The menopause market

Forget hormone treatments -- menopausal women are raiding health-food stores for dong quai and wild yams.

By Pamela Paul
Published March 9, 2004 11:52PM (EST)

Last December 47-year-old Brooklynite Therese Mageau was in the midst of an afternoon walk on the beach when she suddenly felt an intense heat wave. Sure, she was in Southern California, but the temperature was only in the 60s -- so what was happening? "I felt hot and clammy, like I was getting feverishly sick," Mageau says. "I rushed back to the condo and lay down." Only after two more heat waves hit did she think, "Oh, so this is what a hot flash feels like."

Mageau finally understood what all the menopause fuss was about. "Imagine someone lighting a little flame at the bottom of your leg and suddenly turning up the gas all the way," she says. "People hear about menopause and they think, 'So what? You feel a little warm.' They have no idea."

On the recommendation of friends who caught her fanning herself at a party, Mageau picked up a bottle of black cohosh, an herb marketed as an alternative remedy to the conventional -- and controversial -- hormone therapy of estrogen (or a combination of estrogen and progesterone). Like all menopausal medications, black cohosh and other alternative remedies don't claim to "cure" menopause, just to relieve symptoms like hot flashes, vaginal dryness and headaches. None of it has worked yet, but Mageau hasn't given up hope -- "it's only been a couple of months," she says -- and as long as they're not possibly cancer-causing hormones, she's open to other solutions. "Unless it sounds completely wacky, I'll do anything," Mageau says. "If somebody told me to add a drop of iodine to my water in the morning, I'd do it."

"I'm in a risk group for cancer," she says. "I've never had kids and my mother's sister died of breast cancer. And after the study -- well, I don't want to go there unless I have to."

An increasing number of women agree with Mageau. Ever since July 9, 2002, when a front page article in the New York Times reported that the largest study of hormone therapy (HT, formerly called HRT) was abruptly halted, menopausal women have avoided taking estrogen or progesterone the way pregnant women avoided thalidomide in the '70s. According to the study, the largest and most expensive federal study of women's health ever undertaken (conducted by the Women's Health Initiative and funded by the National Institutes of Health), women on HT were more likely to develop strokes, blood clots, breast cancer and dementia -- rather than see their cardiovascular disease rates drop, as doctors had predicted. In the span of a nightly news segment, some 17 million American women on HT went into a panic: There was shock at the 180-degree reversal, anger at doctors and the pharmaceutical industry, and despair over the prospect of returning to night sweats. "Everyone was caught off guard in a very dramatic way," recalls Dr. Isaac Schiff, chair of the American College of Obstetricians and Gynecologists' task force on HT. "Doctors hadn't even been notified first about the results. We were besieged with phone calls." Wyeth, the manufacturer of Prempro, the hormone drug used in the WHI study, saw sales plummet 50 percent.

Last week, menopausal women received more bad news: an additional WHI study (this one based on the use of estrogen alone rather than the estrogen/progesterone combo of the first study) was also halted unexpectedly. This time, estrogen was found to increase the risk of stroke, while offering no additional protection against heart disease.

For the 55 million U.S. women nearing or in the throes of menopausal mayhem, the case on HT is far from closed. And in the meanwhile, marketers can take advantage of the resulting confusion. Does any of it really work? Who knows -- but navel-gazing boomers caught in the flush of menopausal symptoms are eager to glom on to anything that may cool things down. Add a dose of headline-driven panic and distrust of doctors, and the result is a marketing stampede. Vendors of homeopathic, "nutraceutical" ("nutritional" plus "pharmaceutical"), and alternative medicines have descended like harpies on post-HT patients, exhorting them to try everything from black cohosh to dong quai to wild yams to cool their sweaty brows. Dozens of products hawked through health stores include isoflavones, which allegedly impart the benefits of a high-soy diet because they contain estrogens that occur naturally in certain plants such as beans, soy products and whole grains. Prescription medications like clonidine (for blood pressure), Neurontin (an anti-epilepsy drug) and even antidepressants are being touted as viable alternatives to hormone cocktails. All with the goal of tamping down on menopausal symptoms -- the hot flashes and mood swings, the night sweats and the vaginal dryness.

Jeanette (not her real name) is a 53-year-old high school principal from New York who says that she hasn't slept through the night since hitting menopause. But she swears by wild yams, another magical no-sweat remedy. "It seems to be working," she says, even though no medical studies back the Mexican-grown veggie. "I occasionally still have a hot flash, though much less severe." Before yams, there was "natural progesterone" skin cream ("I got nauseous beyond belief") and Remifemin, a popular black cohosh formula ("just not effective").

