For the past year, Barbara Lash, a 49-year-old ex-nurse from Franklin, has been determined to fight her hot flashes with anything but the standard prescription drugs like Premarin.

On the advice of her nurse practitioner, Lash drinks a soy shake and eats tofu every day. She also nibbles cereal with flax seed, uses herbs like black cohosh and chaste tree berry, takes walks daily and lifts weights when she can.

“It’s amazing,” Lash says. Her hot flashes and mood swings are “just about gone” and she feels terrific.

Millions of women swear by prescription hormones to control both short-term menopausal symptoms like hot flashes and vaginal dryness, and to offset the longer-term risks of lowered estrogen levels like heart disease and osteoporosis.

But many others are leery, often because they fear that prescription estrogen drugs may raise breast cancer risk 30 to 40 percent (which is true) or because they feel that all alternative remedies, especially herbs, are “natural” and therefore automatically safe (which is hogwash).

For many herbal alternatives, in fact, there simply aren’t any data on long-term effects — good or bad — on breast cancer risk, says Dr. Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital.

Still, like Lash, many women are willing to try almost anything — as long as it’s not a prescription. But while some alternative remedies show promise, especially for short-term problems like hot flashes, others appear useless. The trick, of course, is to sort out which is which. So here goes:

– Soy. A 12-week Italian study of 104 postmenopausal women last month showed that women who took 76 milligrams of phytoestrogens (plant estrogens) from soy daily had a 45 percent reduction in hot flashes. (Those who took inactive placebo pills had a 30 percent reduction — proof that though hot flashes are real, so are expectations of relief.)

A just-published Australian study and an older American one show similar results, says Tufts University biochemist Margo Woods, who is running a study of women taking 45 mg a day.

There’s also animal data showing that soy can prevent breast cancer, as well as epidemiological data showing that in societies where soy consumption is high, like Japan, women have less breast cancer.

The magic of soy comes from substances called isoflavones (genistein and daidzein) that link up with cells much like estrogen does. Though some women take isoflavones themselves as supplements, it’s probably better to do as Japanese women do and eat the real thing — tofu, soy milk or soy yogurt, at least three to four servings a day.

Don’t use the low fat stuff — it’s too low in phytoestrogens. And if you buy powdered soy products, check the label to make sure each gram of powder has 1 milligram of phytoestrogens.

– Vitamin E. High doses (800 to 1,200 IUs a day) can reduce hot flashes, according to the North American Menopause Society, a nonprofit scientific organization.

– Black cohosh. Studies suggest only one herbal remedy that works for menopausal symptoms “and that’s black cohosh,” says Varro Tyler, emeritus professor of pharmacognosy (plant medicine) at Purdue University. But if you take a black cohosh product like Remifemin, don’t take more than 40 milligrams a day.

And don’t take it for more than three to six months. In fact, the menopause society recommends against taking it at all, arguing there’s not enough data on safety and efficacy of black cohosh, which comes from the cimicifuga plant. And if you still get periods, be wary because it can trigger heavy bleeding, adds Mary Pat Palmer, a Jamaica Plain mental health counsellor aka the “Urban Herbalist.”

– Dong quai. Though this is a favorite among herbalists who treat menopausal women, a study by the Kaiser Permanente Medical Care Program of Northern California in the journal Fertility and Sterility showed it’s no better than placebo.

– Chaste tree fruit. Another favorite of herbalists, this may ease “irregularities of the menstrual cycle,” according to the German Commission E, a world authority on herbal remedies. There are no known contradindications. If it does help, it may do so by increasing dopamine, a brain chemical, says Tyler of Purdue.

– Motherwort. Although there are no known side effects or contraindications, the German Commission E does not recommend it because the claims have not been proven.

– Raspberry leaf. Ditto, says Commission E. Tyler calls it “a popular folk remedy without scientific credentials.”

– Oil of evening primrose and borage seed oil. Mixed data put these “in the question mark category,” says Tyler.

– Ginseng. If you’re worried about breast cancer, don’t take it. Dr. Bruce Kessel, an endocrinologist at Beth Israel Deaconess Medical Center, has test tube data showing ginseng may act like estrogen to stimulate breast cancer cells.

– Progesterone creams, including those made from wild yams. These creams are heavily promoted, but “are so weak they are useless,” says the menopause society. The only reason to take progesterone, the society adds, is as a prescription drug to offset estrogen’s effect on the uterus.

– Acupuncture. Several studies suggest that acupuncture can reduce hot flashes 30 to 40 percent. A small Swedish study showed it cut hot flashes by more than 50 percent.

– Relaxation response. There’s solid data showing meditation and breathing exercises reduce hot flashes 30 to 40 percent.

– Exercise. Preliminary data suggests it reduces hot flashes (and it clearly reduces osteoporosis and heart disease risk.)

As for vaginal dryness, non-prescription options are few. Lubricants and moisturizers can help, as can staying sexually active.

There’s no question that educating yourself about alternatives takes work, says Lash, who works with a nurse practitioner at the Marino Center for Progressive Health in Cambridge. But the alternative approach, especially its emphasis on soy, can help.

“I think about Japanese women,” she says. “I feel if they can do it, I can do it.”

When Barbara Doherty, 32, returned to her job at John Hancock Mutual Life Insurance Co. last year three months after having a baby, she encountered a modern woman’s dream.

Like a growing number of companies, the Hancock provides a “mother’s room,” where Doherty used a company-funded electric breast milk pump three times a day — 20 minutes per session — to express milk for her infant son. She then stored the milk in a refrigerator and took it home at night for the babysitter to give her son the next day while she was at work.

The arrangement not only kept Doherty’s milk supply flowing — if breasts aren’t emptied frequently, the milk supply dries up — but eased her anxieties about being a working mother.

“You do feel pulled in different directions,” says Doherty, who lives in Medfield. “Because I felt I was doing something positive for my child, it helps you feel more focused and productive at work.”

At long last, the corporate and medical establishments are beginning to find ways to help, rather than thwart, breast-feeding.

Last month, the American Academy of Pediatrics, in its strongest statement yet, issued a virtual manifesto on behalf of breast-feeding, saying, “Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions.”

Because even small amounts of formula can sabotage breast-feeding — some babies find it easier to suck from a bottle than the breast — the academy added that “no supplements [water, glucose water, formula and so forth] should be given to breast-feeding newborns unless a medical indication exists.”

The pediatricians went on to urge hospitals and employers to do all they can to “protect” breast-feeding — and in some places, they are.

Many hospitals, for instance, now offer not only breast-feeding classes, lactation consultants and rooming-in of infants with their mothers, but also have stopped giving out samples of formula unless a woman asks for them, because many women felt this undermined their commitment to breast-feed.

And employers are discovering that buttressing a woman’s desire to breast-feed after she returns to work is not just humane personnel policy but good business as well.

Five years ago, Medela, Inc. of McHenry, Ill., believed to be the nation’s leading manufacturer of electric breast pumps, had not sold any of its $600 machines to companies, says company spokeswoman Debra Kurtz.

Today, it has sold pumps to 300 companies, and 75 of the firms also buy Medela’s full package of prenatal classes and lactation consultants.

All of which seems to pay off, for the employers as well as their working mothers.

Two studies supported by Medela show that in companies offering lactation programs, babies who were breast-fed had 36 percent fewer illnesses than those who were bottle-fed, and their mothers experienced 27 percent less absenteeism.

For every dollar spent on lactation programs, the “payback is close to $3,” says spokeswoman Kurtz, because babies are healthier and moms are absent less.

