The iconic Arecibo Observatory has survived a hurricane and dodged deep budget cuts. On November 16, the National Science Foundation, which funds the bulk of the observatory’s operating costs, announced that they would continue funding the radio telescope at a reduced level.

It’s not clear yet who will manage the observatory in the long run, or where the rest of the funding will come from. But scientists are celebrating. For example:
Arecibo, a 305-meter-wide radio telescope located about 95 kilometers west of San Juan, is the second largest radio telescope in the world. It has been instrumental in tasks as diverse as monitoring near-Earth asteroids, watching for bright blasts of energy called fast radio bursts and searching for extraterrestrial intelligence.

But the NSF, which covers $8.3 million of the observatory’s nearly $12 million annual budget, has been trying to back away from that responsibility for several years. After Hurricane Maria hit Puerto Rico on September 20, damaging the telescope’s main antenna, the observatory’s future seemed unclear (SN: 9/29/17).

On November 16, the NSF released a statement announcing it would continue science operations at Arecibo “with reduced agency funding,” and would search for new collaborators to cover the rest.、
“This plan will allow important research to continue while accommodating the agency’s budgetary constraints and its core mission to support cutting-edge science and education,” the statement says.

It would be a memorable sight. But it would also be so wrong to tip over Galápagos giant tortoises to see how shell shape affects their efforts to leg-pump, neck-stretch and rock right-side up again.

Shell shape matters, says evolutionary biologist Ylenia Chiari, though not the way she expected. It’s taken years, plus special insights from a coauthor who more typically studies scorpions, for Chiari and her team to measure and calculate their way to that conclusion. But no endangered species have been upended in the making of the study.
“They’re amazing,” says Chiari of the dozen or so species of Chelonoidis grazing over the Galápagos Islands. Hatchlings start not quite the size of a tennis ball and after decades, depending on species and sex, “could be like — a desk,” says Chiari, of the University of South Alabama in Mobile.

Two extremes among the species’ shell shapes intrigue Chiari: high-domed mountains versus mere hillocks called saddlebacks because of an upward flare saddling the neck. Researchers have dreamed up possible benefits for the shell differences, such as the saddleback flare letting tortoises stretch their necks higher upward in grazing on sparse plants.
At the dryer, lower altitudes where saddleback species tend to live, fields of lava chunks and cacti make walking treacherous. “I fell on a cactus once,” Chiari says. Tortoises tumble over, too, and she wondered whether saddleback shells might be easier to set right again.
She went paparazzi on 89 tortoise shells, taking images from multiple angles to create a 3-D computerized version of each shell. Many shells were century-old museum specimens from the California Academy of Sciences in San Francisco, but she stalked some in the wild, too. The domed tortoises tended to pull into their shells with a huffing noise during their time in front of the lens and just wait till the weirdness ended. A saddleback species plodded toward the interruption, though, butting and biting (toothless but emphatic) at her legs.

To calculate energy needed to rock and roll the two shell types, Chiari needed to know the animals’ centers of mass. No one, however, had measured it for any tortoise. Enter coauthor Arie van der Meijden of CIBIO, Research Center in Biodiversity and Genetic Resources at the University of Porto in Portugal. With expertise in biomechanics, he scaled up from the arthropods he often studies. For a novel test of tortoises, he arranged for a manufacturer to provide equipment measuring force exerted at three points under a tiltable platform. As the first giant tortoise, weighing in at about 100 kilograms, started to lumber aboard the platform at Rotterdam’s zoo, Chiari thought, “Oh my gosh, it’s going to crush everything.” For a gentler and more even landing, four men heaved the tortoise into position.

Calculating the centers of mass for Rotterdam tortoises, the researchers extrapolated to the 89 shells. The low, flattened saddleback shape actually made shells tougher to right, taking more energy, the team reports November 30 in Scientific Reports. Now Chiari muses over whether the saddle at the shell front might let freer neck movements compensate after a trip and a flip.

Hundreds of eggs belonging to a species of flying reptile that lived alongside dinosaurs are giving scientists a peek into the earliest development of the animals.

