Kate G. is one of the lucky ones. She had her last menstrual period right on schedule&emdash;51 is the average age when most women reach menopause&emdash;and experienced no special problems. Kate remembers thinking, "Great, now I don't have to deal with cramps or worry about getting pregnant anymore. Free at last!"

On the other hand, Yvonne R., who is only 42, describes her experience as "biology hell." She recalls, "First I noticed I was forgetting names&emdash;something I never did before. Then I began having trouble sleeping through the night and was tired and muddle-headed, or weepy, the next day. I snapped at my children and felt furious if my boss made even a minor suggestion."

Since Yvonne was still having regular periods, she never suspected that her symptoms might signal the approach of menopause. Instead, she repeatedly asked herself, "What's wrong with me? This can't be normal."

But according to health experts, the experiences of both Kate and Yvonne are completely normal for women during perimenopause. This is the five- or ten-year period before menstruation ends. During these years, a woman's body begins to scale back the production of estrogen, the primary female sex hormone associated with reproduction. The problems that women like Yvonne face are often due to the fact that estrogen rarely declines gradually. Rather than allowing the body to adjust in stages, hormone levels tend to rise and fall erratically.

Besides hot flashes, night sweats, insomnia, and difficulty concentrating, many women experience heart palpitations, headaches, PMS-like mood swings, vaginal irritation, and urinary complaints. Even such odd sensations as tingling fingertips and mysterious bruises may be linked to hormonal changes.

Knowing that perimenopause can begin before the age of 40, and that it needn't be "biology hell," could have saved Yvonne much distress. Fortunately, women today have a wide range of options to help alleviate problems that arise during peri- and postmenopause. Every woman owes it to herself to get the facts so that she and her health provider can make a choice that is right for her.

Midlife Decisions

In our grandmother's day, the "change" was something every women expected to get through, for better or worse. But today, some women think that every health problem and sign of psychological stress during the menopause years stems from raging hormones, and they are desperate to find a quick-fix. At the other extreme are those who pretend they're superwomen and downplay the effects menopause has on them. Both views are misguided says Dr. Ozgul Muneyyirci-Delale, clinical associate professor of obstetrics and gynecology at SUNY Downstate.

"If you are lucky enough to escape uncomfortable menopausal symptoms, congratulations," she says. "However, denying that you are affected at all is unwise." Dr. Muneyyirci feels that controlling unpleasant symptoms is worthwhile. Even more important, she believes a woman can dramatically improve her future health by taking certain steps in her forties and fifties.

All About Estrogen

At the crux of menopause health concerns is the amazing reach of the hormone estrogen. It affects not only the reproductive system but also the healthy function of the heart and circulatory system, the bones, and the nervous system. When estrogen begins to decline for women at midlife, these protections weaken, leading to the possibility of serious health risks later in life.

The greatest threat is heart disease. After the age of 50, a woman's risk begins to increase and her chance of suffering a fatal heart attack starts approaching that of a man. Although we hear more about breast cancer, heart disease actually remains the leading killer of postmenopausal women.

Studies have shown that estrogen significantly reduces the risk of heart disease. It also has an important effect on arteries by raising good cholesterol (HDL) and lowering the harmful kind (LDL). Without the protection of estrogen, bones tend to lose calcium, leaving them weak and brittle. Even though Caucasian and Asian women are at highest risk for developing osteoporosis, a disease that causes the bones to break, slender, small-boned African-American and Hispanic women are also at significant risk.

Estrogen loss also affects the elasticity of dermal tissues, which make up not only our skin but also the lining of the vagina, bladder, and urethra. That is why many women experience sexual discomfort or bladder problems (see "Is There Sex after Menopause?").

Postmenopausal women also may become prone to memory problems and age-related dementia. Researchers now believe there may even be a link between estrogen loss and Alzheimer's disease.

"With all these potential problems due to less estrogen," says Dr. Muneyyirici, "I believe women should discuss their options with a health practitioner and at least consider hormone replacement therapy."

Hormone Replacement Therapy

Estrogen replacement therapy (ERT) has been around for nearly 40 years. In its early versions, it delivered relatively high levels of estrogen. When studies later showed that estrogen can increase the risk of developing breast and uterine cancer, new therapies were introduced with a far lower estrogen content.

Many doctors now prescribe a combination therapy known as hormone replacement therapy (HRT) containing two hormones: estrogen and progesterone (or progestin, the synthetic form). Progesterone triggers a woman's monthly period, when the uterine lining sloughs off, and is believed to reduce the risk of developing uterine cancer.

