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A NATURAL TRANSITION Insights about menopause grow with the population


Twenty years ago, many male physicians thought the hot flashes of menopause took place in their patients' heads. Fact was, they didn't think about menopause much at all.

"The symptoms sound pretty vague: irritability, sleep disturbances, sweating, flushing," says epidemiologist Trudy Bush, associate professor of obstetrics and gynecology at Johns Hopkins Medical School. "Since men never experience any of this themselves, they were apt to take the attitude: 'You know, women get funny around this age.' "

Few questioned this wisdom -- least of all the post-menopausal women who were often too humiliated by the end of their childbearing years even to discuss their discomfort with friends.

No more, says journalist Gail Sheehy, whose new book "The Silent Passage: Menopause" (Random House, $16) is claiming such mass media arenas as "The Oprah Winfrey Show." Ms. Sheehy predicts a blossoming of knowledge as the up-close and personal baby boomers enter their 40s and 50s.

During the next decade, the population of women between 45 and 54 will jump from 13 million to 19 million. These women will demand more information about the physical changes and risks of menopause, Ms. Sheehy says. They will demand more research into the hormonal replacement therapy that most physicians consider the best way to prevent heart disease and bone loss in post-menopausal women.

And they will demand better PR.

Indeed, Ms. Sheehy suspects the vitality of the baby boomers will erase society's perception of menopausal women as second-class females.

"I think menopause has been painted with an ugly image that may hurt menopausal women psychologically as much as anything," says a 51-year-old Baltimore social worker who has gone through menopause. "Mention menopause and everyone still comes up with a negative image of some hump-backed, broken-down person: That's why I don't want my name used. One of the greatest benefits of better information would be to change attitudes."

Researchers say there is a lot of ignorance about menopause, which is officially reached when menstruation has stopped entirely for a year.

For instance, there's confusion about age: Although the average age for the onset of menopause is 51, some of its earliest symptoms, such as changes in menstruation, can begin as early as the late 30s. It seems related to such factors as family history, smoking -- heavy smokers have an earlier menopause -- and size: Thin women tend to reach menopause earlier.

Although physicians used to consider menopause something of

an overnight phenomenon, it is a gradual transition which often takes years. Some researchers believe women's ovaries begin producing less estrogen, the female reproductive hormone, in their 30s.

Ms. Sheehy says most women are unaware of the uncomfortable range of possible menopausal symptoms. As she describes them in her book:

"At the dignified apex of one's adulthood, to have to worry about being hit with surprise periods, hot flashes, night sweats, insomnia, incontinence, sudden bouts of waistline bloat, heart palpitations, crying for no reason, temper outbursts, migraines, itchy, crawly skin, memory lapses -- 'My God, what's going on?' "

"We know that puberty causes profound changes in a woman's body and a man's body. And no one has an issue that puberty is a tough time socially," says Dr. Bush. "Women have just as profound changes in our internal hormonal milieu at menopause."

Hormone replacment

Ms. Sheehy finds the subject of hormone replacement therapy raises particular concern and frustration.

It is now widely acknowledged that estrogen is the best prevention for heart disease, the primary killer of women over 50, and osteoporosis. However, many health professionals disagree on the best form of hormone therapy to use, on its risks and on length of treatment. It is not recommended for women who have had cancer or such conditions as heart, liver and gall bladder disease.

The most commonly prescribed form of treatment uses both estrogen, a female hormone produced in the ovaries, and progestin, a synthetic hormone similar to the natural female hormone progesterone. Researchers believe that progestin protects the endometrium -- the lining of the uterus -- against the increased rate of cancer estrogen may pose to women on hormone therapy. (Although it has been widely used since the 1980s, progestin has never been officially approved by the U.S. Food and Drug Administration.)

Estrogen replacement therapy is considered the best way to slow bone loss for women at risk of developing osteoporosis, a post-menopausal condition in which the bones become fragile and weak by losing calcium. In addition, estrogen can help stop the hot flashes, urinary incontinence, low sex drive and vaginal dryness which often accompany menopause.