The find includes at least 16 partial embryos, several still preserved in 3-D. Those embryos suggest that the animals were able to walk, but not fly, soon after hatching, researchers report in the Dec. 1 Science.

Led by vertebrate paleontologist Xiaolin Wang of the Chinese Academy of Sciences in Beijing, the scientists uncovered at least 215 eggs in a block of sandstone about 3 meters square. All of the eggs belonged to one species of pterosaur, Hamipterus tianshanensis, which lived in the early Cretaceous Period about 120 million years ago in what is now northwestern China.
Previously, researchers have found only a handful of eggs belonging to the winged reptiles, including five eggs from the same site in China (SN: 7/12/14, p. 20) and two more found in Argentina. One of the Argentinian eggs also contained a flattened but well-preserved embryo.
One reason for the dearth of fossils may be that the eggs were rather soft with a thin outer shell, unlike the hard casings of eggs belonging to dinosaurs, birds and crocodiles but similar to those of modern-day lizards. Due to that soft shape, pterosaur eggs also tend to flatten during preservation. Finding fossilized eggs containing 3-D embryos opens a new window into pterosaur development, says coauthor Alexander Kellner, a vertebrate paleontologist at Museu Nacional/Universidade Federal do Rio de Janeiro.
The eggs weren’t found at an original nesting site but had been jumbled and deformed, probably transported by a flood during an intense storm, Kellner says. Sand and other sediments carried by the water would then have rapidly buried the soft eggs, which was necessary to preserve them, Kellner says. “Otherwise, they would have decomposed.”
Using computerized tomography, the researchers scanned the internal contents of the eggs. Two of the best-preserved embryos revealed a tantalizing clue to pterosaur development, Kellner says. A key part of a wing bone, called the deltopectoral crest, was not fully developed in the embryos, even in an embryo the researchers interpret as nearly at term. The femur, or leg bone, of the embryo, however, was well developed. This suggests that, when born, the hatchlings could walk but not yet fly and may have still required some parental care for feeding, the scientists propose.
Such an interpretation requires an abundance of caution, says D. Charles Deeming, a vertebrate paleontologist at the University of Lincoln in England not involved in the study. For example, he says, there isn’t enough evidence to say for certain that the embryo in question was nearly at term and, therefore, to say that it couldn’t fly when born, a point he also raises in a column published in the same issue of Science. “There’s a real danger of overinterpretation.” But with such a large group of eggs, he says, researchers can make quantitative measurements to better understand the range of egg sizes and shapes to get a sense of variation in animal size.

Kellner says this work is ongoing and agrees that there is still a significant amount of study to be done on these and other eggs more recently found at the site. And the hunt is on for more concentrations of eggs in the same site. “Now that we know what they look like, we can go back and find more. You just have to get your knees down and look.”

A new computer program has an ear for dolphin chatter.

The algorithm uncovered six previously unknown types of dolphin echolocation clicks in underwater recordings from the Gulf of Mexico, researchers report online December 7 in PLOS Computational Biology. Identifying which species produce the newly discovered click varieties could help scientists better keep tabs on wild dolphin populations and movements.

Dolphin tracking is traditionally done with boats or planes, but that’s expensive, says study coauthor Kaitlin Frasier, an oceanographer at the Scripps Institution of Oceanography in La Jolla, Calif. A cheaper alternative is to sift through seafloor recordings — which pick up the echolocation clicks that dolphins make to navigate, find food and socialize. By comparing different click types to recordings at the surface — where researchers can see which animals are making the noise — scientists can learn what different species sound like, and use those clicks to map the animals’ movements deep underwater.
But even experts have trouble sorting recorded clicks, because the distinguishing features of these signals are so subtle. “When you have analysts manually going through a dataset, then there’s a lot of bias introduced just from the human perception,” says Simone Baumann-Pickering, a biologist at the Scripps Institution of Oceanography not involved in the work. “Person A may see things differently than person B.” So far, scientists have only determined the distinct sounds of a few species.
To sort clicks faster and more precisely, Frasier and her colleagues outsourced the job to a computer. They fed an algorithm 52 million clicks recorded over two years by near-seafloor sound sensors across the Gulf of Mexico. The algorithm grouped echolocation clicks based on similarities in speed and pitch — the same criteria human experts use to classify clicks. “We don’t tell it how many click types to find,” Frasier says. “We just kind of say, ‘What’s in here?’”
The algorithm picked out seven major kinds of clicks, which the researchers think are made by different dolphin species. Frasier’s team recognized one class as being made by a species called Risso’s dolphin. The scientists suspect that another group of clicks, most common in recordings near the Green Canyon south of Louisiana, was produced by short-finned pilot whales that frequent this region. Another type resembles sounds from the eastern Pacific Ocean that a dolphin called the false killer whale makes.
To confirm the identifications, the researchers now need to compare their computer-generated categories against surface observations of these dolphins, Frasier says.

