Girls start having menstrual periods at about age 12, when they begin to ovulate monthly. This is menarche, the beginning of the fertile period of the female human. Women continue to have regular menstrual cycles, interrupted by pregnancies, until about age 50, when they stop ovulating. Fertility declines from the late 30s, and menopause is its end. Women produce less of the female hormone estrogen in their 40s and much less after menopause. Like menarche and pregnancy, menopause happens: it does not require a physician in attendance. Until the 20th century, in fact, most women didn't live long enough to reach menopause.
Now they do, and as we learn more about the physiology of aging opportunities for fiddling with the process present themselves. For the past 30 years women entering menopause have been able to take female hormones to mimic the premenopausal state. Originally an option exercised by more affluent women for the treatment of menopausal symptoms, hormonal replacement therapy (HRT) is now broadly recommended as a long-term preventive program aimed at osteoporosis and heart disease. When menopause looms on the horizon, women face a decision that seems uncomfortable because it's philosophically distinct from treatment for a disease. Should we take a pill for an indefinite period of time, decades perhaps, not to fix a problem or reduce an abnormal risk factor (like high cholesterol), but to lower our risk of developing two common afflictions?
Proponents of HRT argue that it's not "natural" for women to live for decades without estrogen, since in the "natural" state a woman's life expectancy coincided with her reproductive years. Opponents also argue that it's not natural to give a woman these hormones, pointing to the side effects of the treatment.
Of course if the only thing estrogen contributed to a woman's health was the proper hormonal milieu for ovulation, most women would be more than ready to be rid of it at age 50. But the effects of estrogen are not limited to the reproductive system. Estrogen prevents bone thinning, or osteoporosis, which starts promptly as estrogen levels begin waning in the 40s. In the first ten years after menopause the loss of bone mass speeds up; it continues at a much slower rate, more comparable to that of men, as a woman heads into her 60s. Taking estrogen delays this process; not smoking, weight-bearing exercise (i.e., not swimming), and dietary calcium also help maintain strong bones. Many white women, who have thinner bones than black women, are at high risk for osteoporosis heading into menopause, by virtue of heredity, poor diet, or lack of exercise as young adults. The stooped 70-year-old woman whose vertebral column is painfully collapsing under its own weight and her sister with the hip fracture after a minor fall illustrate the end stage of osteoporosis.
Estrogen increases HDL, the "good" cholesterol, and makes blood vessels more elastic, which probably accounts for the fact that a woman's risk of heart disease is lower than a man's before menopause and catches up shortly after. Estrogen also plays a role in vaginal and urethral lubrication and sex drive. Many women report a greater sense of well-being when they take estrogen, and it definitely prevents hot flashes, the sudden rise in body temperature with sweating that's the hallmark of this change. (The postmenopausal woman who has weathered the hormonal fluctuations and reached a constant, low level of estrogen is free of hot flashes.)
When HRT began in the 1960s doctors prescribed estrogen by itself and noticed an increase in the rate of cancer of the uterus. It's now estimated that one in 1,000 women who take estrogen alone develop uterine cancer. To avoid this side effect physicians now also prescribe progesterone, the hormone women make in the second half of the menstrual cycle. Since this combination mimics the natural menstrual cycle it makes women menstruate. Granted, the periods are generally light, but many women balk at the idea of menstruating until the grave. Moreover, progesterone may also blunt some--no one knows how much--of the protective effect estrogen has on the heart.
The other major concern with estrogen therapy is a small increase in the rate of breast cancer in women who take it for more than five years. Estrogen supplementation is contraindicated in women who've had breast cancer and controversial in women with a strong family history of the disease. Since the risk of a 50-year-old woman dying of heart disease is ten times greater than her risk of dying of breast cancer, even a small protective effect on the heart would statistically outweigh a slight increase in breast cancer for women at average risk for both. But breast cancer carries a much higher emotional charge than coronary-artery disease, and many women stop listening after they hear the words breast cancer.
Menarche, pregnancy, and menopause are expected phases of life, but the woman experiencing them may not feel like herself at all. I have vomited plenty during my pregnancies, and I have friends who've spent years consulting fertility specialists. Other women find their lives disrupted by premenstrual symptoms or severe menstrual cramps. Describing her first hot flash, Gail Sheehy, author of The Silent Passage, wrote, "I felt, for perhaps the first time in my life since the age of thirteen, profoundly ill at ease inside my body."