But Jeanette was determined to steer clear of HT. "I don't like taking drugs to begin with, even aspirin. I only take homeopathic remedies," she explains. "I don't have breast cancer in my family, but I was still scared." In certain ways, her partner, a breast cancer survivor, both fanned that fear and inspired her. "When my partner went on tamoxifen, the powerful medication used for breast cancer patients, she was thrust into early menopause," Jeanette recalls. The two of them would lie in bed reading "Is It Hot in Here or Is It Me?" (a popular menopause memoir) and giggle hysterically. But menopause wasn't exactly fun: "She had horrific hot flashes but of course didn't take hormones, because of the cancer. I thought to myself, If she can survive it, so can I."

"There's been a tremendous increase in new product development and marketing since the WHI study," says Wulf Utian, executive director of the North American Menopause Society. "All sorts of stuff is being pitched to 'the menopause market.' For many of these companies, whether their products work or not is irrelevant. In fact, most of the stuff in the health-food store are just expensive placebos that women think are safe because they've got 'natural' on the label." According to Utian, "They're preying on a vulnerable and gullible population."

"Of course all these companies are jumping in -- that's their business," says Sheldon Segal, a reproductive endocrinologist at the Population Council. "They saw a huge sales opportunity to take advantage of women's concerns over prescription drugs, and they're taking it."

By the time the first study made the news, Irene (not her real name), a retired 62-year-old in Venice, Calif., had been on HT for more than five years. Without consulting a doctor she decided to quit cold turkey. "I figured, there's really no reason to take it if it's so dangerous," Irene says. "I'm a healthy person. I don't have a history of heart problems or osteoporosis. I exercise a lot."

The results surprised her. "I basically launched myself into a major menopausal relapse," she says. "It was like going through menopause all over again." Back came the hot flashes, even worse than the first time around. She suffered through two more years, flirted with alternative remedies like black cohosh, English primrose oil, and phytoestrogens, grew frustrated, and gave up. (Most of her symptoms have since ended the natural way: menopause finis.)

Ever the rebellious establishment debunkers, baby boomers seem particularly keen to believe in alternatives. After all, this is the generation that confabbed over "Our Bodies, Ourselves" and brought botanicals from the backyards of San Francisco to medicine cabinets across America. When Amanita Rosenbush, a 55-year-old book editor in Oakland, began experiencing severe symptoms at age 40, she did everything she could to stay off hormones. "Women I knew in California didn't believe in estrogen, so I tried a whole range of homeopathic products," she explains. Nothing worked. "Words can barely describe how badly my feet itched," she recalls. "I'd have to dig scissors deep in my feet to reach the itch and then sleep with ice packs on them." Finally, Rosenbush relented and signed up for hormones. Her feet immediately lost their torturous tickle, her headaches went away, her body temperature dropped. "I wish it weren't true, but often mainstream pharmaceuticals are just more effective," says Rosenbush. "Hormones have made my life halfway decent."

Many a perspiring woman finds alt-health remedies appealing, but while some studies show that such natural products relieve hot flashes and improve vaginal lubrication, there have been no studies of long-term use. Furthermore, the paucity of industry guidelines means that adulterations, concentrations and doses vary widely. Plus, the risks of "natural" and "bioidentical" hormones may be no different from those of the pregnant-mare hormones used in the dreaded study. "Hormones are hormones," says Rhoda H. Cobin, a fellow at and past president of the American College of Endocrinology. "Phytoestrogens are certainly weaker than pharmacologically produced estrogens, but women are still being misled. They don't know that they're taking real estrogen. And if you're worried about estrogen, then you should worry about it in any form."

In addition to questions over whether herbal products do what they say they do are questions about what they're not saying. Despite the federal Dietary Supplement Health and Education Act of 1994, which limits the claims made on labels, over-the-counter supplements require far less stringent guidelines than do prescription drugs. Testing on homeopathic medications is less rigorous: Sample sizes are limited, tests are not blinded, they include no control groups, they are short-term, or they are nonrandomized.