The algorithm’s click classes may not match up with dolphin species one-to-one, says Baumann-Pickering. If that were the case, “we would expect to see a heck of a lot more categories, really, based on the number of species that ought to be in that area,” she says. That absence suggests that some closely related species produce highly similar clicks the algorithm didn’t tease apart.

Still, “it would be great to be able to confidently assign certain species to each of the different click types, even if more than one species is assigned to a single click type,” says Lynne Hodge, a marine biologist at Duke University who wasn’t involved in the work. More precisely monitoring dolphins with seafloor recordings could provide new insight into how these animals respond to environmental problems such as oil spills and the long-term effects of climate change.

During the world’s first telephone call in 1876, Alexander Graham Bell summoned his assistant from the other room, stating simply, “Mr. Watson, come here. I want to see you.” In 2017, scientists testing another newfangled type of communication were a bit more eloquent. “It is such a privilege and thrill to witness this historical moment with you all,” said Chunli Bai, president of the Chinese Academy of Sciences in Beijing, during the first intercontinental quantum-secured video call.

The more recent call, between researchers in Austria and China, capped a series of milestones reported in 2017 and made possible by the first quantum communications satellite, Micius, named after an ancient Chinese philosopher (SN: 10/28/17, p. 14).
Created by Chinese researchers and launched in 2016, the satellite is fueling scientists’ dreams of a future safe from hacking of sensitive communiqués. One day, impenetrable quantum cryptography could protect correspondences. A secret string of numbers known as a quantum key could encrypt a credit card number sent over the internet, or encode the data transmitted in a video call, for example. That quantum key would be derived by measuring the properties of quantum particles beamed down from such a satellite. Quantum math proves that any snoops trying to intercept the key would give themselves away.

“Quantum cryptography is a fundamentally new way to give us unconditional security ensured by the laws of quantum physics,” says Chao-Yang Lu, a physicist at the University of Science and Technology of China in Hefei, and a member of the team that developed the satellite.

But until this year, there’s been a sticking point in the technology’s development: Long-distance communication is extremely challenging, Lu says. That’s because quantum particles are delicate beings, easily jostled out of their fragile quantum states. In a typical quantum cryptography scheme, particles of light called photons are sent through the air, where the particles may be absorbed or their properties muddled. The longer the journey, the fewer photons make it through intact, eventually preventing accurate transmissions of quantum keys. So quantum cryptography was possible only across short distances, between nearby cities but not far-flung ones.

With Micius, however, scientists smashed that distance barrier. Long-distance quantum communication became possible because traveling through space, with no atmosphere to stand in the way, is much easier on particles.
In the spacecraft’s first record-breaking accomplishment, reported June 16 in Science, the satellite used onboard lasers to beam down pairs of entangled particles, which have eerily linked properties, to two cities in China, where the particles were captured by telescopes (SN: 8/5/17, p. 14). The quantum link remained intact over a separation of 1,200 kilometers between the two cities — about 10 times farther than ever before. The feat revealed that the strange laws of quantum mechanics, despite their small-scale foundations, still apply over incredibly large distances.

Next, scientists tackled quantum teleportation, a process that transmits the properties of one particle to another particle (SN Online: 7/7/17). Micius teleported photons’ quantum properties 1,400 kilometers from the ground to space — farther than ever before, scientists reported September 7 in Nature. Despite its sci-fi name, teleportation won’t be able to beam Captain Kirk up to the Enterprise. Instead, it might be useful for linking up future quantum computers, making the machines more powerful.