For years it was thought that adding progestin could also reduce the risk of breast cancer associated with estrogen therapy. However, scientists now report that progestin may actually increase the danger. A 15-year study of more than 46,000 postmenopausal women, reported in the January 26 issue of the Journal of the American Medical Association, concluded that taking HRT containing progestin nearly doubles the risk of breast cancer compared to taking estrogen alone.

New studies continue to shed light on the benefits and possivle risks of these hormones. The decision to start or continue HRT must be an individual choice made in discussion with your physician.

SERMS

The newest blip on the radar screen for menopause management is SERMS, drugs known as "selective estrogen receptor modulators." Although still experimental, these drugs appear to offer many of the benefits of HRT without its risks.

Studies have shown that SERMS can prevent calcium depletion from bones and lower blood cholesterol levels. At the same time, a clinical trial showed that the SERM tamoxifen reduced the rate of breast cancer occurring in high-risk women. This gives SERM therapy a distinct advantage over HRT for women who have had close relatives with breast cancer, or who know they carry a gene that puts them at higher risk of developing it.

Phytoestrogens, Herbs, and Vitamins

Some foods and herbs contain phytoestrogens ("phyto" means plant-based) that can be absorbed by the body to help abate menopause symptoms. Soy-based products like tofu and tempeh, in particular, are reported by some women to reduce hot flashes. Soy also is low in fat and high in protein and cancer-fighting antioxidants. Wild yam and black cohosh, sold in supplement form in health food stores, also are estrogenic. Vitamins E and C, and several B vitamins, as well as ground flaxseed, evening primrose oil, wild nettle, feverfew and many others herbs may help control menopause symptoms.

Dr. Muneyyirci cautions women to resist believing all claims made for products sold in health food stores and over the Internet. "Some remedies may have value, but the proofs cited are mainly anecdotal&emdash;not based on research studies that meet scientific standards," she says. A particular problem arises around dosage, and women taking several estrogen-rich products may do themselves more harm than good. The best advice is, "Buyer, beware."

Benefits of Exercise

Valerie Roe, assistant professor of midwifery, believes that exercise may be the single best remedy for problems during peri/postmenopause or at any age. It has been shown to help diminish hot flashes, improve sleep, and make people feel better almost immediately. Long-term benefits include minimizing the loss of calcium from bones and improving cardiovascular fitness. Exercise also lowers the risk of type 2 diabetes, another age-related health risk.

Exercise helps control weight and is therefore good for the heart, because it builds muscle, in addition to burning calories during the actual workout. Muscle cells consume more calories than fat cells, even when the body is at rest. Exercise also boosts mood by stimulating the release of endorphins, the "feel good" compounds manufactured in the brain. In addition, when people get physically fit, they tend to become more energetic, are more interested in sex, and enjoy higher self-esteem.

A recent study suggests a further, very important benefit of exercise: Women can reduce their breast cancer risk by 20 percent by exercising one hour daily; even a half-hour of exercise per day can reduce breast cancer risk by 10 percent. This finding emerged from the Nurses' Health Study, which followed the habits and health of 120,000 women between the ages of 30 and 55 for 14 years. The types of exercise reported range from walking to jogging, swimming, and aerobics. Health results were the same, whether exercise was extremely or only moderately vigorous.

Weight Management and Nutrition

Many women gain weight in their forties and fifties, which is probably more a consequence of age than of menopause (adding 10 pounds per decade is common in both men and women). Regardless, adding too much weight is a health threat. To remain healthy for the long term, exercise regularly and consume a diet that is low in sugar and fat and that includes lots of vegetables and fruit.

To counter the loss of bone calcium and avert osteoporosis, eat lots of calcium-rich foods, such as low-fat dairy products and dark green leafy vegetables. Daily calcium supplements also should be considered. A study published last year indicates that taking 1,200 milligrams of calcium daily has the added benefit of helping to reduce PMS-like symptoms by approximately 50 percent.

Taking Control

If you are in your peri/postmenopausal years, you have lots of company. Never have there been so many women between the ages of 40 and 60, and today's woman refuses to view herself as a victim of biology.

"This is a period in our lives when we can develop our talents to the fullest," says Professor Roe. "If we take care of our health, we can be happier and more productive than ever&emdash;and we can remain that way well into old age."