Maria Dube is a 37-year-old Burlington woman with two young sons who has a problem that’s often hushed up, though it’s shared by 20 million Americans, two-thirds of them women.

The wear and tear of childbirth left Dube, a telephone service representative for a Boston bank, with stress incontinence, which meant that every time she sneezed, laughed, jumped or chased her kids, she leaked urine. Asthma made things even worse. “I coughed so frequently, I had to use a pad all the time,” she said.

But several months ago, Dube underwent a 30-minute, minimally invasive surgical procedure that, some doctors say, is the most dramatic improvement in incontinence treatment in years.

While Dube was awake but under local anesthesia, her physician, Dr. George Flesh, head of urogynecology and pelvic reconstructive surgery at Harvard Vanguard Medical Associates, implanted a ribbon called a Tension-free Vaginal Tape between her urethra, through which urine flows, and her vagina. The tape is designed to act like a sling to support the urethra. The procedure is so new that only 20,000 patients worldwide have had it. Many doctors, even in a medical mecca like Boston, haven’t yet had the special training to perform it. But a three-year study in Sweden, where the procedure was developed, shows it works 90 percent of the time, and it clearly did for Dube.

Urinary incontinence comes in two basic forms: urge problems, in which bladder muscles go into spasm, making it impossible to stop urine flow once it starts; and stress problems like Dube’s, in which weak sphincter or pelvic muscles fail to keep the bladder neck closed during sudden physical stresses like coughing or exercising.

Incontinence can also occur in men when an obstruction – such as an enlarged prostate – blocks urine flow, leading to overflow or urge problems.

While the vaginal tape procedure is creating the biggest buzz, other new approaches – including an acupuncture-like system called SANS and a muscle-stimulating device called NeoControl – also may dramatically improve the quality of life for millions of incontinence patients.

For those with mild incontinence, the best way to start is with the simplest, least-invasive options.

For stress incontinence, this means doing Kegel exercises to strengthen pelvic floor muscles (the muscles that support pelvic organs). To identify these muscles, try stopping urine flow in midstream. If you can, you’ve found the right muscles. Once you’ve located them, practice this maneuver 100 times a day, but not during voiding, lest you retain urine.

If you can’t pinpoint the right muscles on your own – and many people can’t – go to a continence center (many hospitals have them) and ask for biofeedback training. Biofeedback is a system in which electrical sensors are placed on patches of skin or in the vagina or rectum; they send a painless signal to let you know you’re contracting the right muscles.

A new alternative, NeoControl, may be more appealing for some people with stress or urge incontinence. You sit on a special chair, fully clothed, with an empty bladder. Magnets under the chair produce a pulsed magnetic field that acts on nerves to cause pelvic muscles to contract.

“When you stand up, you feel like you just got out of the gym, but only in the pelvis. It feels sore but not unpleasant, like a workout,” said Dr. Peter Rosenblatt, a urogynecologist and codirector, with Dr. Neeraj Kohli, of the Cambridge Continence Center at Mt. Auburn Hospital in Cambridge.

About 60 percent of patients who use NeoControl improve after two months of twice-weekly sessions, Rosenblatt said.

Vaginal cones, which are available by prescription, are another simple solution for stress and urge problems. These are tampon-like devices held in the vagina for 15 minutes twice a day to strengthen muscles.

Other devices, also available by prescription, include Capsure and FemAssist, which are reusable suction cups that cover the opening of the urethra and are pulled off before urination. There is also a disposable patch called Impress that sticks to the urethral opening like a BandAid; it, too, must be changed before urination, but it may be available over-the-counter soon.

If urge incontinence is your problem, bladder retraining may help. The idea is to stick to a pre-set schedule, urinating regularly before the bladder gets too full, and learning to suppress the urge to urinate at other times. A variant on this is the AcuTrainer, a prescription beeper that your doctor programs to tell you when to urinate. The program gradually increases the interval between voids.

Recently, the US Food and Drug Administration approved another option for urge incontinence, the SANS (for Stoller Afferent Nerve Stimulation) system, after research showed that 55 percent of women who tried it had at least a 25 percent reduction in urgency or frequency.

In SANS, the tip of an acupuncture-type needle is placed just under the skin above the ankle, a site known to acupuncturists as “spleen 6.” A mild electrical current is passed through the needle to stimulate a nerve that controls the sacral nerve in the lower back, which in turn controls the bladder. The treatment calms the nerves to the bladder, which are hypersensitive in many people with urge incontinence.

