Until up popped that little black cloud. By the 1970s, doctors in the United States had begun to notice a worrying increase in the number of women on oestrogen replacement therapy who developed – and sometimes died of – cancer of the endometrium (the lining of the womb). Suddenly oestrogen therapy was getting a very bad press, and in a short space of time doctors no longer wanted to prescribe it, and women no longer wanted to take it. It seemed as if this wonderful era of eternal youth was over.

Research quickly got under way, and it was discovered that when a woman took oestrogen on its own the lining of the womb would build up each month and remain there instead being shed as a period in the normal way. Eventually, the lining of the womb would become abnormally thickened, and in some women it became cancerous. The solution was to add a form of the hormone progesterone to the oestrogen therapy every month, so that the lining of the womb did not build up, but was shed each month, as a ‘period’. (After the menopause, it is not a true period as it is not triggered by ovulation, nor does it mean you are fertile and could become pregnant; it is an artificial withdrawal bleed, produced when you stop taking each monthly course of progestogen.)

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Decisions about medical treatment such as HRT demand a more careful approach than choosing the route to an appointment, but psychologists tell us that the decision-making process has much in common with that described above. You form a set of expectations about the likelihood of particular outcomes, bearing in mind uncertainties about the information available. You place a particular weight on one or other of those outcomes. You take into consideration other factors that are important to you, for example the inconvenience of this approach or that, the costs involved, the effort of remembering when to do what, the experiences of your friends and others whose judgement you trust.

When Dale Spender was deciding whether or not to try HRT in her early forties, some of the considerations she took into account included the following:

- her experience of menopause, which was of drenching sweats and hot flushes that were messing up her life; and

- her expectations of HRT, which included both positive features – like relief from her symptoms – and negative possibilities such as an increased risk of breast cancer.

‘Any responsible human being knows that taking drugs on a daily basis is not without risk,’ she told a magazine in 1991. ‘There is not a drug on the market that has not been hailed as a wonder drug and then found wanting some years later.’ Dale’s decision to try HRT was not the end of the story. Although the flushes and sweats eased and her life returned to ‘something like a normal existence’, her breasts were unbearably sore. At her doctor’s suggestion she bought a cabbage, went home, tore off a few leaves and wrapped them around her breasts. ‘The smell! I can’t tell you. But it was no good. Nothing is.’

All in all she found the sweats more debilitating than the sore breasts, and she planned to stay on HRT until the age of fifty-two, when she would reassess the situation. Her experience of making decisions about HRT in a situation where some things are known and others are uncertain, and where some of the evidence is conflicting, is common to many women at and after menopause.

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Marie was one of a small number of women with debilitating flushes who took part in a biofeedback training program for a total of eight hours over a four-week period. Her experience was of a marked drop in hot flush activity and associated discomfort. For the first time she felt able to ‘short-circuit’ at least some of her hot flushes by putting her biofeedback training into action at the first sign of a flush.

Relaxation training, yoga, regular acupuncture and meditation also seem capable of reducing hot flush frequency, especially when combined with other coping strategies, like wearing clothes in layers, choosing fabrics that ‘breathe’, and steering clear of neck-hugging dresses and blouses.

Non-hormonal prescription — as distinct from alternative — medications studied as treatments for hot flushes include propanolol (a treatment for angina and abnormal heartbeat, trade name Inderal), clonidine (a blood pressure medication, trade name Dixarit) and naproxen (a treatment for rheumatoid arthritis, trade name Naprosyn). These suffer from the disadvantage of not being as consistently effective in reducing flush activity as hormonal therapies and, like most medications, they have undesirable side effects in some women. Sedatives and tranquillisers are sometimes prescribed for hot flushes and anxiety, but these may worsen other menopausal symptoms like lack of energy, and increase the likelihood of falls and fractures.

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Research that has examined these sorts of questions in women shows that your risk of developing a disease of the heart or blood vessels is higher than average if you have a family history of heart disease, blood clot disorders or strokes; had a hysterectomy before menopause (with or without removal of the ovaries); suffer from high blood pressure; have blood cholesterol that is above average; smoke cigarettes; have diabetes; do not exercise regularly; have a poor diet; or are overweight.

The reassuring thing is that three of the factors on the list — smoking, blood cholesterol and blood pressure – are said to account for as much as 60 per cent of your risk. And each of these factors can be influenced by the kinds of lifestyle changes described in chapter 6. Heart disease risks can decline quite rapidly for the ex-smoker, returning to levels similar to those of a non-smoker in about five years. A balanced diet can lead to a reduction in total cholesterol of about 10 to 15 per cent, which corresponds to a 20 to 30 per cent reduction in the risk of heart disease. In people with very high blood pressure the benefits of antihypertensive treatment are clear, since death rates among those who go untreated are very high.

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PILLS In general pills are the first-line hormone treatment for women at and after menopause. This form of HRT is usually cheaper than the alternatives, and the available research evidence about risks and benefits is more comprehensive for them. It also has the attraction of familiarity for women experienced with the Pill. A range of oestrogens and progestogens are available in tablet form. Reasons for choosing one rather than another will depend on your menopausal symptoms, your medical or family history, side effects experienced if and when you used the Pill, and your doctor’s preference.

An increasing number of hormone varieties are produced in a micronised form that consists of tiny particles easily absorbed by the stomach and intestines. The constituents of the hormone pills then pass through the liver before reaching target tissues like the uterus, vagina and bones.

Advantages of the pill format include the ability to change the dosage or variety of hormone quickly, putting a rapid stop to side effects. This form of hormone therapy also tends to be less expensive than alternatives.

Disadvantages include the potential for gastro-intestinal problems such as nausea and the liver side effects discussed earlier. Those women still prescribed synthetic oestrogen may be at increased risk of high blood pressure and blood clot formation. Taking pills each day may also prove inconvenient if your life tends to be unpredictable and you are one of those people who find pill-taking hard to remember. It may help to put your pills in a place you can’t overlook – in the tea caddy, for instance, if you always start the day with a cuppa, or next to the toothpaste.

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