Most gynecologists now advocate estrogen replacement therapy (ERT) to halt or ease menopausal symptoms, as well as to help prevent osteoporosis and heart disease later in life. Studies show a 50 to 80 percent reduction in hip, wrist, and vertebrae fractures some of the common consequences of steno porosis among women who start taking replacement estrogen within three to five years of menopause. Similarly, estrogen replacement cuts the risk of a heart attack in half, a benefit attributed to estrogen’s role in raising levels of protective HDL cholesterol. Studies also indicate that estrogen may also protect against Alzheimer’s disease, a devastating form of mental decline that is much more common in women than in men. The estrogen may be taken systemically, either by a pill, such as Premarin or Estrace, or by wearing an Estraderm skin patch. If vaginal dryness is the primary concern, localized therapy with an estrogen vaginal cream is usually sufficient. Another localized application, a cervical ring that is impregnated with a time release estrogen, is expect ed to become available soon. Doctors remain divided as to how long estrogen replacement should continue. Some feel that it should stop after two or three years when the body adjusts to its altered hormone levels. In contrast, a growing number of doctors advocate long term or life long ERT, especially for women with a high risk of osteoporosis or heart disease. However, even the most ardent advocates of ERT recognize that there are adverse side effects and risks. The possible side effects include weight gain, fluid retention, increased vaginal secretions, breast tenderness and enlargement, altered libido, nausea, vomiting, bloating, cramps, headaches, dizziness, high blood pressure, uterine bleeding, and depression. Use of the estrogen patch may lessen some of these problems but it can also cause skin irritation or rash at the application site. Even more worrisome is the fact that estrogen replacement increases the risk of uterine cancer. This became apparent in the late 1960s, when estrogen was being prescribed routinely. Almost immediately, ERT dropped dramatically, but returned to favor in the late 1980s when new research showed that uterine cancer could be prevented by lowering the estrogen dosage and adding another hormone, progesterone, to the regimen. Used as part of ERT, progesterone causes a periodic, menstrual like shedding of the uterine lining. It is theorized that preventing an overgrowth of the endometrium is what reduces the risk of uterine cancer. There is still an unresolved question of whether or not ERT increases the risk of breast cancer. Studies to date have produced conflicting results, but one long-term study of 140,000 nurses found a significant increase in breast cancer among women taking estrogen. Estrogen replacement causes blood clots in some women, and should not be used by anyone who has had throm bophlebitis, stroke, or other clotting disorders. It can also cause gallstones and damage the liver, but this last problem probably can be avoided by using an estrogen patch, which allows the hormone to bypass the liver and go directly into the bloodstream. Other women who may have problems with estrogen replacement include those who have diabetes, migraines, asthma, uterine fibroid tumors, endometriosis, hypertension, and lupus or other disorders that are treated with corticosteroid drugs. Although ERT reduces the risk of heart attack, it may actually be hazardous for a woman whose heart muscle has already been damaged, because starting estrogen may provoke congestive heart failure. Other drugs that are sometimes prescribed to treat menopausal symptoms for women who cannot take estrogen include the following:

• Low doses of a beta blocker such as propranolol (Inderal) to alleviate any heart palpitations.
• Diuretics to reduce fluid retention.
• Antidepressants such as fluoxetine to ease severe depression.
• Low doses of oral contraceptives for premenopausal women who experience heavy bleeding.
• Tamoxifen, an antiestrogen drug that appears to protect against osteoporosis and breast cancer.
• Dehydroepiandrosterone, or DHEA, an adrenal hormone that the body converts to androgens, male sex hormones, and estrogen. This experimental hormone therapy is under study as an alternative to ERT

In certain cases, dilation and curettage (D&C), a scraping of the uterine lining, may be recommended, especially when a woman is experiencing irregular another very heavy periods and anemia. Or a hysterectomy may be advised in some instances of severe and unrelenting anemia.

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