The final piece in Micius’ triumvirate of tricks is quantum key distribution — the technology that made the quantum-encrypted video chat possible. Scientists sent strings of photons from space down to Earth, using a method designed to reveal eavesdroppers, the team reported in the same issue of Nature. By performing this process with a ground station near Vienna, and again with one near Beijing, scientists were able to create keys to secure their quantum teleconference. In a paper published in the Nov. 17 Physical Review Letters, the researchers performed another type of quantum key distribution, using entangled particles to exchange keys between the ground and the satellite.

The satellite is “a major development,” says quantum physicist Thomas Jennewein of the University of Waterloo in Canada, who is not involved with Micius. Although quantum communication was already feasible in carefully controlled laboratory environments, the Chinese researchers had to upgrade the technology to function in space. Sensitive instruments were designed to survive fluctuating temperatures and vibrations on the satellite. Meanwhile, the scientists had to scale down their apparatus so it would fit on a satellite. “This has been a grand technical challenge,” Jennewein says.

Eventually, the Chinese team is planning to launch about 10 additional satellites, which would fly in formation to allow for coverage across more areas of the globe.

A type of spiraling wave has been busted for disorderly conduct.

Spiral waves are waves that ripple outward in a swirl. Now scientists from Germany and the United States have created a new type of spiral wave in the lab. The unusual whorl has a jumbled, disordered center rather than an orderly swirl, making it the first “spiral wave chimera,” the researchers report online December 4 in Nature Physics.

Waves, which exhibit a variety of shapes, are common in nature. For example, they can be found in cells that undergo cyclical patterns, such as heart cells rhythmically contracting to produce heartbeats or nerve cells firing in the brain. In a normal heart, electrical signals propagate from one end to another, triggering waves of contractions in heart cells. But sometimes the wave can spiral out of control, creating swirls that can lead to a racing or irregular heartbeat. Such spiral waves emanate in an orderly fashion from a central point, reminiscent of the red and white swirls on a peppermint candy. But the newly observed spiral wave chimera is messy in the middle.
Harnessing an oscillating chemical process known as the Belousov–Zhabotinsky reaction, the researchers created the wave using an array of small beads, each containing a catalyst for the reaction. When placed in a chemical solution, the beads acted as individual pulsating oscillators — analogous to heart cells — in which the reaction took place.

The researchers monitored the brightness of each bead as it alternated between a fluorescent state that emits red light and a dim state. Because the reaction is light sensitive, illuminating individual beads allowed the researchers to induce nearby beads to sync up. Thanks to that syncing, a spiral wave took shape. But, unlike any seen before, it had a muddled center.
The wave is a new kind of “chimera,” a grouping of oscillators in which some sync up, but others march to their own drummer, despite being essentially identical to their neighbors. Although researchers have previously created other kinds of chimeras in the lab, “it’s a step further to show that you can have this in even more complex setups” such as spiral wave chimeras, says Erik Martens of the Technical University of Denmark in Kongens Lyngby, who was not involved with the research.

While spiral wave chimeras had been predicted theoretically, there were some surprises to the real-world curlicues. Single spirals, for example, sometimes broke up into several independent swirls, each with disordered centers. “That was quite unexpected,” says chemist Kenneth Showalter of West Virginia University in Morgantown, a coauthor of the study.

It’s still not known whether the chimera form of spiral waves can appear in biological systems like the heart or the brain — but the new whorl is one to watch out for.

Robots are on their way to passing gym class.