The payoff certainly seems clear at Hancock insurance in Boston, where an average of 300 employees are pregnant every year and 30 percent breast-feed. The company estimates that since its inception in 1993, the mother’s room has saved about $60,0000 in time lost because of sick children.

And it’s relatively easy to arrange.

All an employer must do is “allow, in an 8-hour day, at least two 15-minute breaks and a private area in which a woman can pump,” says Donna M. Norris, a nurse and lactation consultant for Harvard Vanguard Medical Associates, a group practice of doctors and nurses who provide care to members of the Harvard Pilgrim Health Care HMO.

Because electric pumps are much more efficient than hand pumps, the lactation room should have access to electricity — a bathroom stall won’t do — and privacy.

(While the pump itself is shared, each woman has her own attachable kit and tubing so that her milk never comes in contact with any surface touched by another mother’s milk.)

It also helps if employers provide a small refrigerator to store pumped milk, says Jill Landauer, spokeswoman for Work Family Directions, Inc., a Boston-based firm that helps companies adapt to workers’ needs.

“Certain companies are quite progressive in this area,” says Jennifer Swanberg, a senior research associate at the nonprofit Families and Work Institute in New York. “They see it as a real low cost way to help working moms.”

But not all. In some firms, women pump milk in boiler rooms or bathroom stalls and find their own ways of refrigerating it until they go home.

And some face worse hassles.

In Maryland, Alenthia Epps, 36, a correction officer in a state facility, was put on leave without pay after pumping milk for her infant daughter during her lunch break. The prison objected to her bringing an unapproved object — the breast pump — on the premises, said her husband, Leon, 27, last week.

Epps said his wife argued that the prison allowed people to smoke, “whereas during her break, all she wanted to do is pump so she could have milk for her child and keep her milk up. It was like saying she couldn’t do something healthy for her child.”

Epps finally got her job back when the governor’s office intervened, a governor’s spokesman said.

In Michigan, a mother sued her company for not allowing her to pump milk anywhere on company property, including in a car in the parking lot, according to U.S. News & World Report. She reportedly recently settled out of court.

Despite the lingering corporate squeamishness and resistance, the medical arguments for breast-feeding are powerful.

The pediatricians’ academy, for instance, noted that breast-feeding provides many health advantages “while significantly decreasing risk for a large number of acute and chronic diseases.”

Among other things, human milk decreases the incidence and or severity of diarrhea, lower respiratory infection, earaches, bacterial infections including meningitis, urinary tract infections and many other diseases.

It also may protect against sudden infant death, insulin-dependent diabetes, Crohn’s disease, lymphoma, allergies, ulcerative colitis and other digestive problems. It has also been linked to a possible enhancement of intellectual function.

Despite such advantages, women should not be made to “feel guilty if they can’t breast-feed,” says Judy Norsigian, a co-author of the “Our Bodies, Ourselves,” book on women’s health.

And for many women in this country it does prove impossible. An estimated 59.4 percent of American women breast-feed their newborns, a rate lower than in many other industrialized nations. By the time the baby is six months old, only 21.6 percent of American mothers are still nursing.

Part of the problem, lactation specialists say, is sheer lack of time, especially for women who go back to work soon after the baby is born. Newborns need to breast-feed 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes on each breast, the pediatricians’ group says. This translates to as much as six hours a day, a huge time commitment for new mothers.

“But the real burden is that society makes breast-feeding seem overwhelming, when it is not in and of itself so difficult,” says Dr. Kimberly Lee, a neonatologist who is associate director of the newborn nursery at Beth Israel Deaconess Medical Center.

Another part of the problem is that breast-feeding can get off to a rough start because many new mothers are sent home from the hospital within 48 hours — before their milk supply is firmed established. Then, if they have trouble getting the baby to nurse at home, they may panic and switch to bottle-feeding.

To help with such problems, some hospitals, including Brigham and Women’s and Beth Israel Deaconess, operate telephone hotlines or weekly drop-in groups for nursing mothers.

Some babies simply “won’t latch on” at first, says Judy Gundersen, nursing coordinator for parent and childbirth education and the lactation support service at Brigham and Women’s Hospital. They just lick at the nipple “and mom is so anxious that she lets him lick, not really get latched on.”

In fact, it usually takes “three weeks to get breast-feeding well-established — for babies to become proficient, for the [milk] supply to be established, with `letdown’ and flow of milk brisk,” says Dr. Marianne E. Neifert, a pediatrician at the Columbia Presbyterian/St. Luke’s Medical Center in Denver and co-author of the new breast-feeding guidelines.

Ideally, she adds, breast-feeding should be the baby’s sole nutrition for the first six months and be supplemented with solid food for the next six.

But if you can’t manage it or you are an adoptive mother, she says, don’t “get stuck” in guilt. Move on to an iron-fortified infant formula based on cow or soy milk. Don’t prop the bottle while the baby feeds, she adds. Snuggle the baby as you would if you were nursing.

And you can take some comfort in the fact that infant formulas have improved over time. Soon, in fact, mothers who choose or feel they must use formulas may have an expanded choice.

The US Food and Drug Administration is now reviewing evidence for recommending the addition of DHA, an omega-3 fatty acid to infant formula, says Dr. Elizabeth Yetley, director of the FDA office of special nutritionals.

DHA, which is found in breast milk, has been shown in some studies to boost development of the eye and brain.

But even as formulas get better, lactation specialists say, it’s unlikely any product will truly mimic human milk.

Which means, in essence, that the modern world — especially employers — must adapt to the hunter-gatherer lifestyle.

Perhaps the National Organization for Women puts it best: “When women do not have to hide in the bathroom or in a corner to breast-feed or pump, we will have come a long way toward real respect for the job of being a mother.”

This summer, a Canadian study of nearly 7,000 women came to a startling conclusion: that a mammogram done during the second half of the menstrual cycle is twice as likely to miss a lurking cancer as one taken during the first half.

For now, these researchers think this applies only to women who use or have used hormones such as birth control pills. And because there is so little other research on the question, the finding could turn out to be a statistical fluke.

Still, the idea is intriguing — as is the suggestion from a handful of other studies that there may also be an optimal time in the cycle for a woman to have breast cancer surgery.

The hypothesis — and it really is just that — that a woman’s cycle may affect diagnosis or treatment of breast cancer raises “pretty interesting questions,” says Dr. Jay Harris, chief of radiation oncology at Brigham and Women’s Hospital and the Dana-Farber Cancer Institute.

And until recently, there have been few attempts at answers.

In fact, there’s still no evidence that timing chemotherapy or radiation to a woman’s cycle affects the outcome, says Dr. Ken Cowan, head of the medical breast cancer section at the National Cancer Institute. But there are three major studies now underway to see whether the odds of survival increase if a woman has breast cancer surgery at a particular point.

And there are already enough reasons, some specialists say, to recommend that women maximize their chances of an accurate mammogram by having it during the first half of their menstrual cycle, after a period is over.

“Although one never wants to take action on the basis of only one study,” says Dr. Cornelia J. Baines, the University of Toronto epidemiologist who led the Canadian study, having a mammogram in the first half, or follicular phase, of the cycle “can’t do harm and may do good.”

Baines also believes that the apparent increased likelihood of missing a cancer in the second half of the cycle may partially explain why it has proved so hard to document a clear benefit of mammograms for women aged 40 to 49.

Nobody knows why mammograms would be harder to read during the second, or luteal, half of the cycle, she says, though it may be because of increased fluid and cellular activity in the breasts. In general, she notes, it’s harder to read mammograms in women with denser breasts, but it is not clear whether breast density — as opposed to swelling — increases late in the cycle.

