Many women - Crook included - used to rely on synthetic hormones to ease their symptoms. But their use plummeted after 2002, when a major study found they slightly increased women's risks of heart attack, stroke and breast cancer. Pharmaceutical companies lost millions of dollars, and many women searched for alternatives.

In March, a National Institutes of Health panel convened to discover the safest and most effective treatments. But its report said most women should just wait out the hot flashes, mental sluggishness, insomnia and other symptoms associated with changes in their bodies.

Evidence strongly links sleep disturbances, hot flashes, night sweats and vaginal dryness to menopause, but the group of medical experts said treating symptoms with hormone therapies can pose too much of a risk.

Rather than resolving how women can instead find relief, the report downplayed the toll the symptoms take and left unanswered questions about hormone replacement therapy and alternative treatments, say doctors, nurses and women in menopause.

Not every woman experiences menopausal symptoms. But others find the disturbances debilitating, often eroding family life, physical and mental well-being and sexual drive. Making matters worse, many women are hesitant to discuss the once-taboo topic with friends or relatives, so their success or horror stories are often hidden.

Plant-derived hormones: After Crook's gynecologist prescribed synthetic estrogen, her symptoms persisted. For her, the solution has been plant-derived hormones similar to those found in humans, called natural or bioidentical hormones.

"It is very confusing," said Crook, 53, of Salt Lake City. "I would prefer not to do anything, but I felt like my quality of life was going down if I didn't take the hormones. Even if it takes a few years off my life, I would do this again."

Crook had turned to Todd Mangum, a Salt Lake doctor who practices holistic medicine.

Mangum conducted saliva and blood tests to determine the levels of Crook's sex hormones - estrogen, progesterone and testosterone.

When the results came back, he prescribed the bioidentical hormones. She now takes a progesterone hormone at night to help with sleep and an estrogen-testosterone hormone in the morning. Her terrible symptoms have vanished.

"The goal is to balance my patients' hormones on an individual basis," said Mangum. "We're giving women the wrong hormones and acting all surprised when so many things go so wrong. The one-size all fits approach doesn't work. Think how unique we are on the outside. We're even more different on the inside."

Mangum recommends capsules of the plant-based hormones rather than creams, because they seem to give more accurate hormone levels, as shown by testing. Some patients want vegetarian or non-dyed capsules, which they can have made through a process called compounding from University Pharmacy in Salt Lake City. Pharmacists use compounding to design individualized medications.

"The side effects are minimal compared to synthetic hormones," said Trip Hoffman, a pharmacist at University Pharmacy. "The body is able to recognize and better metabolize the bioidenticals."

Jolley's Pharmacy in Salt Lake City and The Medicine Shoppe in Bountiful are also among the pharmacies along the Wasatch Front that offer compounding of hormones. Jolley's owner Dean Jolley sees many women who are perplexed by menopause.

"It's a real problem for many women," Jolley said. "If you don't have your hormones balanced, life is miserable. That's why as women get educated and learn about it, they're flocking to it. We've seen women have a better quality of life, symptoms improved, marriages saved, suicides prevented and improved libidos."

Research debate: But many gynecologists are not confident in bioidentical compounded hormones or the benefits of saliva testing.

"My opinion of bioidenticals is they're being flaunted as being safer, but we have no data to back them up," said Mary Beard, one of the state's leading menopause experts and a gynecologist at the Avenues Women's Clinic. "They're not [U.S. Food and Drug Administration] approved. I cannot guarantee the patient there is a consistency with the compounded products because there are no guidelines. And the saliva tests are not accurate enough; they do not consistently reflect what is going on in the blood stream or cell level."

Many doctors and nurses who work with premenopausal and menopausal women believe more research into bioidenticals is needed.

Marcia Scoville, a certified nurse midwife at All for Women Health Care in Salt Lake City, acknowledged a major study is unlikely because compounded natural hormones can't be patented, so pharmaceutical companies have no financial incentive.

"Women my age or a little younger or older have been the lab rats for hormone replacement," Scoville said.

Scoville, Mangum and other health care professionals say menopausal women who have had a hysterectomy should use progesterone in combination with estrogen, especially to help with sleep deprivation. But mainstream physicians and the North American Menopause Society have long held the position that women without a uterus don't need progesterone.

"There's no evidence women who have had hysterectomies need progesterone," said Wulf Utian, an Ohio gynecologist who is the society's executive director. "The progesterone skin creams that are being sold are a huge scam. They don't help. If you take a high dose of progesterone you become sleepy. But that is not good for the body because you reduce blood flow, and I don't think that's good for the brain."

The society supports only products approved by the FDA.

Synthetic hormones: Some women continue to use synthetic hormones, and doctors' opinions are mixed. The NIH panel said estrogen remains "the most consistently effective therapy" for menopause symptoms and said women must weigh their own personal health risks and benefits.

Mangum and Scoville object to the use of synthetic hormones, such as Premarin, because they think the chemical composition differs too much from natural hormones, causing unwanted side effects. Premarin is made from the estrogen-rich urine of pregnant horses. The molecular structure of synthetic hormones differs from human hormones, while bioidentical hormones mimic humans'.

Beard also prefers to avoid synthetic hormones, favoring low-dose estrogen patches made from soy. She discourages women from "self-medicating" with herbs and is unconvinced there is any benefit for women without uteruses to take progesterone.

The NIH panel "has placed a scare upon women," she said. "My approach is and has always been, we individualize. I'm not going to sit in my office and say, 'Sorry you have to bite the bullet, and I'll see you next year.' I think that's very cruel."

Taking control: Overall, Utian, with the menopause society, said the NIH report was unhelpful and misleading.

"I've got patients coming in three groups: those with terrible symptoms disrupting their lives, mild symptoms or no symptoms," he said. "Those who are having terrible symptoms want help. I think [the report] has an insensitive conclusion."

Marci Hansen, 47, of Syracuse, urges women to find their own best path.

She entered menopause last year after a hysterectomy. The two-time breast cancer survivor cannot take any estrogen-based hormones. Estrogen helps maintain healthy bones and the heart, but lifetime exposure to the hormone is linked to an increase in a woman's risk for breast cancer.

"You have to educate yourself," Hansen said. "You have to take control. We have to talk to other women and educate our daughters and sons. And you have to find a doctor who will work with you."

chamilton@sltrib.com

l Sleep disturbances

l Hot flashes

l Night sweats

l Vaginal dryness

Additional symptoms according to published experts on menopause:

* Decreased sexual drive

l Depression

l Headaches

l Irritability

l Weight gain

l Frequent urination

l Leaking of urine

l Anxiety and panic attacks

l Mood swings

l Crying spells

l Heart palpitations

l Memory lapses

l Joint aches and pains

l Acne

l Dry skin

Rick Egan

The Salt Lake Tribune

Cheryl Crook decided to take bioidentical hormones to deal with her menopausal symptoms. "I would prefer not to do anything, but I felt like my quality of life was going down if I didn't take the hormones." There is a lot of debate about which - if any - hormone treatments are best for women.