The design of a new life-size bot named Kengoro closely resembles the anatomy of a teenage boy in body proportion, skeletal and muscular structure, and joint flexibility, researchers report online December 20 in Science Robotics. Compared with previous humanoid robots with more rigid, bulky bodies, Kengoro’s anatomically inspired design gives the bot a wide range of motion to perform humanlike, full-body exercises.
Constructed by Masayuki Inaba, an engineer at the University of Tokyo, and colleagues, Kengoro has a multi-jointed spine that allows the robot to curl into a sit-up or do back extensions. The bot’s arms are limber enough to execute various stretches or swing a badminton racket. And its artificial muscles are strong enough that Kengoro can stand on tiptoe or do push-ups. Batteries in each leg power Kengoro through about 20 minutes of exercise at a time, and water seeping from inside Kengoro’s metal skeleton like sweat keeps the motors of the artificial muscles cool while the bot works out.

Such a nimble robot that so closely imitates human movement and anatomy is “very unique,” says Luis Sentis, an engineer at the University of Texas at Austin not involved in the work. Building more humanlike robots could lead to the development of more sophisticated prosthetics or more realistic crash-test dummies that make humanlike reflexive movements during an accident.

Improvisation may give jazz artists a creative boost not seen among musicians more likely to stick to the score. Jazz musicians’ brains quickly embrace improvisational surprises, new research on the neural roots of creativity shows.

Neuroscientist Emily Przysinda and colleagues at Wesleyan University in Middletown, Conn., measured the creative aptitudes of 12 jazz improvisers, 12 classical musicians and 12 nonmusicians. The researchers first posed creativity challenges to the volunteers, such as listing every possible use for a paper clip. Volunteers then listened to three different kinds of chord progressions — common ones, some that were a bit off and some that went in wild directions — as the team recorded the subjects’ brain waves with an electroencephalogram. Afterward, volunteers rated how much they liked each progression.

Jazz musicians, more so than the other participants, preferred the unexpected riffs, brain waves confirmed. And the improvisers’ faster and stronger neural responses showed that they were more attuned to unusual music and quickly engaged with it. Classical musicians’ and nonmusicians’ brains hadn’t yet figured out the surprising music by the time the jazz musicians had moved on, the researchers report in the December Brain and Cognition.

The jazz musicians’ striking responses to unexpected chords mirrored their out-of-the-box thinking on the creativity challenges. Training to be receptive to the unexpected in a specific area of expertise can increase creativity in general, says Harvard University cognitive neuroscientist Roger Beaty, who was not involved in the study.

Despite a reputation as mellow apes, bonobos have a thing for bad guys.

Rather than latching on to individuals with a track record of helpfulness, adult bonobos favor obstructionists who keep others from getting what they want. The result may help explain what differentiates humans’ cooperative skills from those of other apes, biological anthropologists Christopher Krupenye of the University of St. Andrews in Scotland and Brian Hare of Duke University report online January 4 in Current Biology.
Previous investigations indicate that, by 3 months old, humans do the opposite of bonobos, choosing to align more frequently with helpers than hinderers. Humans, unlike other apes, have evolved to seek cooperative partnerships that make large-scale collaborations possible (SN: 10/28/17, p. 7), Krupenye and Hare propose.

“Conducting similar experiments with chimpanzees and other apes is a key next step,” Krupenye says. If chimps view hinderers as kindly as bonobos do, that finding would support the duo’s proposal about human cooperation, he says.

Bonobos may view those who impede others’ actions as socially dominant and thus worth grooming as allies, Krupenye says. Although bonobos readily share food, social pecking orders still affect the animals’ behavior.

The researchers showed 24 bonobos four animated videos featuring pairs of colored shapes, most depicted with a pair of eyes. In one video, a circle tries and fails to climb a hill until a “helper” triangle arrives and pushes the circle to the top. In a second video, a circle tries and fails to climb a hill before a “hinderer” square arrives and pushes the circle farther down the hill. In the other two videos, other shapes with eyes push an eyeless, unmoving circle up or down a hill.
After watching the first two videos, bonobos chose between paper cutouts of helper and hinderer shapes placed on top of small apple pieces. The same choice was presented for cutouts of shapes from the last two videos.

Snacks covered by hinderer shapes were chosen about 70 percent of the time by the 14 adult animals, ages 9 and older. Younger bonobos displayed no strong preference either way. Apes of all ages showed no partiality to either shape that had pushed inanimate circles.

Adult bonobos also reached more often for an apple piece offered by a human they had observed snatch a toy dropped by another person, versus a human they had seen return the toy.

