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Starting HT earlier might also positively affect memory, concentration, and cognition. Alas, here again there is no good clinical trial data. But a half-dozen small studies have had promising results, says Sarah Berga, MD, chairwoman of the department of gynecology and obstetrics at Emory University School of Medicine in Atlanta. "Estrogen seems to lubricate the brain, in some ways, for thinking," she explains.

Better evidence for—or against—early timing may arrive when the KEEPS study, whose subjects range in age from 42 to 58, is completed. "What I hope the study will show," says Santoro, one of its principal investigators, "is that for women close to menopause, the risks of hormone therapy are low and they may get some cardio protection."

There is already a growing consensus around this idea. Many leading experts now recommend HT at the lowest dose and for the shortest time possible—the first few years of menopause—along with regular checkups and mammograms for women with debilitating symptoms (assuming they don't have high risk of heart disease or breast cancer). Manson recommends staying on hormones two to three years, five at the most, after which hot flashes usually subside. "Five to 10 percent of women have persistent significant symptoms more than ten years after menopause," she says; in those cases, doctors and patients must weigh the individual health risks against quality of life benefits. "But the vast majority of women can come off HT after a few years and do fine." This, by the way, is now the position of the North American Menopause Society and the American Association of Clinical Endocrinologists.

But we still have a long way to go in terms of getting the answers we need—which means that women really must take the steering wheel in directing their care. For Linda Ekins, the nurse in Utah, menopause has been a challenging journey. "It's not just about medication," she says, explaining that her menopausal troubles started 20 years ago with depression. "I couldn't figure out what was going on. I went into therapy and realized that part of it was menopausal." When hot flashes came soon after, she was able to keep them at bay by taking the herbal supplement dong quai (although research has failed to prove it a reliable treatment). "But at 55," she says, "the hot flashes were breaking through, and I wanted information." She'd read about bioidentical hormones and found her way to the University of Utah's Kirtly Parker Jones, who prescribed them to her in a progesterone pill and estrogen patch. "I asked for the lowest dose possible, and Dr. Jones said I could try cutting the patch in half. I did, but then I started having hot flashes again, so I've gone back to the full dose. The hormones have done really well for me, including helping vaginal dryness, which I don't choose to experience because I'm still sexually active; as long as my husband is happy and I'm happy, things are good." But, she adds, there's so much more to managing menopause on an emotional and spiritual level. To that end, Ekins has expanded her conference by bringing in experts in yoga and energy work. "Find friends and support systems," she urges. "A pill or patch can certainly help, but it won't be the answer to everything."
As a reminder, always consult your doctor for medical advice and treatment before starting any program.

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