Dr. Dan Kopans, director of the breast imaging division at Massachusetts General Hospital, agrees it “just makes good sense” to have a mammogram early in the cycle.

The breasts are softer then, he says, which means there is less pain when they are compressed for the X-ray. And better compression yields more accurate mammograms.

However, many centers do not routinely schedule mammograms according to a woman’s cycle, though some, like Newton-Wellesley Hospital, will do so if asked.

“It’s very difficult to schedule screening mammograms with your cycle because they are booked in advance,” adds Dr. Norman Sadowsky, director of the Faulkner-Sagoff Imaging and Diagnostic Center in Jamaica Plain. But it is “very reasonable” to try to schedule them in the first half of cycle because of the improved compression.

Research with a different type of test, magnetic resonance imaging, supports the idea that the second week of the cycle may be best for mammograms and breast self-exams — and the fourth week the worst, he says.

A far dicier question is whether to schedule surgery to coincide with a presumed optimal time in the cycle. Even if proven desirable, it could be tricky to do because women with suspected cancer often have several surgeries over several weeks — a biopsy to see if a lump is cancerous and later, removal of the lump or breast and some lymph nodes.

Still, the studies are intriguing — and contradictory.

Nearly a decade ago, Dr. William Hrushesky, an oncologist at the Stratton V.A. Medical Center in Albany, N.Y., kicked off the debate with a study in mice that suggested the chances of a cure were doubled or tripled if breast tumors were removed around the time of ovulation.

In a follow-up 1989 study on 41 women, he found that survival was four times greater for women who had surgery at the time of ovulation and a week or so afterwards, than for those who had the operation closer to their periods.

No other study has confirmed that the time around ovulation is crucial, but other studies suggest there may be an advantage to surgery in the second half of the cycle. The theoretical reason for this — and it’s far from proven — is that in the first half of the cycle, the hormone estrogen, which can drive some breast cancers, is “unopposed” in a woman’s body. In the second half of the cycle, estrogen is balanced by the hormone, progesterone.

In early 1991, researchers at Guy’s Hospital in London studied 249 women and found that the optimal time for surgery, at least for women whose cancers had spread to lymph nodes, may be in the second half of the cycle. The team went so far as to recommend scheduling surgery accordingly.

In September, 1991, Ruby Senie, an epidemiologist now at the Columbia University School of Public Health, also found in a study of 283 women that the best time may be the late luteal phase — later in the cycle than Hrushesky had found.

Probably the strongest data in favor of the “timing counts” hypothesis comes from a 1994 Italian study of nearly 1,200 women by Dr. Umberto Veronesi. After eight years of follow-up, he found that in women whose cancer had spread to lymph nodes, those who had surgery in the second half of the cycle had a “significantly better prognosis” than those who had surgery in the first half of the cycle.

But other researchers find all this unconvincing, in part because the studies used different ways of figuring out where a woman is in her cycle. Some say it’s enough to ask the woman to recall the date of her last period. Others believe it’s necessary to measure hormone levels with blood tests or to do ultrasound exams of the uterus and ovaries to see if ovulation has occurred.

There are also studies that come to quite different conclusions, notably a 1994 Danish study of 1,635 women that found the timing of surgery had no effect on survival after 5 or 10 years.

Taken together, this mishmash means the provocative findings may be “due to chance,” says biostatistician Gary Clark of the University of Texas Health Science Center at San Antonio.

Dr. William Wood, chairman of the department of surgery at the Emory University School of Medicine, agrees. Some studies show it’s best to have surgery in the first half of the cycle, he says, some that it’s best in the second half, and there are “three times as many studies showing it makes no difference.”

Yet the hypothesis won’t go away.

In fact, it may even be gaining ground — at least in the sense of being subjected to still more study, according to the Journal of the National Cancer Institute, which in April reported that three big, prospective studies are now in progress in Britain, Italy and the United States.

Will these studies settle the matter? Hrushesky thinks not, in part because the women will not be assigned surgical dates randomly. Instead, the researchers are assuming that women will come in for surgery at different points in their cycles.

Dr. Clive Grant, a surgeon at the Mayo Clinic who is a principal investigator for one of the studies, says it would be premature to randomize women to surgery at a particular time because the data are not yet compelling enough to warrant delay of surgery, as would inevitably happen in some cases.

So until better answers are in, what should a woman do?

Talk it over with your doctor, of course, and perhaps bear in mind the view of breast cancer guru Dr. Susan Love, adjunct professor at the UCLA School of Medicine. She says, through a spokeswoman, that she sees “no harm from scheduling these patients [for surgery] during the early luteal phase.”

But should you do this if it means delaying surgery? “That’s exactly what we’re trying to find out,” says Grant.

It was a moment that 14-year-old Meaghan O’Connor of Dover, N.H., says may stay with her for the rest of her life.

She was charging for the ball in the midst of a heated basketball game last summer. Suddenly, another girl’s knee smashed into hers.

“I fell to the floor,” recalls O’Connor. Right away, “it got all swollen. I was crying.”

Her parents took her home and put ice on her knee, and at first that seemed to do the trick. But a week later, she tried to play again. Her knee really hurt, she recalls. Perhaps even more ominous, it kept buckling as she played.

Her parents took her to one doctor, then another. The diagnosis? A torn ACL, or anterior cruciate ligament, the most common severe joint injury in sports today, and a particular plague for vigorous young women like O’Connor.

A generation ago, it was rare to see a healthy young woman limping in to see her doctor with a knee wrecked in friendly combat on high school or college playing fields.

Today, a knee freshly bandaged from surgery or a high-tech knee brace has become a sign of the times for young female jocks, the kind of dubious honor that shows both how far women have come in crashing the barriers to full participation in sports — and the price some are paying for their shot at athletic glory.

In 1982-83, for instance, there were 80,000 female athletes competing in college sports, according to the National Collegiate Athletic Association. By 1994-1995, the figure had swelled to 110,500, with a 9 percent increase in 1989 to 1992 alone, the NCAA says.

In high school sports, the figures are even more dramatic. In 1971, before the federal law known as Title IX mandated that girls and boys get comparable athletic opportunities, fewer than 300,000 girls participated, according to the National Federation of State High School Associations.

A year later, thanks to Title IX, the number had soard to more than 800,000. Today, there are 2.4 million.

The downside of all this forward motion, sad to say, is that men and women now have a chance to injure themselves at roughly similar rates in many sports.

But certain sports, especially those like soccer and basketball that demand a lot of pivoting and fast changes of speed and direction, seem to take a higher toll on women than on men.

Especially on the anterior cruciate ligament in the knee.

In one recent study, Dr. Elizabeth Arendt, medical director of men’s and women’s varsity athletics at the University of Minnesota, and Randall Dick, associate director of sports sciences at the NCAA, documented striking gender differences in ACL injuries in soccer and basketball, sports in which the rules are comparable for men and women.

Overall, they found, the rate of the injury during the five-year study was three to four times higher among females than males. In basketball, women were three times more likely to rip their ACLs; in soccer, twice as likely. Most of the damage was from non-contact, twisting injuries.

“It’s peculiar why this shows a gender or sex difference,” says Arendt. In fact, “It’s rather alarming that we don’t know the answer, but we don’t know it for men, either.”

Part of the reason the anterior cruciate ligament takes such a beating is that evolution hasn’t yet come up with a better solution for a joint that must be both flexible and capable of carrying tremendous weight.