Although several large studies have shown that women on hormone therapy live longer than those without it, long-term use of estrogen has also been linked to higher rates of breast cancer, Ms. Sheehy says.

L It seems that no one is quite sure what to make of all this.

"We're just beginning to get the first basic information about the most profound natural physical transition in a woman's body," says Ms. Sheehy, 53. "We women in our 50s are pioneer women, absolutely. We're in a landscape here that no one has crossed before."

The first clinical study on hormone replacement, Postmenopausal Estrogen/Progestin Intervention (PEPI), is only now under way. Funded by the National Institutes of Health, it will test the results of five different hormone combinations on volunteers at various centers, including Hopkins. The results are expected in 1995.

"It's astounding that we've had a drug in use in this country for 50 years, and that PEPI is the first clinical trial of this drug in women," says Dr. Bush, who is the principal investigator at Hopkins.

Scientists have known about estrogen's ability to protect against heart disease since the 1950s. In one famous study, chickens were fed a high cholesterol diet. Those chickens who were also given estrogen didn't get heart disease. The results of this research, combined with another study of lipids, prompted a clinical evaluation of estrogen in humans.

However, researchers gave the hormone to men who already had significant heart disease.

"The researchers gave them such high doses of estrogen -- almost 10 to 20 times the normal dose for women -- that they developed breasts and had many bad side effects. And estrogen got a bad name in terms of heart disease," says Dr. Bush.

"We now have clear evidence that estrogen decreases the event of heart disease in women on an order of 40 to 60 percent."

900 women in study

relatively small study, PEPI will track 900 women -- about 160 are women of color -- for three years. It is measuring the effects of estrogen and of estrogen/progestin on cholesterols, blood pressure, bone density, blood clotting factors and serum glucose and insulin. The study will also examine how various combinations affect women's sense of well-being.

And it may also shed some light on the reasons why so many women abandon hormone therapy despite its benefits. Ms. Sheehy writes that fewer than 20 percent of American women in menopause are taking hormone supplements. A study by the drug company American Home Products shows that women follow a course of estrogen for an average of nine months, and that as many as two-thirds of the women who begin a combination therapy of estrogen and progestin drop the progestin.

Ms. Sheehy did. Like many women, she experienced such progestin-related side effects as abdominal bloating, fluid retention, weight gain, headaches and anxiety.

Such symptoms have led many women to try a course of estrogen alone, with biopsies of the endometrial lining to check for cancer.

Most doctors recommend the combination, and many patients have no problems with it. Take 57-year-old Helen McFarlin, who works in hematology at Peninsula Regional Medical Center in Salisbury, and is part of the PEPI study.

Future uncertainties

have a very bad family history of heart disease, and zero history of cancer," she says. "I have had estrogen in my body all of my life and that is the way I think it should be."

Others worry about what science may discover about this pioneer therapy in years to come.

"I don't want to take hormone replacement unless the medical community says I have to," says Win Weppner, a 51-year-old nurse in Hopkins' neonatal intensive care unit. "I haven't experienced that many problems that would make me search for a magic cure to make me feel better."

Alice McKenzie, clinical director of the PEPI study and education director of the Over 40 Women's Health Program at Johns Hopkins Hospital, points out that each woman experiences menopause quite differently. However, most want a tangible reason for taking medication.

"If they believe they're not at high risk for osteoporosis or heart disease, they may not be motivated," she says. "There are so many women who fall into a gray area, for whom there aren't any indications for or against the therapy."

"I think one of the most important things is to restore control over your life by becoming the supervisor of your own transition," says Ms. Sheehy. "We're all grown up at this age. It's no time to surrender your common sense totally to a physician or Chinese medicine practitioner or anyone else."

In making decisions, women often weigh their perceptions of the risks of hormone replacement therapy against the benefits of their medically correct diets -- low fats, fewer proteins, lots of grains and lots of calcium -- and their physically correct fitness programs -- regular aerobic workouts alternated with strenuous weight-bearing exercises.

So far, hormone replacement therapy is a dilemma discussed mostly by well-educated women not afraid to question their doctors. In the outpatient clinic at Hopkins, it is up to the physicians to mention it.

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