Only a few generations ago, when a woman started experiencing hot flashes she knew the end of her life loomed near.
Today the average life expectancy for women in most Western countries is near 80, and menopause -- often announced by hot flashes -- means transition but not end. Many women can expect to spend one-third or more of their lives post-menopausal.
And menopause is becoming the focus of increasing medical attention. The reasons are both demographic and scientific:
* A growing number of baby boomers are nearing the age of menopause, which occurs on average at age 51.
* Medical knowledge about how hormones work is expanding, with hormone replacement therapy being used for increasing numbers of menopausal women. But the use of drugs to treat what some regard not as a medical condition but simply the normal process of aging is controversial.
* Medical research is concentrating more and more on the process of aging and preventing the diseases of aging, two subjects closely related to menopause.
But if this seems like good news for the more than 40 million American women who will turn 40 in the next two decades, it is news tempered with a confusing range of options and often conflicting recommendations.
The consensus that emerges from a study of menopause is that it is a process that varies considerably from woman to woman. "You have to individualize treatment," said Dr. Wulf H. Utian, chairman of reproductive biology at Case Western Reserve University in Cleveland and the founder of both the International and the North American Menopause Societies.
Dr. Utian, in a phone interview, added that menopause remains a mystery for many women, despite the fact that they have become increasingly more educated about their own health care in the past 20 years.
"Menopause is not a subject that mothers tell their daughters too much about," he said. "Many women come into it not knowing what to expect."
And though women may talk among themselves about their menopausal experiences, they may find they don't always have a lot in common.
Case studies: a variable condition
"I would be overwhelmingly hot. My face, my upper body. I had extreme body heat many, many times a day. The flashes would last 10 to 20 minutes. I'd perspire and get very uncomfortable. I was working with patients in a one-on-one situation in a small closed room with no windows and I had to ask my boss to change my duties.
"But the flashes were the worst and the longest at night. I would wake up in the middle of the night overheated and sweaty. It got to the point, I was so tired I was irritable and walking into things."
Carol Kelly, a medical office manager, started experiencing these hot flashes two years ago when she was 46. She remembers in her early 40s looking forward to the cessation of her menstrual periods. Although she now controls her symptoms with estrogen replacement therapy, she says of her menopause: "It has not been what I anticipated. It has been a nightmare."
Cynthia Anderson, 57, a high school science teacher, has quite a different story to tell.
"I had the classic ideal menopause. I didn't even know it had happened. I had warm earlobes seven or eight times, that's it.
"I just noticed a lessening of my monthly discharge. I became more irregular and suspected something was going on. I just eased right into it. I think I must have a marvelous chemistry.
"Women who still have menopause in front of them should take heart from my story. All of the terrible horrors that you hear are not inevitable."
Estrogen replacement therapy: boon or bust?
Gay Guzinski, chief of the division of benign gynecology at University Hospital, leaves little doubt about where she stands on the subject of estrogen replacement therapy.
"With our interest in preventive medicine, we should be looking for reasons not to give estrogen replacement," she said. "I believe we should give it unless it is specifically contraindicated."
Barbara Seamon, a feminist writer specializing in health issues, disagrees.
"Only about 10 percent of the population has serious, debilitating menopausal symptoms," said the 55-year-old author, who described her own menopause as barely noticeable. "Yet the drug companies would have us believe that everyone has these terrible problems. I think that except in the most extreme cases ++ the effects of menopause can be handled without taking a carcinogen."
The case on estrogen replacement is complicated, confusing and incomplete. It effectively treats the uncomfortable symptoms of menopause for most women because it replaces the hormone that the ovaries have stopped producing naturally. It has been shown to have preventive benefits for osteoporosis, a problem for some post-menopausal women, and heart disease, ZTC which rises dramatically in women after menopause. Yet it has also been linked to side effects ranging from breast tenderness to cancer.