This means that you may be asking for knee trouble if you play hard, both in contact sports like football and some non-contact sports like skiing. In skiing, modern technology — in the form of boots that lock the leg in a forward position — actually makes things worse by making the ligament vulnerable to rips if you fall over backwards.

But for growing numbers of young female basketball and soccer players — and for many researchers — the most pressing question is why the risk of the ligament injury is especially acute for women.

One theory is that women’s wider hips cause the femur, or thigh bone, to come into the knee at a broader angle. Men’s hips, knees and feet usually line up straight, says Nicholas Giurleo, director of physical therapy at Concord Avenue Physical Therapy Associates in Cambridge.

But in women, he says, wider hips may make the knees slightly “knocked” or tilted inward, which can make the joints more vulnerable.

Wider hips may also explain why women’s kneecaps slide around too much side to side, adds Lori Thein Brody, a physical therapist at the University of Wisconsin in Madison.

Another theory is that women and men may have a different balance between the quadriceps muscle on the front of the thigh and the hamstrings at the back.

In general, men have bulkier muscles because they have higher levels of male hormones, but even in women with impressive quads, the hamstrings may be relatively weak. Because the hamstrings work with the ligament to stabilize the knee, if they are weak or underused, the knee may be in jeopardy.

Women are also more loose-jointed than men because female hormones make some ligaments stretch, a decided benefit during childbirth but a risk if knees are too loose.

Regardless of why women’s knees are more vulnerable, once the ligament is damaged, the best treatment is to let the knee heal for four to six weeks so that the joint regains its range of motion, then to operate, says Dr. Bertram Zarins, chief of sports medicine at Massachusetts General Hospital.

In surgery to reconstruct torn anterior cruciate ligaments, which is performed more than 10,000 times a year and is considered 90 to 95 percent successful — the repairs are usually made through small viewing tubes called arthroscopes inserted into the knee.

In addition, doctors often make a two-to-three-inch incision to “harvest” a small piece of the kneecap tendon to replace the damaged ligament.

In the procedure, doctors snip off the dangling ends of the damaged ligament, then take a third of the tendon that anchors the kneecap — with small pieces of bone still attached at either end — and screw it into tunnels made in the ends of the thigh bone and the tibia, where the ligament was anchored.

The graft “is almost the same size as the ACL and is the same strength,” says Zarins, adding that the tendon from which it was taken regrows and regains its original strength. Though most reconstructive surgery uses this technique, some Boston surgeons use a piece of the hamstring instead of the patellar tendon.

Like Meaghan O’Connor, some patients who have this surgery spend 23 hours a day for a week with the knee in a continuous passive motion machine to keep it from freezing up as it heals.

The encouraging news, say orthopedic specialists, is that while recovery from ACL surgery used to take a year, accelerated rehabilitation programs now allow athletes to return to sports in about six months.

Even that, of course, is a long time in the life of a healthy young athlete like O’Connor, who has been chafing at the bit since her surgery in August.

She plans to run track this spring to get in shape for basketball next summer. For her, as for many young female athletes, the joy of sports is well worth the risk.

In fact, when her doctor told her that the only way to make sure she didn’t re-injure her knee was to quit basketball, she had her answer all ready: “I didn’t want to do that.”

SIDEBAR 1:

REPAIRING A TORN ANTERIOR CRUCIATE LIGAMENT

PLEASE SEE MICROFILM FOR CHART DATA

GLOBE STAFF GRAPHIC/DAVID BUTLER

SIDEBAR 2:

Some tips to avoid injury

If you’re serious about a sport — and equally serious about not wrecking your knees — there are several things you can do, say physical therapists and doctors who specialize in sports medicine.

While many of these tips can help athletes avoid knee injuries in general, they are designed for female athletes who want to avoid injury to the ACL, or anterior cruciate ligament.

Coaching. Get a good coach as soon as you start doing any sport seriously. Parents don’t count, unless they’re trained as coaches. Ask your coach, nicely, what credentials and training she or he has had.

Skill level. Play with people at your level. In basketball, if you play with klutzes below your level, they may make up for their lack of skills with brute force. And if they can’t move as fast as you, you may end up tripping over them. On the other hand, if you’re the klutz, you may twist yourself into knee-wrecking contortions to keep up.

Fatigue and pain. Don’t play when you’re exhausted and don’t play through real pain. Among other things, this means distinguishing between “I’m sick of this and I want to go home” feelings and the sharp, stabbing pain of genuine injury, a pain that comes back as soon as you start playing again.

Shoes. It’s common sense to wear shoes with good arch support and shock-absorbing capacity — in sports as well as the rest of your life. But studies are mixed on whether shoes can be blamed for women’s ACL injuries. If your shoes are too “good,” that is, give you too much traction, your foot won’t give way on fast stops, and the resulting torque on your knee can rip the ligament.

Posture. For many women, the “default posture” — how you stand when you’re not thinking about it — is with the knees hyperextended or arched slightly backward. Some researchers think that if you habitually stand this way, you may land wrong on jumps, too.

Landings. Many ACL injuries could be prevented if athletes were taught to land correctly from jumps — with knees bent, not hyperextended, and with feet under the hips. Landing on bent knees gives the hamstrings a chance to stabilize the knee.

Fast stops, cuts and turns. When you have to decelerate and change direction fast, take three small “stutter steps” instead of one big one. When this three-step stop was taught to two major women’s basketball teams, the incidence of ACL injuries dropped 89 percent over several years.

Weights. Get to the weight room. Take the time — three sessions a week — to build up your leg muscles, especially your hamstrings. Try to work with a trainer certified by a recognized organization such as the National Strength and Conditioning Association. If you think you’re headed for trouble, get a physical therapist to check you for any abnormalities in your gait and imbalances between muscle groups.

Warm-ups. Never start jumping and pivoting hard unless you’re thoroughly warmed up, i.e., actually sweating.

Stick with the sport you love — sensibly. It may make sense to switch sports if you think the one you’ve chosen is too risky. But don’t let the naysayers get you down too easily.

Decades ago, when women first started competing in long distance running events, half fainted at the finish, prompting the International Olympic Committee to conclude that women were too delicate for the tough stuff, says Dr. Elizabeth Arendt, medical director of men’s and women’s varsity athletics at the University of Minnesota.

That’s a “Neanderthal” attitude, she says. Life is inherently risky, and “people play a sport because they love it.”

Call it coffee klatch research. Or book group medicine. Or just plain winging it.

By whatever name, women of a certain age are trying to figure out for themselves — and with each other — the answers to a midlife question doctors won’t have good answers to for years:

If you’re taking postmenopausal estrogen and cut your dose, say, in half, can you lower the risk of breast cancer that goes with the normal dose — many women’s biggest fear — yet still get the benefits to your heart and bones and ward off hot flashes?

Two new studies — still unpublished, but presented at recent scientific meetings — suggest that women who lower their estrogen are on the right track, though it goes without saying that you shouldn’t do this without checking with your doctor first.

The studies suggest — and that’s really suggest, not prove — that low-dose estrogen may indeed provide at least some of the well-established benefits of the stan-

Don’t change dosage without checking with a doctor

dard dose estrogen regimen, most notably protection against osteoporosis.

Nobody has a clue yet whether lowering estrogen will also reduce the increased risk of breast cancer associated with hormone use, though that hypothesis is both logical and appealing to millions of women who have been scared silly since last year, when a big Harvard research project, the Nurses’ Health Study, documented the increased risk.

