Should every woman be taking hormones at 50? Or is the `natural' way just as healthy? In the last of our series on the five ages of women Jenny Knight looks at the options
The menopause is the beginning of old age. Fertility ceases, the vagina atrophies, sexually attractive women metamorphose into grey- haired old bags. That's the gloomy view. Alternatively, you may prefer the positive outlook expressed in Our Bodies, Ourselves by Angela Phillips and Jill Rakusen, who say: "As women start to value themselves as more than baby-machines, as we increasingly view middle age as a welcome time offering new freedom, and as we make selective use of various treatments to minimise any menopausal discomforts, the menopause can be a positive experience."

Forty years ago, middle age was embraced without a struggle. Both sexes popped off to the dentist to have their teeth out; weight gain was considered inevitable. People in their thirties had similar hairstyles and wore similar clothes to those in their sixties. Now the youth culture imposes the burden of struggling to stay slim, stylish and youthful.

At the onset of menopause, each woman has to decide whether to resist or to accept the countdown to old age. If she chooses to resist - and most do for a time - she must decide whether to try hormone replacement therapy or to rely on "natural" or other methods.

Hormone replacement therapy is said to protect women against heart disease and osteoporosis, and to help us to remain sexually active and to retain a youthful glow. While it is also linked to a slight increase in breast cancer, it can often help women to cope with such distressing symptoms as hot flushes, depression, irritability, palpitations, sleeplessness, joint pains and headaches. Yet critics claim that there is a high drop- out rate, and that women who give up HRT because of unwelcome side-effects such as weight gain may find that their menopausal symptoms recur with a vengeance.

So, who do we believe? We talked to two women, one a messianic believer, the other who has yet to make up her mind.

`Why not enjoy sex into old age?'

Mrs Joan Jenkins, founder president of the advisory service Women's Health Concern, has been on HRT for 24 years.

"Look at me," she says, "straight as a die! No heart disease, no osteoporosis, no wrinkles. My mother suffered terribly from osteoporosis and my younger sister died of a heart attack. I might not be here still if I wasn't taking HRT. I was born in the Twenties but I refuse to reveal my age, because when people know how old you are, they think you're finished.

"When I was in my forties, in the peri-menopause, I got typical symptoms - irregular periods, hot flushes, insecurity, fatigue. I was working for the BBC at the time, with a young son. All the women heads of service were on HRT, and one said to me, `Don't suffer like your mother did'. I went to see an endocrinologist who suggested that, because I had been a nurse, I should take my own vaginal swabs to test for hormone levels. They were found to be low in oestrogen. I was put on HRT and the same year I founded Women's Health Concern.

"I am still very active, I go abroad and do a lot of lecturing. My body is still functioning and people don't imagine I am as old as I am. I believe more women would enjoy life more if they had the advantage of proper medical treatment.

"My younger sister, Betty, believed nature would look after her. She had a hysterectomy and her ovaries were also removed. She thought HRT wasn't natural, and eight years later my dear sister suddenly dropped dead. I was terribly shocked, but 150,000 women in Britain died of heart disease last year, and we know that HRT protects against it. The country spends pounds 750 million each year on osteoporotic women suffering from bone fractures. It's a terrible waste of lives and resources.

"There are all sorts of books suggesting diet and exercise are the answer to the menopause. They may be complementary to taking the appropriate medicine, but they aren't an alternative. Most healthy women enjoy sexual activity into old age, and those who keep their vaginas in good condition because of HRT are able to continue.

"I had no misgivings at all about the menopause, I had had my own planned child. I was busy and healthy. I don't see any harm in growing older. The joy of being a woman is the seven ages you go through. What is the point of worrying because you are 40, 50, or even 80? Life is full of little hiccups, but if you are healthy you can cope. Unfortunately, lots of women do nine-to-five jobs where they are regarded as past it at 48. If they are sensitive and the victim of that sort of harassment, it can be horrendous, but if women would only believe in themselves they could do anything.

