The menopause market

By the time the first study made the news, Irene (not her real name), a retired 62-year-old in Venice, Calif., had been on HT for more than five years. Without consulting a doctor she decided to quit cold turkey. "I figured, there's really no reason to take it if it's so dangerous," Irene says. "I'm a healthy person. I don't have a history of heart problems or osteoporosis. I exercise a lot."

The results surprised her. "I basically launched myself into a major menopausal relapse," she says. "It was like going through menopause all over again." Back came the hot flashes, even worse than the first time around. She suffered through two more years, flirted with alternative remedies like black cohosh, English primrose oil, and phytoestrogens, grew frustrated, and gave up. (Most of her symptoms have since ended the natural way: menopause finis.)

Ever the rebellious establishment debunkers, baby boomers seem particularly keen to believe in alternatives. After all, this is the generation that confabbed over "Our Bodies, Ourselves" and brought botanicals from the backyards of San Francisco to medicine cabinets across America. When Amanita Rosenbush, a 55-year-old book editor in Oakland, began experiencing severe symptoms at age 40, she did everything she could to stay off hormones. "Women I knew in California didn't believe in estrogen, so I tried a whole range of homeopathic products," she explains. Nothing worked. "Words can barely describe how badly my feet itched," she recalls. "I'd have to dig scissors deep in my feet to reach the itch and then sleep with ice packs on them." Finally, Rosenbush relented and signed up for hormones. Her feet immediately lost their torturous tickle, her headaches went away, her body temperature dropped. "I wish it weren't true, but often mainstream pharmaceuticals are just more effective," says Rosenbush. "Hormones have made my life halfway decent."

Many a perspiring woman finds alt-health remedies appealing, but while some studies show that such natural products relieve hot flashes and improve vaginal lubrication, there have been no studies of long-term use. Furthermore, the paucity of industry guidelines means that adulterations, concentrations and doses vary widely. Plus, the risks of "natural" and "bioidentical" hormones may be no different from those of the pregnant-mare hormones used in the dreaded study. "Hormones are hormones," says Rhoda H. Cobin, a fellow at and past president of the American College of Endocrinology. "Phytoestrogens are certainly weaker than pharmacologically produced estrogens, but women are still being misled. They don't know that they're taking real estrogen. And if you're worried about estrogen, then you should worry about it in any form."

In addition to questions over whether herbal products do what they say they do are questions about what they're not saying. Despite the federal Dietary Supplement Health and Education Act of 1994, which limits the claims made on labels, over-the-counter supplements require far less stringent guidelines than do prescription drugs. Testing on homeopathic medications is less rigorous: Sample sizes are limited, tests are not blinded, they include no control groups, they are short-term, or they are nonrandomized.

When Suzanne (not her real name) began menopause four years ago, at age 48, she was devastated. "It's a tremendously heavy thing to go through," says the single and childless New York writer, describing the hot flashes, vaginal dryness, loss of libido, wild mood swings, and uncontrollable anger. Worst of all was the psychological impact. "You're really facing the fact that your years of fertility are over, your years of sexuality are over, and -- at least it feels this way -- your romantic life is over," After watching an "Oprah" show on which Lauren Hutton plugged various products and remedies, Suzanne went out and bought Promensil, which packs a dollop of red clover-derived estrogens. No effect. Next she dropped a wad of cash on a product called Hot Flash -- a mix of soy concentrate, black cohosh, dong quai, licorice root and vitex berry. No effect.

After flirting for two years with assorted creams and potions from the alt market, Suzanne leapt onto the HT wagon. "I was very nervous about the reports coming out," she says. "But all the reports were about Prempro, which has a big monopoly on the market, and I wasn't on that brand of hormone, so I couldn't be sure that the results applied to me. And in any case, I'd rather run the risk of future health problems than have to live with these extreme symptoms in the present."

That some women insist they are helped by alternative products comes as no surprise to doctors, even those unconvinced of their efficacy. According to the North American Menopause Society, for nearly all menopause treatments -- including HT -- control groups show a 25-40 percent responsiveness rate, an exceptionally high placebo effect. (By contrast, HT is 80-85 percent effective and antidepressants about 60 percent.) "If someone is having a hell of time with menopause and doesn't want to take hormones -- even if their reasoning is false, I'm not going to tell them they're full of shit," says Michael Goodman, an ob-gyn and the author of "The Midlife Bible: A Woman's Survival Guide." "I'll tell them about the herbs and botanicals and put a positive spin on it. Because as long as the product feels like it's helping and it's not hurting -- no problem. And many women experience a strong placebo effect even if the products don't 'work' in the traditional sense." Of course, in addition to as yet unknown long-term health costs, such products do carry costs. Irene dabbled in everything from black cohosh to evening primrose oil, to no avail. "For me it was a waste of money," she says. "None of it had any effect whatsoever. It took up shelf space. After three or four months, I dumped the whole lot out."

Ironically, what many women should not have dumped out so fast is hormone therapy. Immediately following its release and continuing to this day, critics have assaulted the WHI study on a number of grounds. According to many ob-gyns, women in the study didn't reflect the population normally prescribed hormone therapy, who tend to be younger, slimmer and healthier. Moreover, though a 26 percent increase in breast cancer, as presented in the report, sounds high, this rate applies to the group as a whole. In other words, the rate of breast cancer among the study group was 26 percent higher than in the control group. However, when looked at on an individualized scale, the risks look slimmer: For any one woman, the increased risk is a mere .08 percent. After weighing the evidence, Mary Jane Minkin, a professor of obstetrics and gynecology at the Yale University School of Medicine still considers herself "fairly pro-HT." According to Minkin, "Estrogen probably won't save you and it won't kill you. It's more for symptom relief than anything else -- and it's still the best form of symptom relief out there."

Many practicing ob-gyns seem to agree. A September 2003 national survey of female ob-gyns conducted by Gallup found that 50 percent still use HT to treat their own menopause. A mere 13 percent had tried some kind of natural treatment, and 19 percent did nothing at all. Despite the hoopla, most doctors say HT comes down to an individual decision, based on an understanding of the real risks and benefits. Isaac Schiff, chair of the American College of Obstetricians and Gynecologists' HT task force, believes the negative interpretations of the WHI have gone much too far. "Women who would really benefit from HT are now so terrified of taking hormones that they're denying themselves something that would immensely improve their lives," he says.

Choosing to forgo hormones out of distrust of Big Pharma doesn't make much sense either. Despite their mom-and-pop-on-an-organic-farm image, many natural products belong to large pharmaceutical firms. Indeed Remifemin, the popular black cohosh product, is manufactured by GlaxoSmithKline. So why doesn't Big Pharma cash in big time by conducting the studies necessary to prove such drugs are effective? There's no incentive to do so: Herbals cannot be patented, and the $10 million FDA approval process doesn't warrant the cost, particularly when women seem to snap up botanicals regardless.

"It's paradoxical that the same women who were angry over the WHI data because they felt like hormones were promoted for benefits they couldn't deliver are now running in the opposite direction to the alternative-medicine industry," says Nanette Santoro, a professor of obstetrics, gynecology and reproductive endocrinology at the Albert Einstein College of Medicine. "To go for products that offer no proof of being effective or safe over the long term is inherently illogical." Which may be exactly what marketers are betting on.

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