The Harvard study found that menopausal women who took estrogen alone raised their risk of breast cancer by about 30 percent, and that those who also took another hormone called progestin raised their risk about 40 percent.

Women who have not had hysterectomies often take progestin with estrogen to avoid the increased risk of uterine cancer that taking estrogen alone poses. In the Harvard study, the risk of breast cancer was increased only among women who had been taking hormones for five years or more.

The troubling Harvard study is a prominent peak in a mountain range of conflicting data on estrogen therapy. There are many good reasons to take estrogen — it reduces the risk of heart disease (which kills six times more women than breast cancer), raises “good” cholesterol and lowers “bad” and clearly wards off osteoporosis.

Estrogen may also protect against Alzheimer’s disease, and it reduces symptoms like hot flashes and vaginal dryness.

Yet many women shy away from hormone therapy because of the added, albeit modest, increased risk of breast cancer.

In the larger of the new studies, Dr. Morris Notelovitz, director of the Women’s Medical and Diagnostic Center in Gainsville, Fla., tested 406 post-menopausal women on various doses of an estrogen pill called Estratab for two years.

All of the women, including those receiving a placebo (a lookalike drug with no estrogen), took 1,000 milligrams a day of calcium, and none took progestin. During the study, neither the women nor the doctors knew who was getting which dose.

The results, presented in September at the North American Menopause Society meeting in Chicago, were very encouraging.

The low dose of 0.3 milligrams a day — half the usual dose of 0.625 mg — increased bone mineral density in the spine and hip without increasing the risk of endometrial hyperplasia, or pre-cancerous cells in the uterus.

The Florida study, if confirmed by other research, means not only that Estratab, which is derived from plant estrogens, can protect bones, but that it can do so without apparently raising the risk of uterine cancer, says Dr. Joseph Mortola, director of reproductive endocrinology at Cook County Hospital in Chicago and a participant in the study.

More work needs to be done, he cautions, but the Florida study, which was funded by Solvay Pharmaceuticals, the maker of Estratab, means some women may be able to avoid taking progestins like Provera to protect the uterus. Progestins can cause bloating, depression and other side effects.

Still, because the data are preliminary, he says, any woman with a uterus who takes only estrogen, even at low doses, and does not take progestin should have an annual endometrial biopsy to make sure she has not developed uterine cancer.

And while it is not yet clear whether low-dose estrogen carries a lower risk for breast cancer, Mortola says the Florida study did find that low-dose estrogen may help protect the heart as well as the bones.

Low-dose estrogen, he says, seemed to have a positive effect on blood lipids — raising good cholesterol and lowering bad, although this finding was not statistically significant.

The low-dose estrogen also reduced hot flashes and vaginal dryness, Mortola noted.

A drawback of the Florida study is that it did not look at Premarin, the estrogen supplement that is derived from horse urine and used most often by American women.

But a small study of about two dozen women by Dr. Karen Prestwood, a specialist in osteoporosis and an assistant professor at the University of Connecticut Health Center, did.

In data presented this fall to the American Society for Bone and Mineral Research, Prestwood found that women taking only 0.3 milligrams a day of Premarin got roughly the same protection against bone loss as those taking 0.625 milligrams.

In related research, Prestwood studied another estrogen formulation called Estrace, a synthetic form of estradiol, the main type of estrogen found in the body.

As long as women also took 1,500 milligrams a day of calcium, low doses (0.5 mg) Estrace — the equivalent of 0.3 mg of Premarin — protect against osteoporosis, she found.

Dr. Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital, says the new studies follow the logic used for years with birth control pills — reducing the dose to decrease side effects yet still achieve contraception.

“The same thinking is carrying over to estrogen replacement therapy,” he says, adding that the findings are “taking us to a new plateau.” Still, he does not recommend low dose estrogen for everyone, though he does prescribe it for some patients.

There may one more benefit to low dose estrogen, though it has yet to be proved, says Dr. Joann Manson, co-director of women’s health at Brigham and Women’s Hospital in Boston.

A small study by Boston researchers showed recently that women who take estrogen and drink alcohol may raise blood levels of estrogen to more than three times the intended dose.

This study focused on Estrace, not Premarin, and the hormone users drank quite a bit — the equivalent of three glasses of wine.

Yet the emerging data suggest that women who drink may want to ask their doctors if they should switch to low dose estrogen.

No matter what the doctor says, it’ll make for an interesting discussion at your next coffee klatch.

SIDEBAR:

Variations on a theme

Estrogen pills and patches — and their dosages — as approved by the US Food and Drug Administration:

• Estrogen-only pills
• Premarin: 2.5 milligrams, 1.25 mg, 0.9 mg, 0.625 mg or 0.3 mg.
• Estratab: 2.5 mg, 1.25 mg, 0.625 mg, or 0.3 mg.
• Estrace: 2 mg, 1 mg or 0.5 mg. (The latter is roughly equivalent to 0.625 mg of Premarin.)
• Ogen: 1.5 mg.
• OrthoEst: 1.25 mg, 0.625 mg or 0.615 mg.
• Menest: 2.5 mg, 1.25 mg, 0.625 mg, 0.3 mg.
• Estrogen-progestin combination pills
• PremPro: one tablet contains 0.625 mg of estrogen and 0.5 mg of medroxyprogesterone (Provera)
• PremPhase: a two-tablet combination regimen containing 0.625 mg of estrogen and 0.25 mg of medroxyprogesterone. [CORRECTION – DATE: Monday, December 23, 1996: CORRECTION: Because of inaccurate information supplied by the FDA, dosages for two estrogen-progestin pills described by Health Sense columnist Judy Foreman last Monday were incorrect. The amount of medroxyprogesterone in is 5 mg; in PremPhase it is 2.5 mg.]
• Estrogen patches (which last from 3 to 7 days)
• Vivelle, which provides daily doses of 0.1mg; 0.075 mg; 0.05 mg; or 0.0375 mg.
• Estraderm, which provides daily doses of 0.1 mg or 0.05 mg.
• FemPatch, which provides a daily dose of 0.025 mg.
• Climara, which provides daily doses of 0.1 mg or 0.05 mg.

Lupus — “the wolf” — began stalking Debra McGann, a 40-year-old Waltham teacher, 15 years ago.

It made her deathly ill during all four of her pregnancies, and probably caused two of those pregnancies to fail.

It also triggered intermittent seizures and what McGann calls “little confusions.” For years, though, neither she nor her doctors had any idea that these and other neurological problems could be part of the disease’s treacherous march through the body.

Lupus has stalked 52-year-old Susan Shumaker of Cohasset for years, too, forcing her to give up her much-loved teaching job. Shumaker, too, suffered baffling neurological problems, including short-term memory loss, numbness on her scalp, “pins and needles” on her face and numerous small strokes — sometimes as many as 10 an hour — which made her temporarily unable to walk.

“It was terrifying,” she recalls. “I didn’t know what was happening,” and for months, neither did her doctors.

Today, “brain lupus,” a constellation of neurological and psychiatric problems including severe headaches, memory loss, strokes, seizures and even psychosis, is increasingly recognized as part of systemic lupus erythematosus, an immune system disease named for the characteristic facial rash that makes some patients look a bit like wolves with red cheeks.

For years, doctors have understood the basic mechanics of lupus: Misguided antibodies attack the body’s own tissues, often in the skin and joints, and sometimes, in organs like the kidneys as well, causing inflammation, pain and tissue damage.

Forty years ago, in fact, kidney failure was such a common consequence that half of all lupus patients died within four years of diagnosis. Today, thanks to better diagnosis and treatment, 90 percent live at least 10 years after diagnosis, and many live 20, 30 years or longer.