The SANS treatment is similar to a more invasive, and expensive, surgical procedure in which a device called InterStim is implanted in the lower back to control nerves to the bladder.

And there are other options, too. For stress incontinence, especially a severe form called intrinsic sphincter deficiency, collagen injections – via a needle passed through the urethra – fill the space around the urethra, squeezing off urine flow.

A similar approach involves injections with Durasphere – carbon pellets in a gel-like suspension. Unlike collagen injections, whose effect tends to wear off after two years, Durasphere injections should last longer because the material is not absorbed by the body.

For sheer convenience, however, many people opt for medications rather than devices.

Estrogen can make the urethra more pliable and help it close more easily. It can be taken as pills, patches, vaginal cream or a vaginal ring called Estring that releases the hormone slowly over three months.

Nasal decongestants like Sudafed and a prescription decongestant called Entex can also help with stress incontinence because, as a side effect, these drugs act on proteins called alpha-receptors, which help the urethra contract.

For urge incontinence, other drugs help – notably the old standbys Ditropan and Levbid, and newer ones such as Detrol and Ditropan XL (extended release). These drugs block acetylcholine, a chemical secreted by nerves that tells muscles to contract. The newer drugs cause fewer side effects like dry mouth and constipation.

Tofranil, an antidepressant that, like the decongestants, has the useful side effect of relaxing bladder spasms and tightening the urethra, can also help. For men with incontinence caused by an enlarged prostate, drugs like Hytrin or Flomax that relax the urethra also work. So does shrinking the prostate itself – with drugs or surgery.

Surgery is an option for some women, too. For those with stress incontinence, the traditional approach is the Burch procedure, a “suspension” technique in which surgeons tighten up the pelvic fascia (fibrous tissue that lies on top of muscles) by stitching it to ligaments near the pubic bone.

Traditionally, this is done through an open abdominal incision, which means the patient spends several days in the hospital, but can count on an 80 to 90 percent chance of being markedly improved for at least five years.

Recently, some surgeons – perhaps half a dozen in Boston – have been using a laparoscopic approach. Instead of making a 4- to 5inch abdominal incision, they operate through two tiny incisions using miniature TV cameras to guide their way. The surgery is technically difficult, but appears to have the same success rate as the standard Burch procedure.

But it’s the new vaginal tape procedure that may prove most appealing for women whose main problem is a sagging urethra, not a sagging bladder as well.

“It’s fantastic,” said Rosenblatt of Mt. Auburn Hospital, who has done 150 such procedures. So far, it seems to enable women to have less pain, a shorter recovery and to solve the problem in 85 to 90 percent of cases.

Dube, the energetic mother who had the tape procedure, agreed. “I used to have to cross my legs every time I sneezed,” she said. “Now I swim, run, everything. I don’t have to use pads.” Her advice? “Just do it. It will take a week of your time” to fully heal. “But it’s worth it.”

Alerting The Neighbors, Doctors, Courts To Domestic Abuse Helps Women Bring problem To The Fore – And It May Save Their Lives

The rice was the tip-off.

When the young woman’s mother came to visit her in New York, she was astounded at all the rice her daughter kept in the cupboard. When the mother asked why, the daughter shrugged. Her husband, she explained, always complained that she “didn’t make rice as fluffy as his mother did.” So she’d keep trying over and over.

“There’s nothing wrong with the way you make rice,” gasped the mother. What was wrong, both women realized, was that the daughter was caught in an abusive relationship. Her husband’s constant criticism about her cooking was part of a larger pattern of psychological humiliation and beatings.Since that incident 22 years ago, the story has become legendary in the domestic violence field, not least because the daughter was Sarah Buel, who left her husband and went on to Harvard Law School, and now runs the domesticviolence clinic at the University of Texas Law School in Austin.Domestic violence – overwhelmingly a male-against-female problem but a major issue in same-sex relationships as well – is a public health dilemma of staggering proportions that crosses boundaries of wealth, race and class.

As researchers probe the enormity – and complexity – of domestic abuse, they are becoming more sophisticated at helping victims fight back with “safety plans” and other long-term strategies for physical, and psychological, survival.

A decade ago, the standard question for a woman in an abusive relationship was: “Why don’t you just leave?”

But evidence is mounting that “just leaving” can be dangerous; some men become vengeful when a woman stands her ground. This is complicated by the fact that women often feel ambivalent toward their abusers, and want legal intervention one day and not the next.