The phases of a woman's reproductive life can share one important characteristic with disease: loss of control. Our energy levels are unpredictable, and symptoms such as vomiting and hot flashes make us socially conspicuous. The nausea catches us in the first trimester, before we're ready to tell the boss about the pregnancy. Hot flashes are a bulletin advertising our aging. At least the pregnant woman has a "blessed event" in front of her. In our ageist society women entering menopause fear an inexorable downhill slide into dotage.
Everyone knows a few women who can't relate to PMS or who never felt better than when they were pregnant. And 15 to 20 percent of women never have a hot flash. But most women find it takes extra effort to cope with these changes. Some women achieve a sense of control by demanding intervention; Sheehy lambasts physicians who wait until periods stop before prescribing estrogen. Other women feel more in control when they reject the medical prescription; Germaine Greer, in her book The Change, lights into doctors for pushing HRT.
We baby boomers are particularly vulnerable to threats to our autonomy. We grew up more shielded from illness and death than any generation in history. Sheehy's book, full of gossipy vignettes about high-powered women, documents the impatience the rich and famous display toward menopausal symptoms. She quotes one "dynamic, tough, successful" executive: "Menopause is the only thing that's made me feel I had an age. Because I can't get rid of it. I hate it, big time." "'I'm a lunatic, I'm going through menopause and empty nest at the same time,' said the beautiful actress-wife of actor Sidney Poitier. (It is culture-specific to Hollywood to identify women by their husbands' professional status.)" Sounds like old-fashioned sexism to me. In fact, Sheehy's book--with its emphasis on maintaining physical attractiveness and the examples from Hollywood, where HRT seems to be equated with face-lifts--struck me as all too accepting of the prevailing doctrine that the only useful woman is a young woman. Still, she notes that at age 48, when she entered menopause, she had just remarried and adopted a child, which may explain her frantic tone.
Greer strikes the opposite tone in her lugubrious book. She views HRT as a plot by male doctors, whom she dubs "Masters of Menopause," to keep women frisky if not fertile. "To dose women with steroids for the sole purpose of keeping them receptive to their husbands' advances is outrageous," she writes. She describes women in traditional societies who achieve greater status as they're relieved of their roles as sex objects and childbearers, and advises us to embrace old age, to become the "crone." ("So let us assume the witches' right and cackle in our turn.") Since she's taken the trouble to write about many vital women over 50, from Madame de Maintenon to Joan Collins to Margaret Thatcher, her definition of crone is singular. Greer may underestimate her own potential, as did Eleanor Roosevelt, who at age 45 stated emphatically, "I hardly think the word 'passionate' applies to me." ("Nevertheless," her biographer Blanche Wieson Cook notes, "the word 'passionate' did apply to Eleanor Roosevelt. Her politics were the politics of passionate intensity. And her affections, as she was soon to learn, were to be woven in new fabrics of surprising and romantic design.")
"So what would you do?" my older sister asks insistently over the phone. She doesn't like my answer: "I don't know." I'm sure if I have intense hot flashes I'll try HRT for a while. Then I'll see how it goes. I don't see HRT as a moral issue. It strikes me that we women are particularly hung up on this "natural" business. Men sign up in droves for coronary-artery bypass grafts without agonizing over whether they're "natural" operations, though it's clear many of them would do just as well with a very low-fat diet, exercise, and medication.
Our family history is not one of early heart disease or crippling osteoporosis, and I'm wary of any long-term medication, especially for prevention of theoretical risk. For the last 15 years I've served as a control in a study of DES daughters; my mother didn't take that hormone, but many other women who delivered at the same hospital did. Each time I have to fill out a questionnaire or chart my menstrual cycles, I'm grateful my mother wasn't at the forefront of hormonal therapy in the 1950s.
The cover of Sheehy's book claims it's "the book that broke the silence." Nonsense. A local bookstore has a two-page list of books about menopause and aging women; an old reliable, published in 1985, is Sadja Greenwood's Menopause Naturally. Sheehy admits that when she wrote Passages at age 35 she couldn't imagine herself at 50, and my experience as a doctor suggests she's not alone. We don't address health issues until they're in our face.
The information we have, imperfect as it is, is out there. What we don't have is a one-size-fits-all answer with a money-back guarantee. Medicine doesn't offer that to anyone, women in menopause or men debating prostate surgery. Technology will not disguise us before death or provide meaning for the years to come.
And did you get what
you wanted from this life, even so?
And what did you want?
To call myself beloved, to feel myself
beloved on the earth.
Raymond Carver, author of those lines, died at age 49. Menopause is a transition, not a tragedy.
Art accompanying story in printed newspaper (not available in this archive): illustration/Kevin Kurtz.