BODY WATCH : Old Age Elixir : More then ever, doctors--bolstered by new studies--say hormone replacement therapy is the best way for post-menopausal women to prevent osteoporosis and heart disease. So why aren’t women buying it?

Dr. Michael Kleerekoper thinks hormone replace therapy is terrific for post-menopausal women--a view widely shared by his colleagues in orthopedics, gynecology, cardiology and internal medicine.

But it is not, he notes wryly, a position widely shared by U.S. women.

The good doctor was reminded of that last spring when he and several other experts faced 1,000 well-informed Los Angeles women for a $75-a-plate luncheon at the Beverly Hilton called “Women and Doctors.” Repeatedly, the physicians touted the value of taking hormone replacement therapy--estrogen or a combination of estrogen and progestin--beginning at menopause.

Then a questioner wanted to know if taking calcium supplements was a good way to prevent osteoporosis.

“It’s not nearly as good as estrogen,” said Kleerekoper, bluntly.

A groan rose from the audience.

“Everything is estrogen, estrogen, estrogen!” one woman complained loudly.

Unbowed, Kleerekoper, a Wayne State University doctor, leaned closer to his microphone and boomed his bottom line: “There is nothing, globally, that takes care of the problems (associated with menopause) like estrogen does.”

Is hormone replacement therapy the great elixir of old age for women? More than ever, doctors--backed by a groundswell of new evidence--say yes.

Several prestigious medical groups, including the American College of Physicians and the American College of Obstetricians and Gynecologists, have released position papers saying post-menopausal women should seriously consider preventive hormone therapy for its benefits in reducing osteoporosis and heart disease--the two major scourges of old age in women.

The balance of evidence has tipped so far that a group of oncologists writing in the Aug. 17 issue of the Journal of the American Medical Assn. called for studies on hormone therapy in breast cancer survivors--long considered prohibitive because of a possible association between estrogen and breast cancer risk.

But in a steely display of consumer independence and--possibly--distrust in medicine, many American women are still saying no to hormone therapy.

“There is no free lunch,” UCLA breast cancer surgeon Dr. Susan Love told the Women and Doctors group. “You’re not going to be able to take something and not pay the price.”

*

“There is an enormous amount of resistance,” says Janine O’Leary Cobb, the director of a Champlain, N.Y.-based consumer group for post-menopausal women called A Friend Indeed.

Various surveys estimate that 15%to 25%of the nation’s 40 million menopausal or post-menopausal women are on hormones.

“In the last two years,” Cobb says, “physicians around the country have come to recognize that many women have dug in their heels about this. Doctors are wondering what they can do differently to get women to take it.”

To be sure, hormone therapy is not a benign treatment. Users commonly experience such annoying side effects as irregular menstrual bleeding, breast tenderness, bloating and headaches, although doctors say dose adjustments can often alleviate these problems. Hormone therapy is not safe for women with certain conditions, such as liver and gallbladder disease. Finally, there is still a question of whether hormones promote breast cancer.

This rare instance in which consumers have, en masse, spurned scientifically based medical advice perplexes health officials who are increasingly sensitive to the dual goals of promoting women’s health objectives and encouraging cost-saving preventive care.

“When you consider that American women live considerably longer than they used to . . . more than one-third of their lives post-menopausally, that heart disease is the leading cause of death, and that one in five or six of them will fracture a hip from osteoporosis and 25% of them will never walk again, that is really important stuff,” says Dr. Diana Dell, a Duke University professor and president of the American Medical Women’s Assn.

Women are thought to be naturally protected from heart disease by hormones produced by the ovaries until menopause. After menopause, however, heart disease skyrockets, surpassing even that of men. Heart disease is the leading cause of death in older women with a half a million U.S. deaths a year--more than twice as many as all cancer deaths combined.

But in a major study--Postmenopausal Estrogen/Progestin Interventions (PEPI)--researchers last month announced that hormones clearly improve a number of key risk factors for heart disease.

Osteoporosis prevention has been another big winner with studies showing that hormones can lower the risk of hip fracture--the most disastrous consequence of osteoporosis--by 60%. So overwhelming is hormone therapy for osteoporosis prevention that the Food and Drug Administration now allows manufacturers to market it for that purpose.

“Estrogen therapy is almost like women immunizing themselves for two of the most prevalent diseases that can affect menopausal women: heart disease and osteoporosis,” says Dr. Morris Notelovitz, president of the National Menopause Foundation in Gainesville, Fla. “When we look back in time to come, the intelligent use of hormone therapy will be one of the greatest boons ever to women’s health.”

According to other research, hormones also look promising for preventing Alzheimer’s disease and cataracts, and improving mood, skin tone, hair texture and sexual functioning. And, according to an English study, women on hormones sleep deeper and think better when awake.

“(The therapy) can have a tremendous effect on the quality and quantity of a woman’s life,” Notelovitz says.

So if the benefits so clearly outweigh the risks, why aren’t more women taking hormones?

