One only has to listen to talk radio or attend a cancer support group to hear rhetoric damning and demeaning the mainstream. At the least, doctors are viewed as ignorant of simple things that induce wellness, such as diet, supplements, and plant medicines. In the extreme, adherents of alternatives rant about medical oncologists who do not want to find a cheap and simple cure for cancer, because they make vast amounts of money by poisoning cancer victims with outrageously expensive, toxic products proffered by greedy pharmaceutical companies. When the gap is this wide, it is difficult if not impossible to cross over. While a small number of consumers completely eschew mainstream medicine, most users of alternatives take a pluralistic tack and combine the use of conventional medicines with that of botanicals and other alternatives.

CONVENTIONAL HORMONAL REPLACEMENT THERAPY

The health benefits offered by estrogen hormone replacement therapy seem irrefutable. Publications in the medical literature repeatedly enumerate reductions in risk of coronary vascular disease by at least 50%,5 and in osteoporotic fracture by as much as 80%. Not only does estrogen therapy hold an important place in coronary disease prevention, but evidence now suggests that HRT has a place in secondary heart disease treatment by lessening mortality in those with angiographic evidence of coronary disease,6 and helping to maintain the patency of bypass grafts7 and angioplasties.8,9 HRT ameliorates the overt symptoms of estrogen deficit, including hot flashes, insomnia, night sweats, vaginal dryness, and sexual dysfunction, which are not life-threatening but do impinge on the quality of life far more than the early progress of vascular disease and bone loss, both of which are silent and insidious.

Although other interventions, including vitamins, clonidine, antidepressants, and other nonhormonal measures have been used to mitigate symptoms and have success rates between 30% to 60%, hormone replacement lessens symptoms by an unchallenged 80% to 90% . Estrogens currently available in the United States include oral preparations and transdermal patches and an intravaginal ring. The low-dose ring, is indicated only for amelioration of urogenital atrophy and does not have documented systemic or preventive effects; the dose is so low that it does not require progestational opposition to protect the endometrium (Table 1).

LIMITATIONS OF CURRENT RESEARCH ON HRT

Until recently, most studies of estrogen replacement have been observational not experimental and have centered on white middle class populations. The dosage, regimen, and duration of hormone use have varied greatly. To some measure the positive impact of HRT has been the result of selection of what epidemiologists term "walking well" biases.10 Starting in 1969, after the Nelson Hearings convened in Congress to investigate vascular disease in oral contraceptive users, estrogens were deemed dangerous for high-risk women. Gynecologic textbooks and the Physicians Desk Reference listed myocardial infarction, stroke, migraine, diabetes, obesity, and other risks for heart disease and a family history of those conditions as contraindications to the use of estrogen.11 Selectively, for a decade and more, the only women using estrogen tended to be those who were by genetic endowment and health performance, the healthiest, while the sickly women were taken off of estrogen; such at risk women often were not even allowed to start taking estrogens. HRT users have been found to be better educated, have better lipid profiles, exercise more, and have lower blood pressure than nonusers at the start of a prospective study of the effects of HRT.12 A meta-analysis by Grady and colleagues suggests that the only groups for whom estrogen replacement therapy (ERT).