Leaving an abusive relationship is no small task – anywhere.

Between 10 and 50 percent of women worldwide are hit or otherwise physically attacked by an intimate male partner at some point in their lives, according to researchers from the Johns Hopkins School of Public Health and the Center for Health and Gender Equity in Takoma Park, Md., in a recent report based on 500 studies.

Often this leads to physical injury. Sometimes it leads to murder. Worldwide, 40 to 70 percent of homicides of women are committed by intimate partners, the Hopkins team found. By contrast, only a small percentage of men who are murdered are killed by their female partners and, in those cases, the women are often acting in self-defense or retaliation.

“Around the world, at least one woman in every three has been beaten, coerced into sex, or otherwise abused in her lifetime,” said the researchers in their report.

Abuse can run the gamut from hitting, slapping and kicking to sexual coercion to psychological control by intimidation and humiliation.

Sometimes the physical symptoms last long beyond the wounds have healed; some women live with irritable bowel syndrome and chronic pain syndrome. Others suffer with psychological problems such as depression, anxiety or abusealcohol and drugs. And because abuse and intimidation mean that a woman often can’t negotiate the terms of sex, she’s also at risk of sexually transmitted diseases such as AIDS and unwanted pregnancy.

While heterosexual women are the main victims, researchers now know that violence is just as common in relationships between gay men and lesbian women.

Studies suggest battering occurs in 25 to 46 percent of same-sex relationships, said Beth Leventhal, executive director of the Boston-based Network for Battered Lesbians and Bisexual Women, a nonprofit group.

Emily Pitt, a domestic violence worker at the Fenway Community Health Center in Boston, said the “cycle of violence” can be similar in heterosexual and homosexual relationships.

It often begins with psychological abuse – threats of violence like walking around the bed with a knife, humiliating comments such as “you’re getting fat” or surrogate violence such as attacking pets, said Lois Haggerty, an associate professor at Boston College School of Nursing who, with colleagues, is studying abuse in women who visit prenatal clinics.

Emotional abuse often escalates into physical abuse, which in turn is often followed by a “honeymoon” period in which the abuser apologizes and the victim takes responsibility for helping him change. Then the cycle begins again.

That abuse is similar in heterosexual and homosexual relationships suggests that, while the basic pattern fits into cultural definitions of masculinity and feminity, abuse is really about power and control, said Sally Engle Merry, a legal anthropologist at Wellesley College. It’s “the opportunity, and the entitlement, for the powerful to use force to control the less powerful.”

How can such a complex dynamic ever be changed?

“What seems most effective,” Merry said, “is a three-layered approach.” First, there must be “some kind of punishment for the batterer. In the absence of punishment, other approaches don’t have much impact. . . . Second, there has to be some effort at reform – treatment programs.” Over time, educating batterers that their behavior is not acceptable can change cultural norms. Data suggest that, although many batterers drop out of treatment programs, 80 percent of those who stay stop battering, at least for a year.

“Third, there must be mechanisms that focus on the woman’s safety.” Shelters help, but so do the much-maligned temporary restraining orders – civil court orders aimed at keeping the batterer away from his victim.

Over time, Merry said, “the law acts not just by imposing sanctions but also by creating normative standards for how people ought to treat each other.” In recent years, the number of restraining orders has soared in many states, including Massachusetts.

Restraining orders may not deter someone who is homicidal but they can work with a “relatively new batterer who has not had a lot of experience with the courts.”

Daria Niewenhous, a health care lawyer at the Lahey Clinic who for years headed the pro bono domestic violence project at the law firm, Mintz Levin, agreed. “Restraining orders can and do work when the batterer has something to lose if the order is violated,” she said. But they “should always be part of a safety plan.”

Such safety plans – specific steps developed over the years from hard-won experience – don’t give blanket advice to women to leave an abuser immediately. For one thing, it’s when a woman leaves that an abuser is most likely to feel he’s losing control, and to attack. For another, it usually takes four to five attempts – and a good long-term plan – before a woman manages to leave for good.

Rather, today’s safety plans read like survival manuals for living in a war zone. They advise, for instance, that a battered woman tell one or more neighbors about the violence so they can call 911 if they hear or see a disturbance in the woman’s home.

During an argument, a woman should walk into a room that she can leave easily. Staying away from rooms, such as the kitchen, where there are items that could be used as weapons, is also a good idea. Having a bag packed with spare keys, money, documents and clothes and keeping it at the home of a friend or relative also makes sense.

