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Strokes or Sleeplessness?

By Jane Gross, the
New York Times

March 23, 2004  

Ask any woman who has had a difficult menopause if she thinks that Mrs. Rochester, locked in the attic in "Jane Eyre," was actually insane. The answer is likely to be a resounding no.  

Poor Mrs. Rochester, living in an era before hormone therapy, has been on my mind lately, as I have tried, unsuccessfully, to wean myself off estrogen. Like me, she was probably dazed from too many sleepless nights, frightened by palpitations with no apparent cause and unable to concentrate on the simplest task or read a sentence from start to finish.  

Hot flashes? No doubt Mrs. Rochester was peeling off clothes and putting them back on, feeling hot and clammy one minute and cold and clammy the next, waking in a tangle of damp sheets. But, chances are, if anyone had asked her, Mrs. Rochester would have said her wayward thermostat was a minor inconvenience compared to being unable to think straight.  

Being locked in the attic was no picnic, for sure, especially while her husband was fooling around with young Jane. But at least Mrs. Rochester did not have to go to work alongside men who considered her ditzy, women her own age who were sailing effortlessly through their own menopause and those half her age who smugly assumed that this would never happen to them.  

Pondering Mrs. Rochester's situation led to a eureka moment after months of gathering misery. I wasn't losing my mind, as I had been thinking in recent months. I was in estrogen withdrawal. So, after polling my physicians, I have fallen off the wagon, given into my craving. I need these little pills to have a life.  

At first, the weaning seemed relatively painless. I cut back by one pill every three days. No problem. When I went to one pill every other day, the hot flashes started, intermittently. I would snap awake, heart pounding, at 3:30 a.m. , always the same time. Throwing off the covers, sweat turned to bone-rattling shivering. It lasted but a few minutes. Not such a big deal except for the lost sleep. I could do this!  

I didn't eliminate the next pill for months, following a doctor's schedule for gentle tapering. I was tired all the time. But what did I expect at 56? So I cut the dose again. One milligram of Estradiol every third day. I was almost clean. And like a recovering alcoholic, I was drinking coffee, pots of coffee, which seemed to fire synapses in my brain that were otherwise barely sputtering.  

My head was fuzzy. I was running around the house in a panic looking for my car keys when they were in my hand. I knew this wasn't Alzheimer's, because I knew the keys were keys, and I knew what they were used for. But something was up.  

There I'd be, sitting at the kitchen table with the morning newspaper, unable to read even a sentence. Somewhere between the capital letter and the period, I became lost. Usually, I did things quickly. Now I had to budget twice as much time for everything. Not quite 14 hours to do 7 hours' work, but something like that, compounding the weariness. Only then did I connect the dots. I had felt this way before, 10 years ago, when I was perimenopausal.  

When my mother's generation hit menopause, hormone therapy was new and promised to keep faces unlined and hair shiny like the Breck girl. It would prevent those hot flashes, and we would remain frisky in bed, keeping our men happy and less inclined to stray. A generation of postwar women, in flared skirts while scrubbing the kitchen floor, jumped at the chance to stay young.  

Their daughters were more impressed with the claims that estrogen seemed to prevent many diseases like heart attacks, osteoporosis and, maybe, Alzheimer's. Smooth skin and lustrous hair were nice, but we could lean on plastic surgeons and hairdressers for that. We were serious people — doctors, lawyers, journalists, corporate executives. We didn't take estrogen because of vanity. We took it because it was healthy, like going to the gym or eating tofu.  

In retrospect, it is easy to say that anything too good to be true probably isn't. Little by little, the wondrous curative properties of hormone therapy have been mostly discredited by the National Institutes of Health, which conducted a large study. The first round, involving women taking a combination of estrogen and progestin — estrogen, alone, is known to cause uterine cancer — was stopped in its tracks in 2002 because of surprising and potentially dangerous findings. Hormone replacement therapy had no salutary effects on the heart or brain, the study found, and it increased the risk of breast cancer and strokes. Other, more innocuous ways, could keep bones strong.  

Women in droves — half of those using hormone replacement, by some accounts — threw out their pills and patches. Many did fine without the hormonal boost and probably never needed it in the first place. Some suffered but soldiered on. Others, with florid symptoms and no family or personal histories of breast cancer, resumed the medications after calculating risks and rewards.  

I didn't have to take sides yet. Women who have had hysterectomies can take estrogen unmediated by progestin, with its many well-documented side effects. "Our" kind of hormone replacement was better, safer. We were the fortunate few who did not have to choose between heart attacks and hot flashes. Sure, that's a simple-minded dichotomy. But how many of us really understand whether eight extra strokes per 10,000 elderly women is a lot or a little?  

"Our" half of the study was chugging along when I decided, with all my doctors on board, to wean myself from estrogen anyway. If the hot flashes came back with a vengeance, if I couldn't sleep or think straight, I would go right back on. Which is what I was about to do when the second shoe dropped. Women in the N.I.H. study taking unopposed estrogen were also gaining no cardiac benefit. They did not share the risk of breast cancer. But a few more of them would have strokes and, maybe, dementia.  

Now it was my turn to agonize. Strokes or sleeplessness? Dementia or oh-that-dizzy dame? I called in the experts, the three doctors I see regularly. All are women. All told me, without an instant's hesitation, to resume my normal dose of estrogen immediately, and a little extra for a while, until I stopped feeling so awful.  

Two doctors are past their own menopause. Each takes hormones. They are not happy about an increased risk of certain diseases. But they know the risk is tiny, and they can balance the books by being vigilant in other ways like having regular mammograms and watching their cholesterol. They have the advantage of understanding the subtleties of footnoted peer-reviewed public health studies whose message, they told me, was that women who need estrogen should take it and those who don't should not.  

The third doctor is younger, knows about hot flashes only through hearsay. She may blink and miss her own menopause, as many women do. But if she has a hard time, she knows exactly what to do: take the pills that weren't there for Mrs. Rochester.

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