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Doctors used to think of menopause as a pathologic deficiency of estrogen.

This made some sense: Women after menopause developed osteoporosis and heart disease at a much faster rate, and some observational studies showed that women who took estrogen after menopause lived longer. Also, many postmenopausal women taking estrogen felt better.

But the Women's Health Study showed that estrogen is likely bad for women after menopause. It increases the risk of breast cancer, heart disease and life-threatening blood clots in the legs.

That's an example of why one should be careful about judging medical treatments using observational studies, by the way. It turned out that the healthiest women probably chose estrogen because they wanted to be healthier.

But now that the issue is clarified, we are left with the problem of how to help menopausal women lower their health risks and reduce symptoms.

Symptoms of menopause vary across cultures, but in the United States, women tend to experience hot flashes, vaginal dryness, sexual dysfunction and mood changes.

A first question is whether treatment is necessary at all. Most symptoms resolve with time, and risk of heart disease and osteoporosis can be reduced with lifestyle changes. But if symptoms are bad enough, or if risks are bad enough, treatment can be chosen in an "a la carte" fashion.

Hot flashes probably represent a transient instability in the body's heat regulatory mechanisms around menopause. They can be treated with antidepressants like paroxetine (Paxil) or sertraline (Zoloft); the herb black cohosh; the anticonvulsant gabapentin (Neurontin); or with soy protein supplements. Vitamin E might help also.

For vaginal dryness, a number of plant-based estrogen-like substances can help. These seem to be safe, but have not been studied well enough to determine whether they, like estrogen itself, actually increase health risks. Vaginal lubricants like Replens are an option.

Loss of libido may be due to menopause itself. However, if depression or anxiety are present, they should be treated because they can reduce libido. Sildenafil (Viagra) and similar drugs might be helpful for women, but this has not been established conclusively. The supplement DHEA seems to help, but its use is controversial in medical circles because of its widespread endocrine effects. Testosterone and its variants seem to increase female sexual drive, but the effects of giving long-term male hormones to women are not clear.

For osteoporosis risk, the elephant in the room is vitamin D deficiency, which probably affects most Western New Yorkers for at least the part of the year when there is no sun. Women should be screened for osteoporosis with a bone mineral test at age 65, or earlier in the presence of any fracture, a body weight of less than 127 pounds, or with a history of a first-degree relative with a hip or spinal fracture. If osteoporosis is present, it can be treated well with standard medical care.

Heart disease risk increases rapidly as soon as women begin menopause. Your doctor can help you treat you for conventional risk factors like high blood pressure, high cholesterol and being overweight. Other interventions that have been shown to be effective in reducing heart disease risk in postmenopausal women include fish oil, soy protein and the drug raloxifene (Evista).

A few other items should be noted.

Women approaching menopause can still become pregnant, and should have pregnancy tests when they develop new symptoms.

The symptoms of thyroid disease, which is very common in this region, can mimic those of menopause. This can be screened for with a blood test.

Above all, women should focus on exercise around menopause. In menopausal women, regular exercise improves quality of life scores, decreases hot flash frequency and severity, increases bone density, and improves cardiac risk factors including hypertension and high cholesterol.

Dr. Mike Merrill is an internist practicing in Buffalo. His column appears every other week on this page. E-mail your comments to him at