Beyond Hormones

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There was widespread shock and dismay last year when researchers reported that a popular combination of female hormones called Prempro, taken for more than a couple of years, increases a woman's risk of developing heart disease and breast cancer. The news seemed to sound the death knell for long-term hormone-replacement therapy (HRT). Yet even at the time, scientists recognized that there was a chance for a reprieve: the estrogen-progestin mix might still delay or even prevent various kinds of dementia, including Alzheimer's disease. To find out, researchers began a careful analysis of a subset of data from the same Women's Health Initiative that had stirred up such a fuss in the first place.

Now the analysis is complete, and even that last hope has been extinguished. Not only does Prempro not protect against dementia, but older women who take it for long periods of time also double their risk of developing Alzheimer's and other cognitive problems. The news, published in last week's Journal of the American Medical Association, comes as a surprise, says principal investigator Sally Shumaker, a public-health expert at Wake Forest University Baptist Medical Center in Winston-Salem, N.C. Earlier studies had suggested that female hormones might be good for the brain.

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As is usual with reports like this, there are a few caveats to keep in mind. But the overall conclusion is inescapable: most women shouldn't be taking HRT for extended periods of time after menopause.

Although the study results directly apply only to Prempro, its conclusions probably also cover other estrogen-progestin combinations. At any rate, those drugs would need to be studied as vigorously as Prempro has been for any manufacturer to claim otherwise. (Wyeth Pharmaceuticals deserves a good corporate-citizenship award for allowing its product to be so thoroughly vetted and for even paying for some of the work.) It is also important to recognize that the absolute number of extra cases of Alzheimer's disease due to HRT is very small.

Intriguingly, the parts of the Women's Health Initiative that look at the possible long-term health benefits of taking estrogen alone — without progestin — are continuing. That suggests that estrogen alone may yet prove beneficial. (Only women who have undergone a hysterectomy can safely take estrogen alone; estrogen without progestin increases the risk of uterine cancer.)

So what's a woman to do? HRT is still the most widely effective medication available for the treatment of acute menopausal symptoms like night sweats and hot flashes. It's O.K. to take it for that reason; just keep the dosage low, and take it for less than two years. As an alternative, some women swear by natural remedies, such as black cohosh and yam creams.

If, on the other hand, you're more concerned about preventing dementia or heart disease, you will have to go back to the basics: exercise, eat right and watch your weight. You should also find out if you have high blood pressure or diabetes and get treated if you do; both conditions are known to increase one's risk of heart disease or stroke, and there is growing evidence that they may have more subtle effects on thinking and memory as well. Adopting a healthy lifestyle may not be as easy as popping a pill, but the effects are much longer lasting.

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