Robyn Gyuru did not need last year's unexpected news from the Women's Health Initiative to tell her that menopause and the drugs long-prescribed to ease its symptoms are a gamble. She'd been trying to select the right combination for months.
Menopause made her mind fuzzy. Not possible, her doctors told her.
Prempro, prescribed to ease hot flashes, made her angry and tense. "I took hormones for six months, and I wanted to kill my husband," Gyuru says.
Let's try an antidepressant, the doctors said.
Fewer flashes. But she was a zombie.
"I had days I couldn't get out of bed," says Gyuru, 51. She is president and CEO of Quick Trip Express Freight Services, an air freight trucking company in Tampa. "I employ 20 people. I have to be on my toes."
Doctors either wanted to dismiss her as a whiner, she says, or medicate her into obliviousness.
"I went to a female gynecologist, and she did everything but open my mouth and force the hormones down," says Gyuru.
Relief came in a friend's recommendation that Gyuru try Eastern medicine. Twice-monthly acupuncture combined with Chinese herbs, multivitamins and a progesterone cream have finally proved the winning combination.
"I have gotten so much better so quickly," she says. "I've gone from 10 hot flashes a day to having two or three. But it's more than that. My whole body started feeling different right away."
Finding what worked for her took Gyuru almost two years. She was frustrated by a dearth of medical proof on treatments and a seeming lack of knowledge by her caregivers. Millions of women were similarly confused last year when Prempro, a drug prescribed for menopause symptoms and heart and bone health, was found to increase a woman's risk for heart attacks, strokes and breast cancer. Thousands quit hormones cold turkey. Hot flashes returned with a vengeance. A search for alternatives often yielded only questions.
A Food and Drug Administration Web site (www.fda.gov/womens/menopause) launched this year as a resource addresses the Women's Health Initiative, but little else. The FDA recommends hormones at low doses for less than five years.
But there is virtually no mention on the site of bio-indentical, or natural, hormones advocated by many doctors and women's advocacy groups as safer because they mimic those made in the body.
Also missing is information about forms of hormone delivery: oral capsules, skin patches, vaginal rings, creams, gels or drops placed under the tongue.
Herbs such as black cohosh, which in small studies has been found to ease hot flashes, are dismissed as unproven.
"Not all HRT (hormone replacement therapy) is created equal. (FDA is) putting all . . . into the same cautionary boat," protested Dr. Jane L. Murray, founder of the Sastun Center of Integrative Health Care in Mission, Kan., in a news release critical of the FDA site.
Women seeking definitive answers won't find them elsewhere, either.
One study published in the journal Lancet found that hormones increase the risk for blood clots when given orally but not transdermally by patch. But the numbers studied were small, the results inconclusive.
Soy protein and herbal supplements often recommended for menopause are also the subjects of conflicting data. In 2003, about 60 postmenopausal women who suffered at least seven hot flashes a day were given either soy-derived isoflavones or placebos. At study's end, both groups had a 40 percent reduction in the number of flashes. Isoflavones from red clover proved ineffective as well. None of the results are conclusive.
"We don't really have the facts. Things are more complex than they appear to be," says Dr. Margery Gass, director of the menopause and osteoporosis center at the University of Cincinnati College of Medicine. Gass is past president of the North American Menopause Society. On Sept. 17 in Miami Beach, the society recommended to doctors and other clinicians that hormone replacement therapy be limited to the lowest effective dose for the shortest possible duration.
What kind of therapy should a woman choose?
Gass says estrogen, whether natural or synthetic, affects the body the same. Delivery method is no guarantee, either. The form of estrogen used in creams and patches is one of the most potent, she says.
"Is that safe?" Gass asks. "We don't know. If you want the most natural, you just (go through) menopause and get on with your life" without therapy.
Menopause is defined as when a woman stops having periods, usually between the ages of 45 and 55. Hormonal changes can begin as early as the 30s, when levels of progesterone begin declining. This transition period can last from six months to 10 years, but experts say its harsher symptoms last only a year or two.
Each woman will experience menopause in her own way, much as she does menstruation or even pregnancy. Some will not suffer. Others will be incapacitated. Gyuru took the antidepressant Paxil for almost a year. The Journal of the American Medical Association in June published research that found paroxetine, the generic equivalent of Paxil, cut hot flashes in half. Gyuru couldn't live with the side effects.
"I couldn't deal with people," she says.
Menopause also made her lose mental focus, she says. Some doctors discount women's complaints of "fuzziness" as unrelated to hormone levels. But changing levels do interrupt sleep patterns, says Dr. Anna Parsons, a reproductive endocrinologist and associate professor at the University of South Florida College of Medicine. Parsons prescribes the anti-anxiety drugs Prozac and Effexor for some patients to not only stop hot flashes but encourage sleep.
"The crankiness, the feelings of loss of control _ most has to do with not having enough sleep," says Parsons. Used for a short time, the anti-anxiety drugs are much safer than hormones, which affect every cell in the body, she says.
"There needs to be an alternative to pharmaceutical HRT," counters acupuncture physician Carol Ann Bates of Clearwater. Her patients, including Gyuru, often do well on a combination of treatments including herbs, vitamins, acupuncture and, during particularly intense stretches, prescription hormones. In menopause, a woman's hormones and thus her treatment needs will fluctuate from week to week, even day to day, Bates says.
"A woman knows what works for her."
There is no debate in the medical community over where treatment should begin: Exercise, good nutrition, adequate sleep and reduced stress all moderate menopause's symptoms, its moods, and its consequences, including loss of bone density. Keeping pounds off is important, too, say Parsons and others. Excess body weight puts additional estrogen in a woman's system, complicating the transition and, potentially, her overall health. The women in the WHI study were an average of 18 pounds overweight, Parsons says. "You don't have to (automatically) gain weight at 40."
Parsons advises women to seek out knowledgeable providers and to ask specific questions. "If they seem disinterested, I would seriously consider moving on or getting a consultation with someone else."
For Gyuru, the choice was between "doctors who have been taught by the drug companies that pharmaceuticals cure everything" and an array of treatments that support what is, after all, a natural phase in a woman's life.