But increasingly, researchers are recognizing that tissue damage is not limited to joints and kidneys but often includes the brain as well.

Sometimes, brain damage occurs when antibodies made by the overactive immune system trigger blood clots, which can form in or travel to the brain, causing strokes. Sometimes, the destruction comes from misguided antibodies that cause inflammation of blood vessels in the brain, triggering seizures and memory loss. Sometimes antibodies or other immune substances called cytokines may directly attack brain tissue.

And sometimes, for obscure reasons, lupus simply causes spasms in blood vessels, resulting in decreased blood flow to parts of the brain, and often, migraine headaches, too.

However the damage occurs, two-thirds of people with lupus are now believed to suffer some kind of brain or behavioral problem, according to data presented at a recent conference at the New York Academy of Sciences.

Strokes, for instance, occur in 15 to 20 percent of patients, says Dr. Robert G. Lahita, a Columbia University specialist who organized the conference. Seizures occur in another 5 percent, he says.

And if one includes milder forms of depression, memory impairment and mood swings, as many as 90 percent of patients have neuropsychiatric problems from lupus, says Dr. Andrea Schneebaum, a lupus specialist at the Lahey-Hitchcock Clinic in Burlington.

Often, the depression is an emotional reaction to the stress of coping with a disease that can flare up painfully and unpredictably. But it may also be a “direct effect” of the immune disorder itself, says Dr. Malcolm Rogers, a Brigham and Women’s Hospital psychiatrist who treats many lupus patients.

In rare cases, people with lupus can become psychotic and wind up, improperly diagnosed, in mental institutions, says Henrietta Aladjem of Watertown, a patient advocate now in her 70s who has been in remission from lupus for 25 years.

Despite considerable progress, nobody really knows what causes lupus, though it is clear that the skin (or “discoid”) form of the disease can be triggered by ultraviolet light — and that avoiding sunlight and using sunscreens can help. At least six genes may be involved in the systemic form.

Nor does anyone know why lupus strikes disproportionately at women of childbearing age, though hormones, especially a tendency to convert one form of estrogen to another, are probably involved, says Lahita.

But doctors do increasingly understand how lupus wreaks havoc all over the body and how to deal with it.

In all of us, cells regularly die off through a process called apoptosis. As they die, they spill their contents, including bits of broken DNA, into the bloodstream. The immune system then makes antibodies that search out and get rid of this debris.

But in lupus patients, apoptosis seems to be excessive, and the body responds by making huge quantities of antibodies to clean up the mess, says Dr. Peter H. Schur, director of the lupus center at Brigham and Women’s Hospital.

Lupus patients, for instance, often make too much of an antibody called ANA, or antinuclear antibody. This antibody gloms onto broken bits of nucleus from dead cells, then the whole complex travels to the kidneys, clogging delicate tissues.

Lupus patients also make excessive amounts of antibodies against other substances in the body, including DNA itself, the proteins that hold DNA together, a protein called ribosomal P and fatty proteins called phospholipids.

The payoff for patients of this increasingly-detailed knowledge of lupus antibodies is that doctors can now track antibody levels to predict incipient flare-ups of disease.

High levels of antiphospholipid antibodies, for instance, can be a warning sign because they can trigger blood clots that can lead to strokes. Strokes can often be prevented by taking aspirin or other blood thinners, such as Coumadin.

High levels of a natural amino acid called homocysteine can also be a signal of increased risk of stroke, says Dr. Ronenn Roubenoff, a rheumatologist at Tufts University.

And brain scans such as PET and SPECT are also helping doctors detect incipient problems such as decreased blood flow to certain areas of the brain, which raises the risk of seizures and memory impairment. Once seizures occur, a growing array of drugs, including Dilantin, Phenobarbital, Tegretol, Depakote and Valproic acid, can help prevent further attacks.

A generation ago, says Schur, there wasn’t much doctors could do except prescribe high doses of corticosteroids such as Prednisone. High-dose steroids do a good job of damping down an overactive immune system, but they can also cause memory problems and leave a patient prey to infections.

Today, says Schur, doctors not only have better antibiotics to manage steroid-induced infections, but better immunosuppressants, too, including Imuran and Cytoxan, and a better sense of how to use them to block inflammation.

And now that doctors are sensitized to look for neuropsychiatric problems in lupus patients, they are getting better at using even simple paper and pencil tests to determine whether cognitive difficulties stem from damage to part of the brain or emotional reactions to the disease. Cognitive problems that stem from depression can be treated with antidepressants; those that stem from an inflammation in the brain can be treated with steroids.

Experimental drugs may soon play a growing role, too, including DHEA (dihydroepiandrosterone), a natural hormone not yet approved as a drug by the Food and Drug Administration, that seems to offset lupus symptoms in some patients.

The bottom line, says Schur, is that lupus “is not as bad as it used to be. There are a lot of things we can do.”

And that goes for brain lupus, too. If you have lupus and run into problems with memory or depression, don’t suffer in silence, says Schneebaum of Lahey-Hitchcock. You should “absolutely tell your doctor,” because treatments can help.

So can your attitude.

“You have two options,” says McGann, the Waltham teacher. “You can let the disease run your life, or you can let go of it and get on with your life the best you can. . . You don’t have to let it be the center of everything.”

Susan Shumaker agrees. While her memory problem has not gone away, she and her husband have learned to deal with it.

Initially, her mental problems were “very frightening for both of us,” Shumaker says, because she had to keep asking the same questions over and over. In fact, her memory problems meant they had to move back to the suburbs, because the city was too confusing.

But she has gradually learned little tricks — like setting timers in the kitchen to remind her to turn off the stove — and, more importantly, how to live day by day.

“My life has really been quite different from what I would have thought,” she says. But she manages well, thanks to “a strong spiritual life and a strong network of wonderful friends and family.”

SIDEBAR:

For more information on lupus, call:

• The Lupus Foundation of America, Massachusetts Chapter, 617-332-9014.
• The Lupus Foundation of America, toll-free national information number 1-800-558-0121.

When a stressed-out man walks into Alice Domar’s office and walks out an hour later with a relaxation tape in hand, chances are he’ll do what she recommends — take 20 minutes a day to listen to it. And feel much better.

But when a woman with the same — or worse — symptoms gets those tips and stress-reduction tapes, things turn out quite differently, says Domar, a psychologist at Deaconess Hospital.

“Women can’t do it. They can’t take 20 minutes for themselves. They say, `Who’ll watch the kids, cook dinner, do the laundry?’ ” she says. “Women feel guilty when they spend time on themselves.” Even exercise, she says, often becomes a mode of punishment for women, not a source of pleasure.

Whether or not women have more stress in their lives — and they may — they are certainly more upfront about it with health professionals. But they seem to have more trouble than men doing what often helps most: taking time for self-care, whether that’s meditation, exercise, yoga or a chat with a friend.

Starting as teen-agers, says psychologist Joan Borysenko of Boulder, Colo., girls begin to struggle with the issue of taking time for themselves, “and nobody resolves it by the end of adolescence. Women fight this all their lives.”

If you put yourself first, you’ll be “selfish;” if you put others first, you’ll be “selfless,” says Borysenko, who has a book on female biology and spirituality due out in January.

But recent research shows that if you are among the hustling hordes of harried heroines, there’s lots you can do to offset stress and the problems it can exacerbate, including hot flashes, infertility, PMS, chronic pain and depression.

First, especially if you’re a working mother, you can start with a healthy recognition of reality.

