine cancer.) This study showed that using estrogen alone for up to seven years did not increase the risk of breast cancer. While this study is reassuring, other studies suggest that longer use of estrogen alone might still carry an increased risk of breast cancer.

A recent analysis of the women in the estrogen-only arm of the WHI study indicated that when estrogen treatment was started between ages 50 and 59, these women did not show an increased risk of heart disease, and might even have had a slightly reduced risk. There was also an added risk of stroke, similar to that seen with combined (estrogen plus progestin) therapy, but it was very low in women under 60 near the time of menopause.

Another important part of menopause that many women experience but that these studies did not address is the symptoms of menopause such as hot flashes, night sweats, vaginal dryness and irritation, and painful intercourse. These symptoms usually occur during the first few years after menopause, but may last longer for some women. For these symptoms, nothing is more effective than estrogen.

Menopause Symptoms Can Be Managed in Two Phases
In the first phase (up to five years), prevention of bone loss (osteoporosis) can begin along with estrogen treatment for specific menopause symptoms such as hot flashes and vaginal dryness. The U.S. Food and Drug Administration (FDA) recommends that hormone therapy for symptom relief be used at the lowest possible dose and for the shortest amount of time needed to relieve symptoms. After the first, short-term phase, women should discuss the risks and benefits of continuing long-term hormone therapy with their doctor.

Remember that the short-term goals of treatment are different from the long-term goals. Short-term therapy is designed to relieve symptoms; long-term therapy helps to prevent bone loss. If you take hormones for less than three to five years, the risks are relatively low. If you are concerned about bone loss and are thinking about taking hormone therapy for more than five years, consult with your doctor to see whether hormone therapy or an alternative treatment is best for you.

Ways to Take Hormone Therapy
Hormone therapies come in a variety of combinations, dosages and forms. Many women take a pill form of estrogen combined with a natural or synthetic progesterone added to protect the uterus. Estrogen-only therapy is also prescribed for certain patients, especially those who have had a hysterectomy.

Forms of estrogen in low doses, such as vaginal rings, creams, or tablets, can help thicken vaginal tissues and relieve vaginal symptoms, with only small amounts absorbed into the bloodstream. In this case, the estrogen is taken at a fraction of the dose typically prescribed for relief of hot flashes. It is believed but not proven that these lower doses have less risk associated with them.

Hormone patches, gels, intrauterine devices, and slow-release capsules are some of the other forms in which hormones are available.

Many women are turning to bioidentical hormones, which are identical to the hormones your body makes. While the term "bioidentical" has come to refer to custom-made products prepared by compounding pharmacies, a number of FDA-approved bioidentical hormone preparations are available that provide more reliable dosing and quality.

Non-estrogen Treatments for the Early Symptoms of Menopause
Several alternative treatments for menopausal symptoms are also available, although none are as effective as estrogen.

Hot Flashes
Several prescription medications have shown some success in treating hot flashes

• SSRIs (selective serotonin reuptake inhibitors, a type of antidepressant)
• Gabapentin
• Megestrol acetate (a progestin-like compound)
• Medroxprogesterone acetate (a progestin)
• Herbal medications and soy products have not been shown to be effective in scientific studies but many women report benefits.
• Paced breathing exercises, acupuncture, or yoga may be helpful for some women.

Vaginal Dryness and Painful Intercourse

• Vaginal moisturizers help to add moisture to vaginal tissues but do not cause the same thickening as estrogen does.
• Water-soluble lubricants may help reduce pain from sexual intercourse.
• SERMs (selective estrogen receptor modulators) are a class of medications that act like estrogen in some tissues but no in others. SERMs that are active vaginally are being studied to help develop non-estrogen alternatives to treat vaginal dryness.

Non-estrogen Treatments for Long-term Health Risks of Menopause

Bone Loss

• Bisphosphonates decrease the rate of bone loss and prevent fractures.
• SERMs that are active in bone tissue prevent bone loss and spine fractures.
• Calcitonin is used to treat bone loss in women who are more than 5 years past the time of menopause.
• Parathyroid hormone builds additional bone on the skeleton. It is used primarily for the treatment of severe osteoporosis and taken by injection.
• Calcium and vitamin D help keep bones strong. Most people over age 50 need 1,200 to 1,500 mg of calcium and at least 1,000 IU (international units) of vitamin D each day. You may need to take supplements to get enough of these nutrients.

Cardiovascular Disease

• Statins lower lipid (fatty substances like cholesterol) levels in the blood and lower the risk of cardiovascular disease in people with abnormal lipid levels and those with a personal or family history of heart disease.
• Controlling blood pressure and blood sugar and following a healthy lifestyle also help protect against cardiovascular disease.

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