In a final experiment, eight of 24 bonobos usually selected apple pieces covered by cutouts of an animated shape that the apes had seen win a contest with another shape to occupy a location. This result suggests that some bonobos’ strong preference for dominant individuals partly accounts for the newly reported fondness for hinderers, Krupenye says.

“The notion that bonobos approach the bully because they view that individual as more dominant is a very plausible interpretation,” says psychologist Felix Warneken of the University of Michigan in Ann Arbor. Warneken, who did not participate in the new study, studies cooperative behavior in human children and nonhuman apes.

Internist Gail Povar has many female patients making their way through menopause, some having a tougher time than others. Several women with similar stories stand out in her mind. Each came to Povar’s Silver Spring, Md., office within a year or two of stopping her period, complaining of frequent hot flashes and poor sleep at night. “They just felt exhausted all the time,” Povar says. “The joy had kind of gone out.”

And all of them “were just absolutely certain that they were not going to take hormone replacement,” she says. But the women had no risk factors that would rule out treating their symptoms with hormones. So Povar suggested the women try hormone therapy for a few months. “If you feel really better and it makes a big difference in your life, then you and I can decide how long we continue it,” Povar told them. “And if it doesn’t make any difference to you, stop it.”
At the follow-up appointments, all of these women reacted the same way, Povar recalls. “They walked in beaming, absolutely beaming, saying, ‘I can’t believe I didn’t do this a year ago. My life! I’ve got my life back.’ ”

That doesn’t mean, Povar says, that she’s pushing hormone replacement on patients. “But it should be on the table,” she says. “It should be part of the discussion.”

Hormone replacement therapy toppled off the table for many menopausal women and their doctors in 2002. That’s when a women’s health study, stopped early after a data review, published results linking a common hormone therapy to an increased risk of breast cancer, heart disease, stroke and blood clots. The trial, part of a multifaceted project called the Women’s Health Initiative, or WHI, was meant to examine hormone therapy’s effectiveness in lowering the risk of heart disease and other conditions in women ages 50 to 79. It wasn’t a study of hormone therapy for treating menopausal symptoms.

But that nuance got lost in the coverage of the study’s results, described at the time as a “bombshell,” a call to get off of hormone therapy right away. Women and doctors in the United States heeded the call. A 2012 study in Obstetrics & Gynecology showed that use plummeted: Oral hormone therapy, taken by an estimated 22 percent of U.S. women 40 and older in 1999–2000, was taken by fewer than 12 percent of women in 2003–2004. Six years later, the number of women using oral hormone therapy had sunk below 5 percent.
Specialists in women’s health say it’s time for the public and the medical profession to reconsider their views on hormone therapy. Research in the last five years, including a long-term follow-up of women in the WHI, has clarified the risks, benefits and ideal ages for hormone therapy. Medical organizations, including the Endocrine Society in 2015 and the North American Menopause Society in 2017, have released updated recommendations. The overall message is that hormone therapy offers more benefits than risks for the relief of menopausal symptoms in mostly healthy women of a specific age range: those who are under age 60 or within 10 years of stopping menstruation.

“A generation of women has missed out on effective treatment because of misinformation,” says JoAnn Pinkerton, executive director of the North American Menopause Society and a gynecologist who specializes in menopause at the University of Virginia Health System in Charlottesville. It’s time to move beyond 2002, she says, and have a conversation based on “what we know now.”

End of an era
Menopause, the final menstrual period, signals the end of fertility and is confirmed after a woman has gone 12 months without having a period. From then on she is postmenopausal. Women reach menopause around age 51, on average. In the four to eight years before, called perimenopause, the amount of estrogen in the body declines as ovarian function winds down. Women may have symptoms related to the lack of estrogen beginning in perimenopause and continuing after the final period.

Probably the best-known symptom is the hot flash, a sudden blast of heat, sweating and flushing in the face and upper chest. These temperature tantrums can occur at all hours. At night, hot flashes can produce drenching sweats and disrupt sleep.