If your abuser is stalking you, you can “tell your employer if you need to be walked to your car,” said Kristie Wang, spokeswoman for the San Francisco-based Family Violence Prevention Fund, a national policy and advocacy group. Your employer may also be able to help if your abuser makes harassing calls at work or if you need to have a desk away from a window.

It also helps to tell health professionals about the violence. They can suggest resources to turn to, offer emotional support and keep records of the injuries.

In fact, asking about domestic abuse is now the standard of care for health care providers. “All health care providers should ask every patient, every visit,” said Buel of Texas.

The key is not to keep the abuse secret. Ask friends and family members, especially men, to confront the abuser if they see or hear him being threatening or humiliating. If a man knows others are watching, he may think twice about his behavior or become embarrassed by it.

No one deserves to be hit or threatened. Even if she overcooks the rice.

Most Americans know by now that eating a diet high in saturated fat can raise cholesterol, a major risk factor for heart disease, which kills nearly 500,000 people a year and is the leading cause of death for both men and women.

But what many people don’t know is that an underactive thyroid – the butterfly-shaped gland in the neck that produces a crucial hormone that regulates metabolism – may also contribute to high cholesterol.

When thyroid hormone levels are too low, the liver makes fewer molecules called LDL receptors, whose job is to pull LDL, or “bad” cholesterol out of the blood. The result is an increase in cholesterol levels. A low thyroid level can also mean high levels of triglycerides – fatty acids that also contribute to heart disease.

Some data suggest that only 5 percent of people with high cholesterol have an underactive thyroid but several studies put the figure as high as 14 percent, said Dr. Lewis Braverman, chief of the endocrine, diabetes and nutrition section atBoston Medical Center. An underactive thyroid is easily treatable with supplemental thyroid hormone, and when it is,cholesterol levels often return to normal.

But, while doctors routinely screen for cholesterol, many don’t do simple blood tests for thyroid levels, even when an elevated cholesterol level should be a signal to do so. Nearly 100 million Americans have cholesterol levels that are either high (240 milligrams per deciliter and up) or borderline (200 to 239 mg per dl), according to the American Heart Association.

There’s a strong economic argument for being more aggressive about detecting and treating potential thyroid problems in people with elevated cholesterol. Thyroid drugs such as Synthroid or Levoxyl cost less than $100 a year. By contrast, the class of cholesterol-lowering drugs called “statins,” which includes Mevacor and Pravachol, can cost many times that.

But there’s an even more compelling medical argument. Better detection and treatment of hypothyroidism, or underactive thyroid gland, could not only lower cholesterol and thereby reduce the risk of future heart disease, but make millions of people feel better.

An estimated 13 million Americans, many of them women over 50, suffer from hypothyroidism, though many don’t know it because symptoms can be mild at first and are often chalked up to aging or “the blues.” The symptoms include fatigue, forgetfulness, depression, chilliness, weight gain, and goiter (an enlarged thyroid gland), as well as elevatedcholesterol.

Another 2 million Americans, many of them women aged 20 to 40, have the opposite problem – an overactive thyroidgland, which causes nervousness, weight loss, intolerance to heat and goiter.

Both hypothyroidism and hyperthyroidism can result from a misguided attack by the body’s immune cells and antibodies on the thyroid gland – in the first case, inhibiting or destroying the gland; in the second, forcing it into high gear.

Testing for thyroid problems is fairly straightforward – a blood test for TSH, or thyroid stimulating hormone, which is made by the pituitary gland. When the pituitary gland senses that the body is not making enough thyroid hormone, TSH levels rise, signaling the thyroid gland to make more.

If a TSH test comes back abnormal, the doctor usually does another test for blood levels of thyroid hormone itself. If TSH is high and thyroid hormone levels are low, it’s a clear sign that supplemental hormones are needed to get things back in balance. A person also clearly needs treatment if the reverse is true – low TSH and high thyroid levels.

But many people, especially those with “subclinical” hypothyroidism, have more ambiguous test results – typically an elevated TSH but normal levels of thyroid hormone itself. Some doctors advise treating this form of mild disease, while others hold off, arguing that when the disease is still too mild to cause symptoms, treatment may not help.

If your cholesterol is high, ask your doctor for a thyroid test if he or she hasn’t suggested it already.

You may have to fight for the thyroid test, though, because some insurers balk at paying for routine thyroid screening, noted Dr. Richard A. Dickey, an endocrinologist at Wake Foreest University in Winston-Salem, N.C, and president of the American Association of Clinical Endocrinologists.

