Two in five menopausal women in the U.S. take estrogen, but recent studies seem to upset the benefit-risk balance

One headline in January announced that a popular combination of hormones for menopause symptoms increased the risk of breast cancer, the biggest killer of women in their 40s.

Another headline earlier this month proclaimed that, for older women who have had heart attacks, hormones do not slow heart disease, the biggest killer of women in general.

This for a therapy used by nearly two in five American women between the ages of 50 and 74. One drug commonly used in the therapy, a form of estrogen called Premarin, is the most widely prescribed drug in America.

Hormone-replacement therapy is used to replace estrogen and progesterone, two hormones the body stops producing when a woman's fertile years end. But as the recent reports show, the science on taking hormones is far from complete and sometimes contradictory.

Answers to some of the most basic and frequently asked questions can help. So can the stories of other women. Here are the experiences of six who, like so many others, have grappled with the decisions surrounding hormone-replacement therapy (HRT). Demographically, these women are not representative. Indeed, the rate of breast problems among them is out of proportion with rates among women in general.

But many of these women are from a generation that may be among the most committed to taking control of their bodies. Their deliberations underscore how menopause makes for a difficult stewardship.

Becky Brown

Becky Brown, 47, has been laying the groundwork for the onset of menopause for two years now.

She visited a naturopath "to clean out my body to have it ready . . . I had friends who had gone through menopause. I don't walk around with my head in the sand."

Now Brown is in a holding pattern - holding out as long as possible in the early stages of menopause before even considering taking a supplement.

She's been fitting into her diet more soy products, a natural source of estrogen. She's reading "The Pause: Positive Approaches to Perimenopause and Menopause," by Lonnie Barbach. But as prepared and informed as she is, she still talks in questions.

What about the cancer risk posed by hormone-replacement therapy?

"My golly, every time I turn around - and it's not just famous people, it's people I know - more people are getting breast cancer and they're getting it younger," said Brown, capital-campaign director for Planned Parenthood.

Just how bad, she asks herself, will I let the symptoms get before seeking medical therapy?

A sound sleeper, she had a brief spell of sleeplessness and hot flashes last September. It passed but then returned about three weeks ago. Married, with a 7-year-old girl and a 10-year-old boy, the Ravenna resident worries about the strains of menopause symptoms affecting her daily life.

"I'm finding that I'm much more irritable and I don't know if that's from lack of sleep or whether . . ." She pauses. "And the other thing that happens, is your memory goes."

And now there's a report that says hormone-replacement therapy doesn't slow the advance of heart disease in older women who have had heart attacks. The report cuts into the generally accepted thinking that estrogen replacement improves heart health.

"How can you even begin to evaluate this?" she asks.

As with so many women wrestling with the issues of menopause and hormone therapies, the answers aren't coming easily to Brown.

"What did women do for years before we had HRT?" she said. "We lived before we had HRT. So I have to wait to where I'm at a level where I can't take this anymore, I can't stand this, before I decide if I'm going to take this."

Linda MacIsaac

Linda MacIsaac, 57, feels like a victim of the "born-too-soon syndrome." A few years later and she might have had a clearer picture of the risks and benefits of hormone-replacement therapy, as well as more alternatives from which to choose.

When the first waves of hot flashes and moodiness hit in 1993, she tried to forgo estrogen.

"My philosophy has always been the best medicine is the least medicine," she said.

But the flashes were incredible. "You're sweating buckets," she said. "You're wiping your brow."

Worse yet, there were times she simply didn't want to get out of bed, let alone go to work, a liability when your job is dealing with at-risk middle-schoolers.

"I work in a classroom that is very out of control," said MacIsaac, who is taking time off her job as an instructional assistant for the Bellevue School District to care for the 2-year-old son of her daughter. "All I needed was for me to be out of control."

Reconsidering her options, she concluded she was only replacing something that was already in her body and started taking a combination of estrogen and progestin, a synthetic form of progesterone. Instantly, her life returned to normal.

"This is a life-changing crisis if you're an active, intelligent, outgoing person," she said. "Having the HRT was like, `Wow, this is the answer.' "

But in 1997, two years after starting the therapy, a mammogram showed MacIsaac had a fast-growing, inch-wide lump. It was malignant. She had the lump removed, then six months of chemotherapy and daily radiation treatments for close to three months.

She is now on tamoxifen, a breast-cancer preventive, and off estrogen.

In retrospect, she wishes she had had more information before taking estrogen. But while she blames the estrogen for causing her cancer, she'd consider taking it again - after trying other options. Her symptoms were that bad.

Mattie Taplin

Mattie Taplin, 49, started having hot flashes three or four years ago and feels agitated from time to time. But she's healthy. Taking a pill under such circumstances would be like fixing something that is not broken.

"It's still not something that I feel is worth going to the doctor and taking something for," said the Seattle resident. "I feel like anything you have to have every day has to have some kind of side effect."

Which is not to say Taplin, the mother of an 8-year-old girl and an outreach specialist for Senior Services, is cavalier about menopause's implications.

Last year she attended a YWCA workshop on hormone-replacement therapy. She talked about it with her doctor.