Two years ago, Labor Secretary Robert Reich released a major study confirming what women have long known. Women who work enjoy it — 79 percent say they “like” or “love” their jobs.

But they’re also stressed. In fact, 60 percent said stress is the most critical problem they face. Among other things, women still have trouble finding good childcare. They still earn less than men. And they still get less respect.

So it’s no surprise that working women with kids at home wind up with higher levels of the stress hormone cortisol in their urine than women in the same jobs without kids, says Dr. Redford Williams, director of the behavioral medicine research center at Duke University Medical Center.

Granted, men get stressed, too, both at home and at work. But one of the five biggest “psychosocial stress factors” — along with hostility, depression, social isolation and poverty — is having a “high-demand, low-control” job like being a file clerk or working on an assembly line, says Williams, and “women are more likely to be in low-control jobs.”

But women also have some advantages, says Williams. They clearly live longer than men and are “better off than men when it comes to being able to handle stress because they’re less hostile, better listeners and less aggressive.”

In fact, women can play to these social strengths to offset stress, he says. In his recent randomized study of 98 women, Williams found that 8-to-10-week stress management support groups clearly reduced stress among married mothers — far more so than simple group lectures.

But in reality, he says, “just about any stress management technique would work for women — if they’d use them.”

Getting women past that big “if” is the tough part, because “women have self-esteem issues,” says psychologist Domar, author of a new book called “Healing Mind, Healthy Woman.”

“They’re great at taking care of others, but not themselves.

“I’m not saying men don’t have self-esteem issues,” she adds, “but I find it easier to teach mind/body skills to men.”

Still, recent data show that once a woman allows herself time for stress reduction, troubling symptoms often improve. Some examples:

– Menopause. In a study by Domar and colleague Judith Irvin, 33 menopausal women were randomly assigned to listen to a relaxation tape for 20 minutes a day for seven weeks and keep a diary of this practice, to read daily for 20 minutes and keep a diary of this, or simply to record their hot flashes.

The women who practiced daily relaxation had a statistically significant — 28 percent — decline in hot flash intensity while the other two groups did not, says Domar, adding that these findings are in line with those of several other studies.

In another study, Domar showed that women with breast cancer who had hot flashes from the estrogen-blocking drug tamoxifen got a similar benefit from relaxation techniques.

– PMS, a set of symptoms including fatigue, irritability and mood swings that may precede a woman’s period. In a study of 70 women conducted with Irene Goodale, Domar randomly divided women into a group that practiced a relaxation technique daily, a group that read and a group that simply charted their PMS symptoms.

The women who were taught a meditation-like technique that Domar’s mentor, mind/body guru Dr. Herbert Benson, calls the “relaxation response” — which has been shown to decrease the body’s response to adrenalin — showed a 58 percent decline in PMS symptoms. The group that read had a 27 percent decline, and the women who simply charted symptoms, a 17 percent decline.

The improvement from simply charting symptoms, by the way, fits with a large body of research showing that just tracking your symptoms can help by enhancing a sense of control.

– Infertility. Domar’s previous research has shown that infertile women are often so depressed and anxious that their scores on mental health tests are indistinguishable from those of women with cancer, AIDS and heart disease.

But the nearly 300 women who have taken Domar’s 10-week program that teaches relaxation and other coping skills show a dramatic improvement in mental health, she says, ending up with mental health scores, on average, in the normal range.

And 42 percent get a bonus — pregnancy, though the most important outcome, she says, is that even women who do not get pregnant are much less distressed than they had been.

– Pain. Chronic pain is a major reason that patients, two-thirds of them women, flock to the stress reduction clinic at the UMass Medical Center in Worcester, says executive director Jon Kabat-Zinn.

While the Deaconess mind/body program stresses the relaxation response, including meditation or prayer by focusing on a word or mantra to clear the mind of distracting thoughts, Kabat-Zinn advocates another approach: mindfulness meditation.

In this technique, the goal is not to block things out but to “put out the welcome mat,” he says. “So if you have a headache or pain, you move into that sensation with awareness” — and without adding to distress by judging your own reactions.

Overall, his 8-week program leads to a 30 to 40 percent reduction in pain, he says, adding that pain reduction can be maintained for several years if patients keep meditating.

– Depression. Emerging data suggest that God may be as good as Prozac in fighting depression — especially for older women.

In a 1988 study of 850 people over 60, two-thirds of them women, Dr. Harold Koenig, a psychiatrist and head of Duke University’s Program on Religion, Aging and Health, found a strong link between “intrinsic religiosity” and well-being.

In other words, there seems to be something beneficial about having a strong faith, Koenig says, above and beyond the social support church activities can provides and regardless of financial status or physical health.

Perhaps a belief in God provides a worldview that gives peace by enabling people to understand negative events as God’s will, he says. Or perhaps it helps to believe that God is always there, even in the middle of the night or when death approaches.

The bottom line, say those who study women and stress, is that if you’re young and stressed, get going now. Don’t spend your whole life believing you don’t deserve time for yourself.

And there are signs, says Barrie R. Cassileth, a psychologist and medical sociologist at Duke and the University of North Carolina medical centers, that young women are doing just that.

“I hear it like a mantra,” she says of younger women’s determination to take care of themselves, a far cry from her mother’s days in which that attitude was almost “immoral.”

And if you’re an older woman and feeling stressed out?

Don’t give up. It’s never too late to learn to reduce stress, says Domar. And there may be an added bonus. “If you start treating yourself better,” she says, “you’ll not only profit yourself, you’ll be a great role model for your daughter, too.”

Judy Foreman is a member of the Globe staff. Her E-mail address, via Internet is: foreman(AT SIGN SYMBOL)globe.com

SIDEBAR:

To learn more

For more information on stress reduction programs, call:

• Division of Behavioral Medicine, Deaconess Hospital, 617-632-9530.
• Stress Reduction Clinic, UMass Medical Center, 508-856-2656.

What if you had breast cancer and discovered that timing surgery to coincide with a particular point in the menstrual cycle might make a difference in your prognosis?

Or what if you had diabetes and learned that insulin sensitivity varies with menstrual rhythms?

And what if you were plagued by other miseries, like migraine headaches or yeast infections or systemic lupus erythematosus, that also seem to wax and wane along with the menstrual cycle?

Would you use menstrual cues to time your surgery, to watch your blood sugar extra closely, or to predict the onset of troubling symptoms?

Chances are you would — in these and many other cases.

In fact, if you’re among the millions of women who have not yet hit menopause, you’ve probably already become a kind of amateur scientist, searching for connections between your own monthly rhythms and the ups and downs of your health.

The problem is, the medical establishment hasn’t exactly shared in this enthusiasm for finding links between menstrual rhythms and patterns of disease. Until recently.

Like the circadian, or daily, rhythms now known to be part of many basic biological processes, like hormone secretion and temperature control, our bodies also have longer rhythms, none more obvious than the menstrual, or monthly, cycle.

To be sure, the question of why humans and many other primates menstruate — pass blood from the uterus periodically when conception does not occur — is still an open one.

Perhaps evolution just isn’t done with us yet. In fact, if women held the evolutionary cards, maybe we’d get rid of menstruation, especially if we could have babies without it.

Or perhaps menstruation, just as the textbooks say, is what happens when something else — conception — doesn’t happen, though in energy costs to the body, it seems a high price to pay for a fancy reproductive design.

Or perhaps, as maverick scientist and MacArthur “genius” award recipient Margie Profet contends, menstruation is the female’s way of getting rid of all sorts of nasty bacteria and other pathogens that ride into the body on the tails of sperm.