Still, it’s important to find out because doctors need to “eliminate secondary causes of high cholesterol, which include low thyroid function,” says Dr. David Gordon, a heart researcher at the National Heart, Lung and Blood Institute.

It also works the other way around, said Dr. Peter Wilson, an endocrinologist at the Framingham Heart Study. If you are tested for thyroid function and that is low, ask to be tested for cholesterol, too.

It takes a village, or so they say, to raise a child.

Well, it’s beginning to take a whole village – and a high-tech one at that – to sort out the risks and benefits of hormone-replacement therapy.

Luckily, there is such a village. It’s at New England Medical Center in Boston, where Drs. Nananda Col, John Wong, and Stephen Pauker in the Division of Clinical Decision Making have created a mathematical model to see how the benefits of hormone therapy – such as reduced risk of osteoporosis – stack up against the risks, including breast cancer, for a hypothetical 50-year-old woman at average risk of both diseases.

But their endeavor has its limits. Chief among them is that the estimates they feed into their computers come from observational studies, and not randomized, double-blind, placebo-controlled trials, the “gold standard” of medical research.

That means their data are derived from women who chose to take hormones at menopause.

In general, women who choose hormones are better educated and have better health habits than women who don’t, which can skew the results of observational studies, noted Dr. JoAnn Manson, an endocrinologist and chief of preventive medicine at Brigham and Women’s Hospital in Boston.

A better sense of the true risks and benefits of hormone therapy is expected in 2005, when the results of the massive, $625 million Women’s Health Initiative are in.

In that trial, which involves 27,000 women at medical centers around the country, volunteers are randomly assigned to take hormones or placebo for an average of nine years. Since the women who take hormones and those who don’t are otherwise similar, differences in subsequent disease risk are probably due to hormones – or lack of them.

But, for many women, five years is too long to wait for guidance, so we asked Col to use her model to run projections of risks and benefits 10 and 20 years from now for a 50-year old woman at average risk of breast cancer, hip fracture, uterine cancer, and coronary disease (defined as nonfatal heart attack, clogged arteries, chest pain or sudden cardiac death).

Because models only work if one plugs in certain assumptions, Col decided that, to be as representative as possible, our 50-year-old would have a total cholesterol of 239 milligrams per deciliter and systolic blood pressure (the top number on a blood pressure test) of 134 millimeters of mercury.

In addition, instead of flipping a coin to decide whether our heroine should have the health risks of a smoker or nonsmoker, and of a diabetic or nondiabetic, Col gave her 44 percent of the disease risks that go with smoking and one-eighth of those due to diabetes. Col also assumed the woman had no family history of heart disease or osteoporosis.

Lastly, because 20 percent of the population has a mother, sister or daughter with breast cancer, Col assumed our hypothetical woman had a 20 percent chance of such a family history, too. She also assumed there was a 28 percent chance that our woman had one breast biopsy and that she had her first child between ages 25 and 29.

Col then calculated the woman’s chances of getting breast cancer, uterine cancer, a hip fracture or heart disease in the next 10 and 20 years, and the odds of her dying from those diseases under different scenarios – no hormone replacement therapy, combination therapy with two hormones (estrogen and progestin) for 10 or 20 years, or estrogen alone for 10 or 20 years. (Progestin is added to hormone therapy to protect the uterus from cancer in women who have not had a hysterectomy.)

The data that Col fed into her computer was derived from several large observational studies, including the Nurses’ Health Study and a major study on breast cancer risk published recently in the Journal of the National Cancer Institute.

In these studies, women took the standard dose of estrogen (usually 0.625 milligrams a day of Premarin), and if they took progestin, it was 5 to 10 milligrams a day of Provera.

Col also fed into her model the risks and benefits associated with a newer hormonal therapy called raloxifene (Evista) instead of estrogen. (Raloxifene’s advantage is that, unlike estrogen, it can lower the risk of osteoporosis without raising the risk of breast or uterine cancer.) She did likewise with alendronate (Fosamax), a non-hormone drug that protects the bones and has no known effect on breast cancer, uterine cancer or heart disease.

The results were intriguing. Ten years from now, our hypothetical woman’s risk of getting breast cancer was clearly lower (one in 45) if she took estrogen alone than if she took estrogen and progestin (one in 37), much as two recent studies in JNCI and the Journal of the American Medical Association showed.

