The HRT Dilemma

Hot flashes, night sweats, and mood swings are the bane of millions of menopausal women, and escape is far from simple. That old miracle cure, hormone replacement therapy, has been largely shunned since the government's landmark Women's Health Initiative study in 2002 reported higher rates of breast cancer, heart disease, and strokes in postmenopausal women who took hormones. Indeed, about 75 percent fewer women are taking hormones during menopause now, and a recent study in the New England Journal of Medicine suggests that this pullback might have contributed to a 9 percent drop over the past few years in the number of women diagnosed with breast cancer. (A decline in screening may be responsible, too.)

Natural remedies like soy and exercise give some women sufficient relief. But others have no choice but to bear the risk of at least a short course of HRT. "It's still the most effective treatment," says JoAnn Manson, a professor of medicine at Harvard Medical School who was one of the principal WHI investigators and is the author of Hot Flashes, Hormones, and Your Health. The American College of Obstetricians and Gynecologists now recommends that women seeking medication be given the lowest effective dose for the shortest possible time. The latest data suggest that taking hormones for up to five years directly after the onset of menopause adds no heart risks and might actually be protective. Studies conflict on the breast-cancer dangers associated with short-term use, but any added risk declines after going off the hormones. Here's how three women, all experiencing severe symptoms, have decided to cope:

Hormones or Ambien? For Barbara, 48, the need for sleep has overwhelmed her nagging fears (her mother battled breast cancer after using hormones for two decades). The New York public-relations executive, who prefers only her first name be used, found herself waking up six or seven times a night over the past six months, sweating and overheated. "Going to sleep became very stressful," she says, "and I was exhausted all the time." Because Barbara was still getting bimonthly periods, and her doctor didn't want to discuss hormones until she was officially in menopause, she was given a prescription for the sleeping pill Ambien. But rather than waking up well rested, she felt groggy the entire day.

So, Barbara threw the pills away and got a second opinion. It would be OK, she was told, to take hormone therapy as long as she kept her IUD in place and didn't rely on the low doses of estrogen and progesterone to prevent pregnancy. Almost at once, Barbara slept significantly better. With the consent of her doctor, Barbara plans to taper off every six months to see if her body has adjusted to her natural hormone levels and she can sleep without help. "I definitely keep the risks in mind," she says.

Going the natural route. Debra Stokes, 52, certainly could use HRT: Several times a day, without warning, sweat suddenly pours down her face while she's singing in her church choir or standing in line at the grocery store. But the mother of two from Marietta, Ga., had a breast lump a few years ago and declines to take a chance on hormones. The lump turned out to be benign, but "I feel like there's already something unusual going on with my breast tissue," she says, "and I don't want to add any complications to it."

Stress and particular foods aggravate her symptoms--probably by leading to a slight rise in core body temperature. So she lets off steam by playing tennis, practices staying calm in the face of life's irritations, and watches her diet. "My hot flashes don't like red wine and hot coffee," she explains, "so I try to drink pinot grigio and tea." She also carries a freezer-chilled gel pack that she designed to apply to the back of her neck. It works so well she named it "Glistens" and sells it on the Internet.

When nothing else work. Flaxseed oil and soy supplements didn't help at all to relieve P. J. Nunn's night sweats and mood swings. So the 50-year-old publicist from Cedar Hill, Texas, who was adamantly opposed to hormone treatment, began swimming every day after reading that exercise eases these symptoms. Though she did gain energy from getting physically fit, Nunn still suffered from sudden periods of despair. "It was almost a split-personality sort of thing," she recalls.

Finally, four months ago, Nunn, who is overweight, was diagnosed with severe hypertension for the first time. Blood pressure medications brought her to a safer level, but she still had dangerous spikes from time to time. Suspecting that hormonal changes might be a factor, her doctor persuaded her to add hormones to the mix. Besides lower pressure, she has enjoyed an added benefit: no more hot flashes or mood swings. "I don't intend to be taking hormones for the rest of my life," she says. Meantime, she's counting on any bad they might do being outweighed by the good.

By Deborah Kotz