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When menopause 'comes roaring,' what do you do?

By Elizabeth Landau, CNN
Doctors continue to recommend hormone replacement therapy, but it may carry risks.
Doctors continue to recommend hormone replacement therapy, but it may carry risks.
  • Menopausal symptoms include mood swings, hot flashes, sleep disruption, changes in libido
  • Hormone replacement therapy is the only treatment that targets all of those symptoms
  • An alternative to hormone replacement therapy for some women is antidepressants

(CNN) -- Just after she'd gotten a divorce and gone back to work, Alice Thornton would feel cold one minute and hot the next, and her temper was shorter than usual.

"It was irritating because when it comes, it comes roaring through," said Thornton, 61, of Huntington, West Virginia, whose symptoms began around age 49 or 50. She wrote about the experience in her iReport.

A deficiency in the hormone estrogen is responsible for the symptoms of menopause, which include mood swings, hot flashes, sleep disruption and changes in libido.

As baby boomers continue to go through menopause in record numbers, questions about how to curb these symptoms, especially those that interrupt daily life, are all the more relevant. At the same time, research on hormone replacement therapy keeps emerging without hard conclusions, leading doctors to recommend the lowest dose for the shortest duration.

Not every woman feels troublesome effects from menopause; in fact, 30 percent don't report any significant symptoms. But that means up to 70 percent of women have moderate to severe symptoms that can cause changes in daily living, said women's health expert Dr. Donnica Moore.

For 80 percent of women, symptoms generally resolve within five years, but it's not known how long the unpleasantness lasts beyond that for the remaining 20 percent of women, Moore said. Because every woman is different, there is no certain quick fix for menopausal symptoms.

"This is why medicine is an art and not a science," she said. "We don't have the tools to be able to make these decisions by computer or a checklist."

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The HRT controversy

Marilyn Grounds, 51, of Springboro, Ohio, hasn't slept well in years. She feels exhausted all the time, and is also going through hot flashes. Recently she decided it's time to look into hormone replacement therapy, she said in her iReport.

Hormone replacement therapy too risky?
HRT and risk of breast cancer death

Hormone replacement therapy is the only treatment that would target all of the potential symptoms of menopause at once, Moore said. It comes in forms such as pills and patches, and is designed to replace estrogen.

Women taking estrogen who have not had their uterus removed also need to take progesterone, as this helps reduce the risk of uterine cancer.

Hormone replacement therapy, also called HRT, has generated much debate in recent years because of concerns about elevated risks of breast cancer and cardiovascular events.

A recent study in the Journal of the American Medical Association found that women who took a specific hormone therapy that included estrogen and progestin were twice as likely to die from breast cancer as women who took a placebo. This was part of a large government study called the Women's Health Initiative, which stopped a study on the topic in 2002 due to concerns about heart health, breast cancer and other health problems. The latest results are from the same women who participated in that, after 11 years of follow-up.

Moore and other doctors caution that the Women's Health Initiative study has numerous flaws -- for instance, it looked at only one particular drug: Pfizer's Prempro. There are all kinds of formulations and varieties of hormone replacement therapy, with estrogen and progestin in combination in different amounts, Moore said. It's hard to know whether it is one or both hormones, or the dosing, or something else entirely, that may have contributed to negative outcomes, she said.

There are some women who should not consider hormone replacement therapy because of underlying conditions such as liver problems and gallstones, Moore said.

But in appropriate situations, Moore continues to recommend it. So does Dr. Camelia Davtyan, director of Women's Health at the Comprehensive Health Program at the University of California, Los Angeles.

Davtyan said she's not as "generous" with recommending hormone replacement therapy as she used to be, given the research on risks. Of the available options, she prefers prescribing a hormone-releasing patch, as there has been some suggestion that it causes fewer blood clots, she said.


Virginia Olander of New Orleans, Louisiana, remembers feeling like an 85-year-old at age 52. She had to have a complete hysterectomy, which threw her body out of whack in severe menopausal symptoms. Her brain was in a fog, her energy had dropped, and she felt generally miserable, she said in her iReport.

Traditional hormone replacement therapy didn't relieve any of her symptoms. She thought, "I cannot continue to work full time and take care of my family if I'm going to continue to feel this way."

Long-lasting relief came from pellets containing "bioidenticals," which are chemical equivalents of the hormones that the body produces naturally, but are derived from plants. Synthetic estrogen, on the other hand, is made in a laboratory, but functions the same. Grounds, like Olander, has also opted to try the bioidenticals, but hasn't gone to her first appointment yet.

The specific treatment Olander chose and others like it are controversial because they are not approved by the U.S. Food and Drug Administration, and therefore have not undergone the same level of scrutiny in terms of dosing. But Olander doesn't care, as long as it works.

There are some hormone replacement therapies on the market that are approved by the FDA, and also use plant-derived hormones, such as Estrace, Climara patch, Vivelle-Dot patch, and Prometrium natural progesterone, according to the Mayo Clinic's Dr. Mary Gallenberg.

Still, bioidentical treatments carry the same risks of breast cancer and cardiovascular risks as other forms of hormone replacement therapy, Davtyan said.

Olander's pellets have a combination of estradiol -- the chemical that synthetic estrogen mimics -- and testosterone. They are like grains of rice inserted into the hip, in an outpatient procedure that takes about 30 minutes, Olander said.

Olander said she'll have to be on the pellets for life, but doesn't mind, since they give her relief. That's contrary to the current philosophy of major medical organizations: to administer the minimum dose for the shortest period of time, Davtyan said.


An alternative to hormone replacement therapy for some women is antidepressants.

Although depression is not itself a symptom of menopause, doctors have found that antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) can be effective for some women in reducing mood swings and hot flashes. These drugs can also help with sleep disturbances.

"This does not mean the doctor thinks you are depressed or that it's all in your head," Moore said. "That's a huge point of confusion."

Alice Thornton had been taking Zoloft, an SSRI, since long before menopause, and speculates it may have helped stave off menopause's more severe symptoms.

The natural way

Grounds has reached the point where she feels she needs a new medical option, but she has found some relief in yoga, meditation and hiking.

Small interventions such as keeping a fan at your desk, carrying ice packs, sleeping naked, keeping the room temperature lower and wearing athletic clothing can all help with hot flashes, Moore said. Some women with mild symptoms also feel better with drinking soy milk, exercising and taking herbal remedies, such as black cohosh.

Thornton's doctor put her on hormone replacement therapy, but she only lasted about 30 days on it. She didn't like the weight gain or the idea that she was messing with nature.

For the rest of her four years of menopausal symptoms, Thornton braved it without additional medical assistance: taking off layers of clothing during sweats and locking herself in the bathroom with a glass of wine when she felt her temper acting up.

"Deal with the discomfort as it is what we must do; compared to childbirth and abdominal surgery, this was a breeze!" she wrote in her iReport.