But what shows up even more dramatically in Col’s model is the bigger difference in risk of uterine cancer depending on whether a woman takes estrogen alone or with progestin. The risk of uterine cancer over 10 years is one in 19 if a woman takes estrogen alone, compared to one in 102 if she takes it with progestin.

That’s a strong reason, Col said, for women not to act on fears generated by the recent studies and dump combination therapy in favor of estrogen alone.

Manson, the Brigham and Women’s endocrinologist, agreed. Manson, who is one of the chief investigators in the Women’s Health Initiative, said she fears some women in that study may drop out because of concern about the risks of combination therapy. But there are two different ways to take combination therapy – a woman can take both hormones every day, or sequentially – estrogen every day and progestin only part of the month.

The former is thought to be safer – and, in fact, in the recent JNCI study, the risk of breast cancer was lower in women who used the simultaneous therapy than in the sequential therapy group, though this did not quite reach statistical significance.

Another observation for our mythical matron is that the benefits of hormone therapy in preventing hip fracture grow with time and become more pronounced after 20 years. “And if you go out to the next 30 years, it’s even bigger,” Col said.

With heart disease, the benefits appear to kick in earlier and persist as long as a woman takes hormones. Heart disease is both more common and more likely to be lethal than breast cancer.

In Col’s model, Fosamax, the osteoporosis drug, was comparable to hormone therapies in reducing the risk of hip fractures without raising the risk of breast cancer.

Raloxifene, the hormonal alternative to estrogen, lowers the risk of hip fracture without raising breast cancer risk, but does not help much with heart disease risk. (And some younger women who try raloxifene quit because, like some who take a similar drug called tamoxifen, they simply do not feel as well on it.)

In five years, if all goes well with the Women’s Health Initiative, there will be better ways to assess the risks and benefits of hormone therapy. And that study should answer other questions as well, such as whether hormone therapy reduces the risk of cognitive problems and Alzheimer’s disease and how hormones affect mood, sleep and other quality-of-life issues.

The expectation is that the benefits of hormone therapy will outweigh its risks for most women, Manson said.

Until then, we’re in the land of educated guesses. And women who would like to do less guessing can have their doctors contact the decision-making gurus at the New England Medical Center (hrt@lifespan.org). 

I sat there glued to the TV, trying to imitate the model on the video, who was cheerily flexing her zygomaticus muscles – which run from the cheekbone to the corners of the lips – and keeping the rest of her face relaxed.

Not so easy. Then she worked her levator labii superioris, raising her lips up into a sneer. Then she attacked her chin, working the depressor labialis.

We should be doing these exercises 10 to 15 minutes a day, six days a week, according to the narrator, a 71-year-old British lady named Eva Fraser, who’s about to launch in this country the “facial fitness” program she’s promoted for years in England.

On the video, Fraser, who looks closer to 50, spoke through clenched teeth, her face barely moving. Were her muscles so exhausted from all her facial workouts that she could no longer move them?

No, she was not her usual animated self in the video, she explained in a telephone interview, because she was trying to keep still so the microphone didn’t pick up extra noise.

In any case, her take-home message seemed to make sense: Weak muscles, sagging face; strong muscles, a young, vibrant one.

Too bad it’s not true.

The real problem when faces droop with age, it turns out, is loss of collagen in the skin, the pull of gravity on fascia (that gristly tissue that lies between muscles and skin), and the loosening of facial ligaments.

And, sadly enough, exercise is useless for collapsing collagen, falling fascia and lax ligaments.

That means, at least as doctors see it, that not only won’t facial fitness do you much good, neither will those mouth-stretching gadgets called Facial Flex, advertised in magazines and the Internet, or electrical stimulation devices like those also touted on the Net by Boulder, Colo., esthetician Kay Young.

Now, you could take the cynical – or is it the hopeful? – view that dermatologists and plastic surgeons would naturally dump on exercise and other do-it-yourself tricks because they can make a fortune doing chemical peels, facelifts, and other nips and tucks that may hide the ravages of age.

But the doctors make a pretty good case against facial workouts.

Exercising may “work partly,” concedes Dr. Jessica Fewkes, a dermatologist at the Massachusetts Eye and Ear Infirmary in Boston. “It can work on the part of the face that is due to just sagging muscles. . . . But a lot of our drooping skin isn’t necessarily due to muscles; a lot of it is due to photoaging.”

