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" Not long ago, a friend told me about a coffee date she&amp;#039;d had with a 50-something former office mate, Susan. As the two women were sipping their lattes and catching up on each other&amp;#039;s lives, Susan nervously glanced around the coffee shop, then leaned across the table and confided in a low voice, &amp;quot;I&amp;#039;m taking estrogen.&amp;quot; So it&amp;#039;s come to this. Whereas women once chatted openly about their hormone-therapy regimens, they now confess their dependence on estrogen in a whisper, as though it were an illicit street drug. Chalk it up to the 2002 report from the Women&amp;#039;s Health Initiative, when researchers announced that the popular drug Prempro \u2014 a combination of estrogen and progestin \u2014 raised the risk of breast cancer, stroke, heart attack, and blood clots. The study was stopped, and millions of women threw away their hormones.  But then came what sounded like a reversal: In 2004, additional WHI data crunching showed that women taking estrogen alone were not more likely to develop breast cancer or have heart attacks (though the higher risks for strokes and blood clots still stood). And just last year, two studies on women in their 50s suggested that taking estrogen alone might actually protect middle-aged women&amp;#039;s hearts. Even researchers have been scrambling to sort out what&amp;#039;s behind the seeming contradictions. Is it the type and mix of hormones that are making a difference? The timing of when women start hormone therapy and how long they stay on it? All of the above \u2014 and more?  Answers are still coming in, but meanwhile, thanks to studies already completed, doctors today have a more nuanced understanding of how to weigh the benefits and risks of taking hormones. Better information is helping them tailor prescriptions to individual patients. And an ever-growing number of new formulations offer options that may minimize dangers while still easing the often stormy passage through perimenopause and menopause.  The Long Goodbye  Typically, perimenopause starts in your 40s. It may take mere months or drag on for years. During this time, your ovaries shrink, causing drop-offs in the amount of estrogen and progesterone circulating in the bloodstream. But don&amp;#039;t think &amp;quot;gentle, steady decline.&amp;quot; Rather, hormone levels spike and sputter. That&amp;#039;s why periods become irregular or sometimes shockingly heavy. It also may be why some women struggle with irritability and moodiness that echo PMS but strike more randomly and, frequently, more often. Somewhere between 45 and 55, perimenopause becomes true menopause, which is confirmed only after 12 months pass without a period. After menopause occurs, estrogen and progesterone flatline at a low, even state that many women find more comfortable than the sudden fluctuations.  Not that every woman is miserable during the transition. Right now, Charlotte Pierce, a 51-year-old mother of two who runs a home-based publishing company, is only mildly bothered by irregular periods and occasional forgetfulness. That&amp;#039;s true for plenty of women, says Margery Gass, M.D., director of the University Hospital Menopause and Osteoporosis Center in Cincinnati. You&amp;#039;re just less likely to hear about those who cruise through with little disruption to their lives.  But if you&amp;#039;re less fortunate than Pierce, there is help, whether you&amp;#039;re struggling with wildly unpredictable periods, annoying hot flashes, or sexual difficulties. What will work best depends on your symptoms. Here&amp;#039;s a guide to the new hormone decisions you may confront.  If You Have Irregular or Heavy Bleeding  Early in perimenopause, the time between menstrual cycles frequently shortens. Later, it&amp;#039;s typical for cycles to both shrink and expand as out-of-whack hormones stop triggering ovulation and releasing progesterone like clockwork. Skipped periods are common, sometimes contributing to heavier bleeding in the next cycle. Don&amp;#039;t be fooled by those missed months: Pregnancy is still a real possibility.  Will hormones help? Yes, if your problem is hormonal. Your doctor may prescribe birth control pills, which suppress ovulation and provide more even levels of estrogen and progesterone. Another option for some women is taking progestin (the synthetic form of progesterone) alone, to help regulate cycles. But very heavy or prolonged bleeding could also signal fibroids, polyps, or possibly precancerous growths, so be sure to see a gynecologist to find out what&amp;#039;s behind your symptoms, says Marcie Richardson, M.D., director of the Menopause Consultation Service at Harvard Vanguard Medical Associates in Boston.  