She settled on four Tums tablets a day for the calcium that might fight osteoporosis, a weakening of the bones exacerbated by menopause and slowed by estrogen supplements. But she stopped after she thought they were actually making her feel stiff. As an African American, she is also at less risk for osteoporosis and has seen no signs of bone problems in her 80-year-old mother.

Moreover, if she were to go on hormone replacements and then develop cancer, "I would be angry and mad, like the people that have been smoking cigarettes and are now suing the cigarette companies."

In the end, it's just a matter of taking things as they come, occasionally fanning herself to cool off.

"Some feel like when you have to fan, people say, `She must be in menopause,' " she said. "I really don't care. I'm not ashamed of my age."

Jean Carpenter

You're getting testy, Jean Carpenter's husband and two grown kids said.

I'm not the testy one, she would say. You are.

On top of that, she was getting hot flashes to the point where she would wake up in a sweat and want to peel her clothes off. "It was just exasperating for everyone concerned," said Carpenter, 55, regional-governmental-relations manager for King County and a former Bellevue City Council member.

Two years ago, she had a long conversation with her doctor, who suggested she might feel better with Prempro, a combination of estrogen and progestin.

"It was true - I felt better," she said. "I slept better. Everybody said I was much easier to deal with. The hot flashes went away. I didn't have night sweats. It was really great."

But even before the therapy, she was worried about breast cancer, which had hit both a friend and her own mother. In October, after the cancer returned, Carpenter's mother died of it.

Then Carpenter read about the Jan. 26 Journal of the American Medical Association report saying breast cancer can be even more likely in women taking estrogen and progestin combined.

"I just took the Prempro and threw it out the window," Carpenter said. "I just decided I'd rather die of a heart attack because it is a very, very difficult thing, this breast cancer."

This time, her symptoms don't seem so bad, she said, possibly because she is eating more soy, a source of plant estrogens said to ease symptoms in some women. She's exercising more.

She's also wondering if the furor over hormone therapy stems from an outsized desire to have "something that fixes everything."

"Basically we do go through different physiological changes as we age, and we're in different periods of our lives," she said. "Instead of accepting those and loving the wrinkles because they mean we've been through life, we tend to say, `Oh no, no, no, no.'

"I've just given up on all that silly stuff and I'm loving my wrinkles and my gray hair and I've decided to embrace my moods. And if people don't embrace them with me, they can go embrace somebody else's mood."

Last Wednesday, Carpenter had a small lump removed from her breast. It was benign.

Sandy Valko

It has been seven years now since Sandy Valko started taking hormone-replacement therapy. She doesn't know what would happen if she were to stop, but she doesn't want to find out.

She's got too much to do.

"I was having menopausal symptoms that I felt were preventing me from doing my work," said Valko, 58, who commutes from Bellevue to Seattle for work as a health educator for the federal Cancer Information Service.

"I wasn't sleeping well at night. And because I was having night sweats, and I just wasn't feeling well generally - low-energy - I just didn't have that spark that I was used to having."

Moreover, because she has small bones, she is at risk for osteoporosis. After talking at length with her doctor, she went on combination therapy.

"For me, that works. I feel good," she said. "But I know a lot of other women don't want to deal with that, so they do it differently. It's a very personal thing."

Because of her job with the information arm of the National Cancer Institute, Valko was, of course, aware of the possibility of breast cancer.

"I'm inundated with cancer information here," she said. "I think what I decided is that the cardiac benefits and the osteoporosis benefits outweighed the small increase in breast-cancer risk." But that was then.

"We have more information now," she said. "We now know the breast-cancer risk is higher and we think that there's no cardiac benefit.

"I feel like I'm at Square 1, like I've really got to re-evaluate this." Indeed, Valko saw a suspicious shadow in her last breast exam. If it proves to be a cancerous lump, she will have to stop her hormone therapy. For now, she's exploring exercise as a way to fend off osteoporosis. Other than that, she doesn't know what she will do.

"I wish I did."

Suzanne Davis

It's not easy for a woman to decide if she should undergo mainstream hormone-replacement therapy, but the "natural" route isn't easy either.

Witness Suzanne Davis, a Bellevue mother of two teenagers, who has felt mild symptoms for about a year now.

"I guess I'm all for it happening naturally," she said. "If the body shuts down, it does it for a reason. We're not talking long-term. The body regulates itself after a while."

A former ballerina in London and in her native Australia, Davis, 48, now has a hard time remembering the names of her students at the Washington Academy of Performing Arts in Redmond. Her attention span is shorter. She gets snappy more easily. She used to be up at 5 a.m.

"The energy resource is not there anymore," she said. "If I wasn't flexible and was working and cooking and ironing for my family, I could go down pretty quickly."

Her naturopathic physician suggested homeopathic and Chinese herbal remedies. They didn't work.

A thin woman, she is at risk for osteoporosis and needs to watch out for bone loss.

She eats mostly natural foods and tries to avoid processed foods. She stays fit and suspects it will help keep the symptoms of menopause at bay. She meditates regularly.

Whatever happens, Davis is giving no sign of turning back.

"I'm just open for all the symptoms that I'm going to experience from now on," she said.

She also feels women should share more of their experiences.

"If they knew other women were going through the same thing, they might have more patience."

Eric Sorensen's phone message number is 206-464-8253. His e-mail address is