"Women's Health Concern fields 60,000 calls a year. We hear from people who are not getting treated properly by doctors. Lots of women are schooled to think that at certain ages things will happen to them. They say at 55 you can't expect to be what you were at 25. I've been a widow for five years, but HRT enables you to continue your working life and your pleasures.

"Women's attitudes have got to change. They have to realise that they are not reaching their potential, especially if they are knocked back when nature switches them off. We are the only mammal which lives beyond the menopause. Men are not shut off from their hormones in old age. They still produce testosterone. Lots of women don't like infertility, so many of them get to the menopause and feel hard done by, but I think it's a good thing or women would carry on having babies just because they could.

"The link between HRT and breast cancer has been tested for 25 years, and the results are pretty inconclusive. One in 12 women gets breast cancer, which is a much lower figure than for heart disease, which HRT protects against. It looks as if, after 18 years on HRT, there is a slight increase in the risk of breast cancer, but I feel the risk of osteoporosis and heart disease exceed that risk, and anyway, research shows that women on HRT are more likely to survive breast cancer than those who are not.

"Some women complain of side-effects with HRT, but many of these are caused by underlying gynaecological problems which haven't been properly diagnosed or treated. Too many take it for too short a time. Most doctors think you should take HRT for five years and then give up. Women's Health Concern runs postgraduate seminars for GPs, to inform them.

"There are more women like me than people realise, women who have been taking HRT for 20 or 30 years. The medical profession has not monitored how many long-term users there are. I look at women such as Barbara Castle and the Queen Mother, and I can't help suspecting they're on HRT."

`Men think of you as some old bat'

Viv Southorn is 49, and is studying garden design. She has two children, aged 13 and nine. She is not taking HRT.

"I'm in the pre-menopause. In the past couple of years my periods have become erratic. My family say I have been menopausal since I turned 40. I'm depressed, miserable, and I've developed premenstrual tension, which I didn't have before. I have hot flushes for a couple of months, and then they stop when I have a period. They happen all the time, not just at night. I had a lot last year in the hot weather, and they also happened when we were on holiday in China. It was freezing cold, yet I was saying `Open the windows'. I don't find it embarrassing. My friends tell me everyone has them. They say `Oh, I'm having a hot flush'. They don't care, so I don't either. Most of the blokes I know are New Men and know all about it from their wives, but I don't think they really understand what's happening to your body.

"Another thing that bothers me is that I can't remember things. I'm so absent-minded. I don't know whether my depression is just age or something else. I'm at the point of life where I'm losing my youth. I can't go back. It bothers me that my looks are going. I'm developing wrinkles and grey hair, which I cover up by dyeing. I can't believe there is anything liberating about the menopause. You have 20 to 30 years of being attractive to men, and now it's going. A lot of people won't accept that, and spend a fortune on make-up to keep looking young. I notice men don't pay any attention to women who don't attract them.

"On the plus side, now I'm older I'm more aggressive and less easily put off. I find most men don't think of you as interesting, just as some old bat. But at parties where men don't pay me any attention, now I'm older and more confident, I go and chat to them.

"I can't decide about HRT. I don't know enough about it. I suppose I don't want to admit that I am old enough to take it. I've read a couple of books, and I contacted the Amarant Trust, but they were so positively in favour, it put me off - HRT is about oestrogen replacement, but there was a Woman's Hour programme recently about progesterone. It was very pro and gave a helpline number where they were incredibly helpful, but I still can't decide whether they are right or not. I have a friend taking HRT, and she bounces, but she always has.

"I am quite attracted to alternative methods. There's the idea of growing old gracefully, and the philosophy that you should go with it and not try to beat it ... I take evening primrose oil and I'm vaguely homeopathic.

"Older men in this society are treated worse than young men, but nothing like as badly as women. There is a definite contempt for people over 40. When we were in China, all the elderly people seemed to have a wonderful time. I think I'd feel more positive if our society was more like that.

"My daughter is entering puberty, and can't cope with her own emotions. I can't expect her to cope with mine, so we don't talk about what's happening to me.

"John is fed up. He is always saying I'm premenstrual. He thinks aspects of our life might improve if I were on HRT, but I think he uses the menopause as a get-out for being serious about our lives and what might be wrong."