The key concept of the unifying theory is that hormone therapy tends to be beneficial when started early after menopause (as was done in the observational studies that seemed to show favorable results) and harmful when started late after menopause when women already have less-than-healthy blood vessels (as was the case with most women in the randomized clinical trials, which showed the negative results). In other words, a woman who starts taking hormone therapy when she already has advanced atherosclerosis is particularly susceptible to having a heart attack or stroke while on treatment, while a woman just entering menopause who has healthy blood vessels may even receive heart protection. A similar pattern may apply to the effect of hormone therapy on memory and cognition: hormone use may help preserve thinking ability when initiated in newly menopausal women but hasten the progression of preexisting memory problems when started later in life.

There are several biological reasons for these differences in outcomes, which I’ll explain in detail in these pages. But let me clarify-although the evidence is mounting, it is not yet conclusive, and no woman should begin taking hormones for the express purpose of preventing cardiovascular disease or cognitive decline. However, the findings to date can be reassuring to women who have recently entered menopause and are considering hormone therapy for treatment of moderate-to-severe menopausal symptoms. (At the very least, such women generally have an extremely low underlying risk of heart attack, stroke, and other complications.) This book is the first to present the unified theory in a way that I hope will be accessible to any woman who is struggling with the decision of whether or not to take hormones.

And I know that there are many of you out there. Besides having had the extraordinary opportunity to investigate the relation between hormone therapy and women’s health in not just one but two landmark research studies, I’ve also been fortunate enough to have had nearly 20 years’ experience as an internist and endocrinologist in a clinical practice largely devoted to women’s health. In that role, I’ve been called upon by innumerable patients for advice on how to best navigate the menopausal transition. Some of my patients requested a prescription for hormone therapy for relief of their symptoms with nary a thought about the potential health consequences, while others wouldn’t hear of taking hormones under any circumstances, even though their hot flashes and night sweats were making them miserable. Yet by far the most common situation I’ve encountered is that of the perplexed patient who sought a clear explanation of the benefits and risks of menopause hormones so that, with my input, she could ultimately make the choice with which she was most at ease. When I began practicing medicine, providing satisfactory answers to these women was hard to do, because I was acutely aware of how little information about the health outcomes of women on hormone therapy was actually out there. But now that such data have begun to accumulate, it’s possible to give evidence-based answers to those questions. So that’s why I wrote this book.

I’m often asked if there was a particular event that inspired my interest in women’s health and my commitment to helping women get the health information they need. When I started medical school, I was curious about endocrinology and the effects of hormones on health, but I didn’t know that medical research would become my mission. But early in my medical training, my mother died of ovarian cancer at a relatively young age, an event that raised my awareness-in a profoundly painful and personal way-of the relative inattention paid by the medical establishment to women’s health issues in comparison to men’s. Once I realized how little research had actually been done on health issues unique to women, including the effects of hormones on health, I decided to pursue my interest in endocrinology and plan a dual career in both research and patient care. But let’s return to the present.

Several health concerns should figure prominently when you weigh the potential benefits against the risks of hormone therapy, and heart disease is only one of many that should be factored into your choice. This book provides a step-by-step personalized framework for making the most informed hormone-therapy decision for your own symptoms and health profile. The following issues are addressed:

•  Which women are now considered good candidates for hormone therapy and who should avoid hormone therapy at all costs?
•  How can you calculate your personal risk for common conditions likely to be affected by hormone therapy-namely heart disease, stroke, blood clots in the legs and lungs, breast cancer, and hip fracture? How should these calculations guide your decision making about hormone therapy?
•  For women who are good candidates, what is the best formulation and dose of estrogen to take,  the preferred progestogen,  and the optimal duration of treatment?
•  For women who can’t-or prefer not to-take hormone therapy, what are the best options for symptom relief and general health?
•  What is the appropriate role for soy, black cohosh, and other alternative remedies in relieving menopausal symptoms?
•  How can you work effectively with your healthcare provider to manage the transition to menopause?

In short, this book is my attempt to clear the confusion regarding the latest scientific data on hormone therapy-to make sense of the seeming chaos, so to speak-and present the facts you need to help you decide if hormone therapy is right for you. We are still in the thick of the learning process, but the evidence is now sufficiently firm that you can make an informed choice about using hormones for relieving symptoms of menopause with the reasonable expectation of keeping healthy and active for many years to come.

Disclaimer: The Women’s Health Initiative (WHI) study and Nurses’ Health Study (NHS) are supported by the National Institutes of Health (NIH) and conducted in collaboration with study investigators. This book does not necessarily reflect the opinions or views of the NIH or of study coinvestigators. Guidelines in this book are not intended to replace advice and medical care provided by your personal physician or other healthcare provider.

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By Manson, JoAnn E. and Bassuk, Shari S.
Hot Flashes, Hormones, and Your Health

JoAnn E. Manson, M.D., is a professor of medicine and the Elizabeth F. Brigham Professor of Women’s Health at Harvard Medical School, Chief of Preventive Medicine at Brigham and Women’s Hospital, and codirector of the Connors Center for Women’s Health and Gender Biology. The only person to have served as a lead investigator on two of the most influential studies of women’s health ever conducted-the Women’s Health Initiative and the Harvard Nurses’ Health Study-Dr. Manson is widely recognized as one of the world’s leading authorities on women’s health.

Shari S. Bassuk, Sc.D., is an epidemiologist and science writer at Brigham and Women’s Hospital in Boston who frequently collaborates with Dr. Manson.