Next Page: Read more about menopause symptoms and hormone therapy solutions. If You Have Hot Flashes and Sweats  Getting a close-up of global warming? As hormones fluctuate during perimenopause, roughly three out of four women experience hot flashes. One in 10 is truly miserable. During the day, these episodes, which last one to five minutes, range from mild to wildly uncomfortable and deeply embarrassing. At night, they can cause major misery, as sleep becomes an idle dream.  Will hormones help? Lifestyle changes may help you cool off sufficiently. But if not, hormone therapy (HT) does ease hot flashes and sweats. Indeed, that&amp;#039;s one of the three FDA-approved uses of HT (the others are treatment of vaginal dryness and osteoporosis prevention). For some women, like Tricia Droney, 52, who was having up to 40 hot flashes a day, HT is the most reliable remedy. You&amp;#039;ll need the kind that works systemically \u2014 pills (many brands, including Prempro, Femhrt), patches (Vivelle-Dot, CombiPatch), gel (Divigel, EstroGel), spray (Evamist), lotion (Estrasorb), or one type of vaginal ring (Femring).  Unless you&amp;#039;ve had a hysterectomy, it&amp;#039;s standard for doctors to prescribe estrogen combined with progestin to block overgrowth of your uterine lining (which can lead to endometrial cancer). Combination therapies can be continuous (both hormones daily) or cyclic (typically, progestin added 10 to 14 days a month). Medically speaking, none of these regimens has clear benefits over the others.  If You Have Vaginal Dryness  As you enter menopause, vaginal walls thin and become drier. This is one symptom that doesn&amp;#039;t settle down with time \u2014 if anything, it can grow worse. Sex may be painful, and you may become more prone to urinary tract infections because the urethra, which carries urine from the bladder, is more easily irritated.  Will hormones help? Estrogen works well to rejuvenate and lubricate vaginal walls. Unless you&amp;#039;re also having bad hot flashes, both the FDA and the North American Menopause Society advise that you try a product that you apply locally (but not Femring, which is a systemic product). Since minimal estrogen spills into the bloodstream, these products are a better option if you have health issues that rule out pills or patches. Choices include a vaginal ring worn for three months (Estring), cream (Estrace), or suppositories (Vagifem). You may also want to try hormone-free personal moisturizers (such as Replens), which you apply twice weekly, and in-the-moment lubricants (such as Astroglide and K-Y Silk-E) before or during sex.  If Your Sex Drive Is in a Dive  This is tricky territory, says Dr. Richardson. Yes, libido generally wanes with age. &amp;quot;But how much of that is estrogen related, how much is linked to other hormones, and how much stems from aging nerve and connective tissues, life stresses, or relationship issues isn&amp;#039;t clear,&amp;quot; she says. Lack of sleep, changing body image, and painful sex due to vaginal dryness also dash desire.  Will hormones help? In one small four-month study of healthy women between ages 45 and 55, HT boosted sexual thoughts and interest. But research has been mixed, and if a lack of estrogen isn&amp;#039;t the problem in your case, it&amp;#039;s unlikely to help. Try out a few quick fixes \u2014 lubricants, perhaps, or making some fantasies real (including the one where your partner does more housework). If these fail, talk to your doctor about specific issues and options.  If Your Memory Is Shot  Foggy brain? Fumbled words? Frantic hunts for cell phones and keys? &amp;quot;It takes a village to complete a thought,&amp;quot; says Kaye Denny, 53, who works alongside several women facing the same frustrations. The estrogen dips of menopause have been blamed for these cognitive challenges, but midlife brings other stresses \u2014 and often, an overloaded plate \u2014 that also mess with your mind.  Will hormones help? A multicenter study recently showed that hormone therapy did nothing for memory. One exception: If your brain fog is the result of patchy sleep due to hot flashes and sweats, then HT might be part of the solution.  If You Can&amp;#039;t Sleep  Waking up repeatedly because of hot flashes and sweats leaves many women dragging the next day, not to mention irritable and forgetful. But temperature-control problems may not be the only cause: Some people simply start to have trouble falling asleep or staying asleep during these years, even if they&amp;#039;re not getting overheated or drenched.  