Profet, an enthusiastic visiting scholar at the University of Washington in Seattle and author of a controversial article on menstruation three years ago in the Quarterly Review of Biology, thinks menstruation, far from being an evolutionary accident, is a nifty adaptation to the threat of infection.

Citing evidence from numerous species, including those that may menstruate invisibly, she says that “sperm are vectors of disease” and that menstruation exists “to protect the uterus and oviducts from colonization by pathogens.”

Whatever its reason for being, the menstrual cycle in humans is a lot more complex — and potentially more closely linked to the rhythms of health and disease — than scientists used to think.

Susceptibility to AIDS infection, for instance, may vary as hormone levels fluctuate across the menstrual cycle.

In May, scientists at the Aaron Diamond AIDS Research Center in New York and the National Institute of Child Health and Human Development found that monkeys given a high dose of progesterone were more likely than other monkeys to become infected by SIV, the monkey AIDS virus, following vaginal exposure to the virus.

Cindy Pearson, executive director of the National Women’s Health Network, notes in a soon-to-be-released newsletter that this study involved monkeys, not women; SIV, not HIV; and progesterone implanted in pellets under the monkeys’ skin, not the body’s own natural surges of the hormone.

Still, the network is “extremely concerned” because the study showed that when progesterone is high, vaginal tissue thins, perhaps making it easier for the AIDS virus to gain entry.

This suggests that women who have sex with HIV-positive men might be more vulnerable during the second half of their cycles, and that women using progesterone-based birth control, such as Norplant and Depo-Provera, might also be at extra risk.

And there are other potential links between health and menstrual rhythms, though the quality of the research varies from study to study, says epidemiologist Sioban Harlow of the University of Michigan, who has combed the medical literature looking for such links.

Basic metabolic rate, for instance, appears to be higher in the second half of the cycle, with women often consuming — and expending — 500 extra calories a day. “You’re hungrier and with reason, not because of lack of will power,” says Harlow.

Immune function also seems to fluctuate with the time of the month — in still-perplexing ways. Some researchers say progesterone acts as an immune suppressant; others have found that infection-fighting white cell counts are lowest when estrogen is highest.

In one study, Dr. Barbara Mittleman, an immunologist at the National Institute of Mental Health, found that the kind and degree of immune fluctuation across the menstrual cycle seems to vary from woman to woman.

Yet some auto-immune conditions clearly wax and wane with menstrual rhythms, among them rheumatoid arthritis and systemic lupus erythematosus, says Dr. Balu Athreya, a rheumatologist at Thomas Jefferson University in Philadelphia. The worst flare-ups of lupus, for instance, often come in the luteal phase.

And with arthritis, some hormones — like those in pregnancy — often offer relief, while those of lactation may make it worse.

Asthma, too, seems to flare just before menstrual periods, many women say, though a 1989 review found that detailed studies on the subject showed no clear pattern.

It has also been shown that progesterone, the dominant hormone of the second half of the cycle, can trigger adverse changes in cholesterol, says Dr. JoAnn Manson, co-director of women’s health at Brigham and Women’s Hospital. Because younger women are at low risk of heart disease to begin with, however, these fluctuations may not pose a huge risk.

Far more likely to cause grief are migraine, acne, panic attacks, changes in bowel function and an increased tendency toward epileptic seizures — all of which have been shown to get worse before a woman’s period, says Dr. Karen Carlson, director of Women’s Health Associates at Massachusetts General Hospital and a co-author of the Harvard Guide to Women’s Health.

Diabetic women, too, may have an extra tough time just before their periods, she says, because progesterone increases resistance to insulin. This means it takes more insulin to get sugar into cells — so diabetic women may need to increase insulin as their periods approach.

But of all the potential links between menstrual rhythms and health, perhaps none has greater implications than the timing of breast cancer surgery to ovulation.

“This is really where the rubber meets the road,” says Dr. William Hrushesky, senior attending oncologist at the Samuel Stratton Veteran’s Administration Medical Center in Albany, N.Y.

For years, says Hrushesky, the idea that the timing of breast surgery might be important was greeted “with ridicule; then [it] went to outright hostility, then has been ignored.”

But even skeptics like Dr. Kent Osborne, chief of medical oncology at the University of Texas Health Science Center in San Antonio, now say “what’s really needed is a prospective trial” in which menstrual data are correlated with timing of surgery and results are compared.

So far, there have been about 20 retrospective studies in women with breast cancer. About a dozen of them have concluded that, at least in women whose cancer has spread to underarm lymph nodes, the best time for surgery may be just after ovulation, when estrogen is falling and progesterone is surging. This is the early part of the luteal phase, or second half, of the menstrual cycle.

In 1991, an American study of nearly 300 women found the luteal phase was best for surgery, as did a British study of nearly 250 women. In a 1994 study, the British team noted that the high progesterone in the luteal phase seems to contribute to “significantly better survival.”

A 1994 Italian study of nearly 1,200 women came to a similar conclusion, finding that women who had surgery in the luteal phase had a “significantly better prognosis” than those who had surgery in the follicular, or first half of the month.

Some other studies have found no relationship between the timing of surgery and prognosis, but there are theoretical reasons why there might be a connection.

In the first half of the cycle, women have high levels of estrogen without any accompanying progesterone. Estrogen can trigger a tumor growth factor called IGF-1 and may increase enzymes like cathepsin-D that help cancer spread.

By contrast, there are hints that progesterone may damp down such enzymes and keep small blood vessels from leaking cancer cells into the bloodstream. Both estrogen and progesterone may also influence immune response to cancer, though how this plays out across the menstrual cycle is difficult to pin down.

The bottom line, as the Society for Menstrual Cycle Research has been saying for nearly 20 years, is that more research is needed into the menstrual cycle’s effects on health.

Until that research is done, one of the best things you can do for your own health is to keep records of recurring symptoms and chart them against your menstrual cycle.

Whichever way your data turns out, says Carlson, you’ll get valuable information. You may find some connections with menstrual rhythms that you never suspected.

And some troubles that you might have linked to monthly periods may turn out to be utterly random strokes of fate.

 

SIDEBAR:

The premenstrual syndrome paradox

One of the most controversial conditions linked to menstrual rhythms is PMS, or premenstrual syndrome, now also called premenstrual dysphoric disorder.

Politically, PMS represents a no-win situation for feminists.

The risk in legitimizing it is in “medicalizing” the normal menstrual process and potentially branding all women as sufferers of emotional distress before their periods, says Ann Voda, director of the Tremin Trust Research Program on Women’s Health at the University of Utah College of Nursing.

On the other hand, failing to recognize the genuine suffering of some women — perhaps 5 to 8 percent, according to Nancy Fugate Woods, director of the center for women’s health research at the University of Washington in Seattle — is no solution either.

Clearly, some women do have a terrible time as their periods approach, with bloating, breast tenderness, irritability, changeable moods, depression and fatigue among the symptoms.

One hypothesis is that this misery is caused by low levels of the brain chemical serotonin, though this is not proved.

Still, for some women, the premenstrual time does seem to be “almost a serotonin-deficiency state,” says Dr. JoAnn Manson, co-director of women’s health at Brigham and Women’s Hospital. And some, she says, get “a good response to Prozac,” an antidepressant drug that increases serotonin levels.

For others, the anti-anxiety Xanax taken for a week before the period may also help, says Dr. Karen Carlson, director of Women’s Health Associates at Massachusetts General Hospital.