*

The negative column bears one of the primary reasons women hesitate to sign up for hormone therapy: It may increase the risk of breast cancer. While a few long observational studies found that estrogen users had a 20% to 30% higher risk of breast cancers, similar studies found no risk; the issue is far from settled.

The association between hormone therapy and uterine cancer is much better understood. The PEPI study and others have demonstrated that estrogen therapy causes tissue growth in the uterus that can lead to cancer. But when estrogen is combined with the hormone progestin--the most popular regimen used today--the increased risk of uterine cancer is eliminated.

Still, when women hear estrogen, they often think cancer, doctors say.

“The risk of breast cancer is minute compared to the benefits they get from prevention of heart disease and osteoporosis. But the bottom line is the word cancer ,” Notelovitz says. “And that is unfortunate. Estrogen does not cause breast cancer. It may promote breast cancer.”

But it will take time to undo the myths and misconceptions of the past, says Dr. Lila Nachtigall, a New York University professor and author of a consumer book on menopause. She blames some of her colleagues for dissuading patients from taking hormones in the ‘70s and ‘80s--even though many of those same doctors today are writing prescriptions by the fistfuls.

“Cardiologists and internists have done the biggest turnaround. Ten years ago, I would put a woman on estrogen and the internist would take her off. They wouldn’t even call, they would just take her off. Now, they call me and say ‘She just had a heart attack. She needs estrogen,’ ” Nachtigall says.

Doctors have tended to emphasize the traditional use of hormone therapy--as a short-term drug to alleviate hot flashes, vaginal dryness and night sweats. As such, too few women understand that hormones are a much weightier tool when used for long-term prevention of disease, Dell says. In a recent survey of 1,000 women by Wyeth-Ayerst Laboratories, the makers of the hormone product Premarin, only 5% of women identified heart disease and osteoporosis as long-term post-menopausal risks.

“We have too often improperly characterized hormone therapy in a way that infantilizes women; that once their hot flashes go away, they won’t need hormones,” she says. “If women got clear-cut messages instead, many will begin and continue therapy. But a lot of this has to do with the amount of time a doctor spends with a patient in discussing whether or not to take hormones.”

Cobb, of the consumer group A Friend Indeed, agrees that doctors take too little time to educate women.

“It takes a lot of time and care to prescribe hormones. What doctors should do is delegate this task; turn it over to nurse-practitioners who can take more time,” she says.

She also blames doctors for not helping women adjust to hormones in a more sensitive manner. In the 1991 meeting of the North American Menopause Society in Montreal, Cobb hung a poster in an exhibition hall displaying letters from women complaining of how their doctors handled their hormone therapy.

“I had a lot of doctors hanging around my board,” she says wryly.

The marketplace is packed with numerous hormone formulations including pills, skin patches and vaginal creams; products to prevent osteoporosis and others for various menopausal symptoms. Finding the right product for an individual woman can involve time and experimentation. But, Cobb says, two-thirds of women who start hormone therapy quit within a year because of bothersome side effects--far too short a time to gain any disease-prevention benefits.

“I don’t think any of us are very good at prevention,” Dell says. “All of us live for today and don’t live for what will happen in the future. You only have to look at the number of American women who smoke to see how true that is.”

Moreover, Dell says she often sees patients who believe that since menopause is nature’s way, she must live with nature’s consequences rather than take hormones.

“But that same patient will think nothing of taking anti-hypertensive drugs to prevent stroke,” Dell notes. “I don’t see the difference. Hormones are a medicine used for prevention purposes just like other medicines are.”

Notelovitz says he likes to remind his patients that they do have a choice if they want to try to live out their final third of life in vigorous health but don’t want to take hormones. Osteoporosis can often be prevented in mid-life with hefty calcium supplements and regular weight-bearing exercise. Heart disease can be prevented with a regimen consisting of a low-fat diet, no smoking, exercise, stress reduction, antioxidant supplements and low-dose aspirin.

“We have to give women an option: Do you want to take hormone therapy or do you feel more comfortable with diet, exercise, antioxidants and aspirin? The problem with the later is compliance. Once you stop, you lose the protective effect,” he says.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Pros and Cons of Hormone Therapy Benefits

* Prevents osteoporosis.

* Decreases some risk factors for heart disease.

* Prevents vaginal dryness and thinning of the walls.

* Provides relief from such menopausal symptoms as hot flashes.

Possible benefits

* May reduce the onset of Alzheimer’s and/or dementia.

* May prevent cataracts.

Risks

* Uterine cancer (with estrogen use only).

* Blood clots in women with certain risk factors, such as history of phlebitis.

* Gallstones in women with risk factors for gallbladder disease.

Possible risk

* May increase risk for breast cancer.

Possible side effects

* Vaginal bleeding.

* Breast tenderness.

* Nausea.

* PMS-like symptoms.

* Headaches.

Sources: National Women’s Health Resource Center; Los Angeles Times files.