When Suzanne (not her real name) began menopause four years ago, at age 48, she was devastated. "It's a tremendously heavy thing to go through," says the single and childless New York writer, describing the hot flashes, vaginal dryness, loss of libido, wild mood swings, and uncontrollable anger. Worst of all was the psychological impact. "You're really facing the fact that your years of fertility are over, your years of sexuality are over, and -- at least it feels this way -- your romantic life is over," After watching an "Oprah" show on which Lauren Hutton plugged various products and remedies, Suzanne went out and bought Promensil, which packs a dollop of red clover-derived estrogens. No effect. Next she dropped a wad of cash on a product called Hot Flash -- a mix of soy concentrate, black cohosh, dong quai, licorice root and vitex berry. No effect.

After flirting for two years with assorted creams and potions from the alt market, Suzanne leapt onto the HT wagon. "I was very nervous about the reports coming out," she says. "But all the reports were about Prempro, which has a big monopoly on the market, and I wasn't on that brand of hormone, so I couldn't be sure that the results applied to me. And in any case, I'd rather run the risk of future health problems than have to live with these extreme symptoms in the present."

That some women insist they are helped by alternative products comes as no surprise to doctors, even those unconvinced of their efficacy. According to the North American Menopause Society, for nearly all menopause treatments -- including HT -- control groups show a 25-40 percent responsiveness rate, an exceptionally high placebo effect. (By contrast, HT is 80-85 percent effective and antidepressants about 60 percent.) "If someone is having a hell of time with menopause and doesn't want to take hormones -- even if their reasoning is false, I'm not going to tell them they're full of shit," says Michael Goodman, an ob-gyn and the author of "The Midlife Bible: A Woman's Survival Guide." "I'll tell them about the herbs and botanicals and put a positive spin on it. Because as long as the product feels like it's helping and it's not hurting -- no problem. And many women experience a strong placebo effect even if the products don't 'work' in the traditional sense." Of course, in addition to as yet unknown long-term health costs, such products do carry costs. Irene dabbled in everything from black cohosh to evening primrose oil, to no avail. "For me it was a waste of money," she says. "None of it had any effect whatsoever. It took up shelf space. After three or four months, I dumped the whole lot out."

Ironically, what many women should not have dumped out so fast is hormone therapy. Immediately following its release and continuing to this day, critics have assaulted the WHI study on a number of grounds. According to many ob-gyns, women in the study didn't reflect the population normally prescribed hormone therapy, who tend to be younger, slimmer and healthier. Moreover, though a 26 percent increase in breast cancer, as presented in the report, sounds high, this rate applies to the group as a whole. In other words, the rate of breast cancer among the study group was 26 percent higher than in the control group. However, when looked at on an individualized scale, the risks look slimmer: For any one woman, the increased risk is a mere .08 percent. After weighing the evidence, Mary Jane Minkin, a professor of obstetrics and gynecology at the Yale University School of Medicine still considers herself "fairly pro-HT." According to Minkin, "Estrogen probably won't save you and it won't kill you. It's more for symptom relief than anything else -- and it's still the best form of symptom relief out there."

Many practicing ob-gyns seem to agree. A September 2003 national survey of female ob-gyns conducted by Gallup found that 50 percent still use HT to treat their own menopause. A mere 13 percent had tried some kind of natural treatment, and 19 percent did nothing at all. Despite the hoopla, most doctors say HT comes down to an individual decision, based on an understanding of the real risks and benefits. Isaac Schiff, chair of the American College of Obstetricians and Gynecologists' HT task force, believes the negative interpretations of the WHI have gone much too far. "Women who would really benefit from HT are now so terrified of taking hormones that they're denying themselves something that would immensely improve their lives," he says.

Choosing to forgo hormones out of distrust of Big Pharma doesn't make much sense either. Despite their mom-and-pop-on-an-organic-farm image, many natural products belong to large pharmaceutical firms. Indeed Remifemin, the popular black cohosh product, is manufactured by GlaxoSmithKline. So why doesn't Big Pharma cash in big time by conducting the studies necessary to prove such drugs are effective? There's no incentive to do so: Herbals cannot be patented, and the $10 million FDA approval process doesn't warrant the cost, particularly when women seem to snap up botanicals regardless.

"It's paradoxical that the same women who were angry over the WHI data because they felt like hormones were promoted for benefits they couldn't deliver are now running in the opposite direction to the alternative-medicine industry," says Nanette Santoro, a professor of obstetrics, gynecology and reproductive endocrinology at the Albert Einstein College of Medicine. "To go for products that offer no proof of being effective or safe over the long term is inherently illogical." Which may be exactly what marketers are betting on.

Pamela Paul

Pamela Paul is a writer living in New York. Her most recent book, "The Starter Marriage and the Future of Matrimony" (Random House, 2003), is now out in paperback.

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