Photoaging is caused by exposure to sunlight. The ultraviolet light destroys the elastic fibers in skin that hold it together, causing the collagen to become much thinner.

“When you pinch a baby’s cheek,” Fewkes says, “it has a nice, solid feel to it. When you pinch your mother’s skin, it’s thin. It’s missing that layer. That’s not muscle we’ve lost, it’s collagen.”

That’s why “the number-one thing for looking good is sun protection,” she adds. Indeed, people with darker skin, like blacks and Asians, “tend to look younger longer because they have so much pigment in their skin they don’t get the same radiation damage.”

Exercising facial muscles “really won’t do anything for the sagging face,” says Dr. Devinder Mangat, a Cincinnati plastic surgeon and president of the American Academy of Facial, Plastic and Reconstructive Surgeons.

Jowls, for instance, which often run in families, are caused “almost 100 percent by displacement of the `SMAS’ [or superficial muscular aponeurotic system] layer of fascia,” says Dr. Mack Cheney, director of facial and cosmetic surgery at Mass. Eye and Ear.

In a face lift by plastic surgery, it’s this layer of tissue that is “redraped” over bone and muscle to tighten sagging cheeks, says Cheney.

And facial exercises could make some problems worse.

Horizontal lines in the forehead are caused by the frontalis muscle. “The stronger this muscle gets, the deeper the creases,” says Cheney. “So strengthening the frontalis muscle is a negative thing. It will make furrows deeper.”

Short of a face lift, what may help for forehead furrows, including vertical ones in the corrugator muscles between the eyebrows, is botox, or botulism toxin. While botulism is fatal if injected in high doses, in the tiny doses injected cosmetically, it can paralyze the frown muscles for a few months without causing harm.

Puffy eyes aren’t caused by muscle weakness, either, even though the eyes are surrounded by the orbicularis oculi muscle.

The problem with droopy eyelids – upper and lower – lies with a ligament-like structure called the orbital septum, which lies just below the muscles, and stretches with time.

“Exercises wouldn’t help that,” he says. “It’s not muscle that’s holding the orbital fat, which produces the puffiness. It’s this ligament-like structure.”

And what of those Facial Flex gadgets that you put in your mouth to exercise muscles in the lower face? The ads tout research suggesting these gadgets can increase muscle strength by 250 percent.

Sorry, they can’t. “If you’re trying to get improvement in skin and fascia, a stronger muscle won’t do that,” says Cheney.

And electrical stimulation to tone the face? “That is unlikely to help, either,” he says.

The bottom line is simple. Forget facial workouts. You’ll have to love the face you’ve got – unless you choose to go under the knife.

It’s never been easy sorting out the pros and cons of taking estrogen supplements at menopause. Women have always had to weigh the many benefits — reduced hot flashes, lower risk of heart disease, osteoporosis, colon cancer, and perhaps Alzheimer’s — against the modest but distressing risks, notably an increased chance of breast cancer and blood clots.

But lately, with every new study, it’s gotten more complicated.

About a month ago, researchers studying 37,000 Iowa women reported what looked like reassuring news: Hormone replacement therapy was not linked to an increase in many common types of breast cancer. But it was linked to a higher risk of other breast cancers, though these had better prognoses to begin with.

Then, about two weeks ago, California researchers reported that one of the new “designer estrogens,” a drug called raloxifene (Evista), reduced breast cancer risk by an impressive 76 percent in 7,705 older women with osteoporosis.

So should women now toss out their Premarin and switch to the new stuff?

It depends on many factors.

It’s no longer just: Estrogen, yes or no? It’s estrogen, for how long? It’s should you start at 50, when hot flashes and bone loss are worst, then stop before breast cancer risk kicks in?

Should you switch to low-dose estrogen? Or wait until age 65 to start? Or take raloxifene instead, which, unlike estrogen, can be used without another hormone called progesterone and does not raise the risk of uterine cancer?

“We’re getting more and more information, but that’s raising more and more questions, though it also means we have more choices,” says Dr. Nananda Col, an internist at New England Medical Center.

Next week in the Archives of Internal Medicine, Col’s team will publish a sophisticated decision-analysis technology to guide hormone replacement decisions.

She says the first question every woman should ask is why she would take any hormone at menopause. If the answer is to control hot flashes and vaginal dryness, estrogen may be the best bet — for a few years, until symptoms have subsided.

But if osteoporosis is your main concern, the equation may change, notes Dr. JoAnn Manson, co-director of women’s health at Brigham and Women’s Hospital.

