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BETHESDA, Md. -- Considering that every woman confronts menopause if she lives long enough, surprisingly little is known about it.
Clearly, women's menopause experiences vary widely, but it's not clear why. Some sail through with nary a hot flash (or flush, depending on where you live), while others have hundreds a week. Hot flashes usually subside after a few years. But for some, they last through old age.
For those with intolerable hot flashes and night sweats, estrogen is the most effective treatment, but doctors aren't certain about how much to take, how long to take it or how best to get off of it.
A conference last week at the National Institutes of Health raised more questions than it answered about treating menopause symptoms. But even that was a refreshing change from the not-too-distant time when dogma governed the care of menopausal women, women's health advocate Cynthia Pearson said after one session.
In 2002, the landmark NIH-sponsored Women's Health Initiative (WHI) dispelled the popular notion that long-term postmenopausal hormone therapy was a virtual fountain-of-youth in a pill or patch. Compared with women who took placebo pills, those given estrogen plus progestin were more likely to have a heart attack, stroke or breast cancer. But the study was not designed to weigh the risks and benefits of hormone use for symptom relief.
The average age of WHI participants was 63. The average age of menopause -- one year after a woman's last menstrual period -- is 51, and women experience the hormonal changes and irregular periods of perimenopause for several years beforehand. (About 300,000 U.S. women have their ovaries removed each year, and if they already had not gone through menopause, they begin having hot flashes within 24 hours of the operation.)
Genetics plays a role
Genetics, hormones and social factors all probably play a role in whether perimenopausal women have symptoms, said University of Pittsburgh psychologist Karen Matthews.
Few women in India or Japan report having menopause symptoms, noted Nancy Avis, professor of social sciences and health policy at Wake Forest University School of Medicine. In an ongoing study of more than 16,000 middle-aged U.S. women, those of Japanese or Chinese descent have been less likely to report symptoms, but it's ''almost impossible'' to explain why, Avis said.
Studies suggest that African-American women are more likely to feel relieved about menopause and no longer having to worry about getting pregnant, said obstetrician/gynecologist Valerie Montgomery-Rice of Meharry Medical College in Nashville. White women are more likely to view menopause as a medical problem needing treatment, she said.
Sorting menopause symptoms from aging symptoms is tricky. For example, incontinence is more common in older women, said University of Iowa endocrinologist Bradley Van Voorhis. But the WHI found that bladder control worsened in women on hormones, compared with those on a placebo, suggesting the problem is unrelated to menopause, he said.
After listening to Van Voorhis and other speakers, an independent panel convened by the NIH concluded that only hot flashes, night sweats, vaginal dryness, painful intercourse and, probably, sleep disturbances were linked to declining estrogen.
Estrogen's uncertain role
Most women don't get depressed during perimenopause, and researchers have not yet identified characteristics that might predict who will, said Peter Schmidt, chief of reproductive endocrine studies at the National Institute of Mental Health. Studies have shown that three to six weeks of estrogen therapy improves the mood of depressed perimenopausal women but not postmenopausal women, Schmidt said.
Although estrogen is the most effective treatment for menopause symptoms, conference speakers cited a lack of information about how to take it.
Women have numerous products to chose from, said Marcia Stefanick, professor of obstetrics and gynecology at the Stanford University School of Medicine. ''Many women would like to know which one of these is the best for me,'' she said. ''Side-by-side comparisons of the many available products haven't been done.'' Part of the problem, Stefanick said, is that Food and Drug Administration guidelines for testing new estrogen-containing therapies exclude symptomatic perimenopausal women.
After the WHI findings were announced, the FDA and others advised women with menopause symptoms to take the lowest dose of hormones for the shortest time possible. Little is known about the risks of using low-dose hormones for a few years, but scientists assume the lower doses are probably safer than the higher doses.
University of California-San Francisco internist Deborah Grady noted that symptoms often resume when women stop hormone therapy. ''It treats symptoms essentially by delaying menopause,'' Grady said. ''They may have to flush now or flush later if they're going to go on hormone therapy.''
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