Will hormones help? HT does seem to help some women fall asleep faster, says Michelle P. Warren, M.D., medical director of the Center for Menopause, Hormonal Disorders and Women&amp;#039;s Health at Columbia University Medical Center. It may also help you stay asleep, Dr. Richardson says. But this research isn&amp;#039;t definitive. Upping daytime activity, dealing with stress, and practicing good sleep habits might do more to get you the rest you need. Lesley Bannatyne, 54, found exercising regularly helped cure her sleeplessness. &amp;quot;I had to make myself physically tired every single day,&amp;quot; she says. &amp;quot;When I started walking more and taking exercise classes, I really slept better.&amp;quot;  Next Page: More menopause symptoms and how to safely stop hormone therapy. If You Have Joint Pains  When millions of women stopped hormones after the WHI report in 2002, some doctors were suddenly fielding fears about arthritis, says Dr. Richardson. Kathleen Kalell, who started HT in her mid-40s for hot flashes, has been on and off several times in more than a decade. &amp;quot;Each time I go off, my mobility is really impaired,&amp;quot; she says. Exercising and even climbing stairs become difficult because of her knee pain.  Will hormones help? HT is controversial here \u2014 taking hormones for joint pain is definitely an off-label use \u2014 but there are women and gynecologists who swear by it. &amp;quot;I don&amp;#039;t look like I&amp;#039;m 200 years old when I&amp;#039;m walking,&amp;quot; says Kalell. If achiness is your only symptom, talk to your doctor about other possible causes and other forms of relief first.  If You Are Moody  Hormonal spikes and dips may prompt bursts of irritability, anxiety, depression, and overall moodiness. &amp;quot;It&amp;#039;s very much like PMS, but no longer confined to the week before your period,&amp;quot; says Dr. Gass. &amp;quot;It&amp;#039;s one thing to cope with it one week out of the month. Dealing with it randomly \u2014 and sometimes many times a month \u2014 is more exasperating.&amp;quot; But don&amp;#039;t discount other familiar midlife stressors, like combined demands of tweens, teens, work, and aging parents, particularly if you&amp;#039;re also struggling with hot flashes and your sleep is disrupted.  Will hormones help? Most women actually feel quite a bit better once they&amp;#039;ve made it into the stable hormonal state of menopause, notes Dr. Richardson. But if you can&amp;#039;t wait till then, talk to your doctor about which options make sense for you. Depending on other symptoms, you might take birth control pills to level out hormones during perimenopause, then, if you&amp;#039;re still feeling out of sorts once your periods stop, switch to systemic HT. Some women also benefit from antidepressants or antianxiety medications, along with talk therapy or holistic strategies.  When (and How) to Get Off HT  Here&amp;#039;s the mantra: the lowest effective dose for the shortest time possible. And, some doctors add, for no longer than three to five years. Sounds good, but as much as half the time, symptoms recur when you stop, no matter what your age or how long you used HT. So what then?  Plan ahead: Expect some rebound and be prepared with alternatives to handle annoying symptoms \u2014 lubricants for vaginal dryness, for example, or dressing in sheddable layers to cope with hot flashes.  Time it right: Sometimes menopause hits when women feel they cannot deal with one more problem in their lives, says Dr. Gass. But later, life may settle down, making even bothersome symptoms more manageable. Just don&amp;#039;t try to stop in summer, when hot flashes are harder to deal with, advises Dr. Richardson.  Taper off: Experts really aren&amp;#039;t sure whether this is better than quitting cold turkey, but many doctors suggest a step-down plan: taking a lower dose or skipping pills every other day. Dr. Richardson believes that tapering off helps, but it should be done very slowly, and a woman should stay at any given level for at least three months. If you get to the point where symptoms start to crank up slightly, stay at that level for up to a year, then try lowering some more. In any case, don&amp;#039;t try these approaches on your own; work with your doctor.  Some women quit hormones more than once \u2014 &amp;quot;five times and counting,&amp;quot; says Kalell \u2014 and some stay on for years, having decided that it&amp;#039;s reasonably safe for them. It&amp;#039;s critical to report unusual symptoms, especially unexpected bleeding or spotting, a possible warning sign of cancer, and to be scrupulous about mammograms. It&amp;#039;s also important to keep revisiting the question of risk and benefit, especially as you get older and your health issues change. "^^<http://www.w3.org/2001/XMLSchema#string>
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