By PATRICIA GUTHRIE 
The Atlanta Journal-Constitution 

Marisue Bevacqua tried life without hormones.

But she didn't last long. Within one month she was back to her morning mix of one dark green capsule, one little white pill -- an estrogen and progestin combination.

"I had hot flashes, night sweats, I couldn't sleep. It all started up again," said Bevacqua, 64, of Dunwoody. "I tried the patch for about two weeks but then went back to the pills. I really don't like to have to take anything, but my body still needed the hormones."

Bevacqua could be Every Woman of a Certain Age in America. Millions face her same double-edged dilemma: coping with menopause, or in her case post-menopause -- and the continuing bad and baffling news about hormone replacement therapy.

"Many women don't know whether to take hormone replacement therapy or to listen to [a] new study about anti-depressants and hot flashes, or if they should try herbal therapy, such as black cohosh or soy," said Dee Baldwin, executive director of the Office of Women's Health, a division of the state Department of Community Health. "It's all over the place. You don't know what to advise people other than to have them sit down with their doctors and discuss all the options."

That's been the standard advice since July 9, 2002, when researchers announced halting a clinical trial involving 16,608 post-menopausal women because long-term hormone replacement therapy that combines progestin and estrogen caused more harm than good. The study involved Prempro, the nation's most popular HRT.

The Women's Health Initiative, funded by the National Institutes of Health, found that specific form of HRT to increase the risk for breast cancer, heart disease, strokes and blood clots, while lowering the risk of developing colon cancer and hip fractures. Further analysis revealed the combination drug also increased the risk of dementia in post-menopausal women, and rebuffed popular beliefs that it increased vitality, sexual satisfaction and sound sleep.

Dory Ingram, 56, of Morningside, said she was "horrified" when she heard the 180-degree turnaround of medical advice on the "wonder" drug she'd taken for a decade.

"I did everything I could to educate myself on the situation, including reading, sitting in Web M.D. chat rooms, talking to my doctors and consulting with friends," Ingram said. "I became the HRT maven in my circle of friends."

First, her doctor switched her to another synthetic hormonal therapy. Then, with her internist's blessing, she decided to wean herself off the hormone over six weeks.

Although hot flashes and night sweats returned, some good side effects also occurred. "I lost 5 pounds and I felt better than I had in years," Ingram said. "There were fewer stress-related headaches and a feeling of increased energy."

With a brand-new bachelor's degree in fine arts from Georgia State University and brushes in hand, Ingram is painting a series of works about menopause and aging.

"They are self-portraits, and I'm the 'Fool' in the tarot cards," she said, "portraying myself as a menopausal woman dealing with this whole mess."

Short-term use of combination estrogen and progestin for relief of menopausal symptoms is now the recommended use of Prempro, according to the U.S. Food and Drug Administration. HRT had never been approved for cardiovascular protection, but this "off-label" use had become standard medical practice based on observational studies. Using it for osteoporosis prevention for post-menopausal women was also widely practiced -- doctors are now more likely to prescribe drugs such as Fosamax, which helps to slow the breakdown of the bone.

The number of women who use Prempro has dropped from 3.4 million to 1.2 million in the past year, according to Wyeth Pharmaceuticals, the drug's manufacturer.

Wyeth has added a warning about cardiovascular risks to its Prempro, Premarin and Premphase packaging. Premarin is estrogen only and used by women who've undergone a hysterectomy; another federal study involving some 11,000 women taking Premarin only is still underway. Premphase is a lower-dose combination hormonal therapy. And the FDA has just approved a lower-dose Prempro. Whether taking a lower-dose combination synthetic hormone will produce similar health risks as the standard dose of Prempro remains unknown.

Many women are turning to other forms of therapy. Which is exactly what Ingram and her physician did. She now takes the estrogen-receptor drug Evista to help protect her thinning bones.

Charlotte Weinstein, 51, uses a patch filled with the drug Clonidine. Relief of hot flashes has become one of the "off-label" uses of the drug, which is approved to lower blood pressure.

"It has been, for me, miraculous," said Weinstein, who works at a cardiology specialty office. "My hot flashes are mild now, not like before. They were occurring every two hours and were a pain in the butt at work. It worked very quickly. I could tell the difference the first week."

More and more, the category of "other" is being tried to help women through menopause. A study released this month revealed that a popular anti-depressant drug, Paxil, reduces the severity and frequency of hot flashes. Similar successes have been reported with other relatively new anti-depressants.

Hot flashes, which are often accompanied by flushing and heart palpitations, are thought to involve low levels of serotonin, a chemical that lets brain cells communicate with each other. This is why drugs known as selective serotonin reuptake inhibitors provide some relief.

Doctors point out that there are also fairly simple solutions that work for many women -- such as giving up caffeine and spicy foods to reduce hot flashes and adopting a healthier diet and exercise routine for reducing heart disease.

Baldwin, the state director of women's health, admitted she's still looking for solutions to the temperature tantrums that her body throws day and night. She's ruled out taking HRT because of cardiovascular disease in her family.

She does make soy-based shakes because studies have shown soy can help lessen hot flashes. However, she shies away from other alternative therapies because many haven't been scientifically scrutinized. "Just the other day someone told me to take some kava," Baldwin said, "and I asked, 'Is that a herbal product or what?' And they didn't know. They just said they were taking it because someone else told them to take it." Kava, also called kava kava, is said to lessen anxiety and help with hot flashes; however, it is under investigation by the FDA for its association with liver damage. Consumers are advised to consult their doctor before taking any herbal supplement.

Addie Alberghini, 54, said that when her "change of life" kicked in early more than 10 years ago, she "went to hell and back." And her husband, Al, suffered in his own way through his wife's monumental menopausal swings.

"She would absolutely explode and be virtually out of control for no reason at all," Al Alberghini, 70, recalled of the not-so-good old days. "She would dredge up things from five years before. Initially I would explode, too, but that would serve no purpose.

"I knew she wasn't sleeping, and it's not right when someone doesn't sleep."

Now both wake up rested since Addie switched to Biest, a soy-based pill that mimics two estrogens, called estradiol and estriol, that decline in a woman's body when menses cease. The prescription drug must be ordered through a compound pharmacist who customizes the mixing of drugs and doses for individuals.

Alberghini also takes melatonin to help with sleep, as well as vitamins.

Relief is sweet and cool and quiet for the Dunwoody couple. "It was like walking through the fires of hell before," Addie said. "I'd have two or three hot flashes in a row and just be dripping with sweat. . . . I think if I'd married a different man, we'd be divorced by now. God bless him."

Copyright 2003 The Atlanta Journal-Constitution
 

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