Both raloxifene and estrogen increase bone density a little (1 to 2 percent over several years, with estrogen somewhat more effective than raloxifene). But since raloxifene decreases breast cancer risk, it may be a better choice for women who are particularly worried about getting the disease.

On the other hand, if you don’t want to take any estrogenic hormones, there are other options (besides exercise, which women should do anyway.) The prescription pill Fosamax and a nasal spray called Miacalcin can boost bone density. (And San Francisco researchers recently reported that parathyroid hormone does, too, but it’s still experimental.)

The key point is that the most rapid bone loss occurs right at menopause, so women should not put off a decision on treatments to prevent osteoporosis. If you do choose to skip hormones or other drugs, it’s important to get enough calcium — about 1,500 milligrams a day — and 400 to 800 IUs of vit D, too.

Suppose, though, that heart disease is your major concern. Then estrogen may be a good choice. But if you don’t want to take it and your cholesterol is high, you have another option: “statins,” the cholesterol-lowering drugs.

For its part, estrogen raises HDL, or “good” cholesterol, lowers LDL, or “bad” cholesterol, and keeps total cholesterol under control. It also seems to prevent heart attacks. By contrast, raloxifene helps with total cholesterol, but not HDL.

Okay, say amidst all this, you’re also petrified of breast cancer, as many women are, even though women tend to vastly overestimate their risk of breast cancer and underestimate their risk of heart disease, which kills six times as many women.

If you’re at high risk for breast cancer, it makes sense to talk to your doctor about taking tamoxifen, a kind of anti-estrogen that appears to help prevent the disease.

And if you want to take regular estrogen, consider the following. In 1997, British researchers combined data from 51 studies and concluded that estrogen raises breast cancer risk about 35 percent if taken for five years or more.

But how much of an increase is that, really? “Not very much for the average woman,” says Dr. Eric Winer, director of breast oncology at Dana-Farber Cancer Institute.

If you’re a 50-year old woman, your risk of developing breast cancer in the next 10 years is 2.67 percent. Taking hormones for five years raises this by 35 percent, to 3.6 percent. In other words, Winer says, “it doesn’t make sense to worry excessively if you take it for a couple of years to fight hot flashes.” Furthermore, breast cancers are not all equally likely to be fatal or to be spurred by estrogen supplements.

In fact, one of the most puzzling things about the apparently reassuring Iowa study, is that hormone use was linked to some types of breast cancer but not others. The study of 37,000 women is the first to analyze cancer risk and hormone use by the type of breast tumor, notes Thomas A. Sellers, a co-author and epidemiologist at the Mayo Clinic.

But the results don’t tally up neatly. The researchers found the greatest risk of cancer among hormone users was in tumors with the most favorable prognosis, that is, tumors that under the microscope are classified as tubular, mucinous, or papillary.

Many of these tumors are estrogen-driven, but so are many tumors with less favorable prognoses.

The Iowa study also doesn’t fit with the overall evidence, notes Manson. In fact, not only is there a 35 percent increased risk of getting breast cancer if you take hormones for five or more years starting at menopause, there’s a comparable increased risk of dying of it if you take hormones for 10 years or more.

That suggests, Manson says, that minimizing the duration of hormone use is a wise idea. One approach is to take hormones for five years or less at onset of menopause, then start again at 65, when the risk of heart disease begins to rise more steeply.

“Another strategy is to use hormones for less than five years around menopause, then switch to raloxifene,” though follow-up data on raloxifene only extends about three years.

It may also make sense, she says, to start on low-dose estrogen (0.3 milligrams a day) instead of the usual dose (0.625 mg a day). Some studies have shown that low-dose estrogen protects bones as well as the standard dose. It’s less clear how well lower dose estrogen affects cholesterol.

If you do try lower-dose estrogen, however, keep track of potential bone loss with bone density testing, says Dr. Isaac Schiff, chief of the Vincent Obstetrics and Gynecology service at Massachusetts General Hospital.

And what about waiting to take estrogen until you’re 60 or 65, when preventing heart disease becomes more of a concern? It depends on your risk profile. If you have a family history of heart disease, if you’re sedentary, overweight, diabetic, have high cholesterol and smoke, you are at higher risk of heart disease regardless of age, so it makes sense to consider estrogen.

The bottom line is that, because the research is rapidly evolving, read all you can, talk to your doctor and remember that you can — and should — keep re-assessing your decision as your health status, and age, change.