Hot flashes arise because the temperature range in which the body normally feels comfortable narrows during the menopause transition, partly in response to the drop in estrogen. Normally, the body takes small changes in core body temperature in stride. But for menopausal women, the slightest uptick in degree can be a trigger for the vessels to dilate, which increases blood flow and sweating.

About 75 to 80 percent of menopausal women experience hot flashes and night sweats, on and off, for anywhere from a couple of years to more than a decade. In a study in JAMA Internal Medicine in 2015, more than half of almost 1,500 women enrolled at ages 42 to 52 reported frequent hot flashes — occurring at least six days in the previous two weeks — with symptoms lasting more than seven years.

A sizable number of women have moderate or severe hot flashes, which spread throughout the body and can include profuse sweating, heart palpitations or anxiety. In a study of 255 menopausal women, moderate to severe hot flashes were most common, occurring in 46 percent of women, during the two years after participants’ last menstrual period. A third of all the women still experienced heightened hot flashes 10 years after menopause, researchers reported in 2014 in Menopause.

Besides hot flashes and night sweats, roughly 40 percent of menopausal women experience irritation and dryness of the vulva and vagina, which can make sexual intercourse painful. These symptoms tend to arise after the final period.

Alarm bells
In the 1980s and ’90s, researchers observed that women using hormone therapy for menopausal symptoms had a lower risk of heart disease, bone fractures and overall death. Some doctors began recommending the medication not just for symptom relief, but also for disease prevention.

Observational studies of the apparent health benefits of hormone therapy spurred a more stringent study, a randomized controlled trial, which tested the treatment’s impact by randomly assigning hormones to some volunteers and not others. The WHI hormone therapy trials assessed heart disease, breast cancer, stroke, blood clots, colorectal cancer, hip fractures and deaths from other causes in women who used the hormones versus those who took a placebo. Two commonly prescribed formulations were tested: a combined hormone therapy — estrogen sourced from horses plus synthetic progesterone — and estrogen alone. (Today, additional U.S. Food and Drug Administration–approved formulations are available.)
The 2002 WHI report in JAMA, which described early results of the combined hormone therapy, shocked the medical community. The study was halted prematurely because after about five years, women taking the hormones had a slightly higher risk of breast cancer and an overall poor risk-to-benefit ratio compared with women taking the placebo. While the women taking hormones had fewer hip fractures and colorectal cancers, they had more breast cancers, heart disease, blood clots and strokes. The findings were reported in terms of the relative risk, the ratio of how often a disease happened in one group versus another. News of a 26 percent increase in breast cancers and a 41 percent increase in strokes caused confusion and alarm.

Women dropped the hormones in droves. From 2001 to 2009, the use of all hormone therapy among menopausal women, as reported by physicians based on U.S. office visits, fell 52 percent, according to a 2011 study in Menopause.

But, researchers say, the message that hormone therapy was bad for all was unwarranted. “The goal of the WHI was to evaluate the balance of benefits and risks of menopausal hormone therapy when used for prevention of chronic disease,” says JoAnn Manson, a physician epidemiologist at Harvard-affiliated Brigham and Women’s Hospital in Boston and one of the lead investigators of the WHI. “It was not intended to evaluate its role in managing menopausal symptoms.”

Along with the focus on prevention, the WHI hormone therapy trials were largely studies of older women — in their 60s and 70s. Only around one-third of participants started the trial between ages 50 and 59, the age group more likely to be in need of symptom relief. Hormone therapy “was always primarily a product to use in women entering menopause,” says Howard Hodis, a physician scientist who focuses on preventive medicine at the University of Southern California’s Keck School of Medicine in Los Angeles. “The observational studies were based on these women.”

Also lost in the coverage of the 2002 study results was the absolute risk, the actual difference in the number of cases of disease between two groups. The group on combined hormone therapy had eight more cases of breast cancer per 10,000 women per year than the group taking a placebo. Hodis notes that that absolute risk translates to less than one extra case for every 1,000 women, which is classified as a rare risk by the Council for International Organizations of Medical Sciences, a World Health Organization group. There was also less than one additional case for every 1,000 women per year for heart disease and for stroke in the hormone-treated women compared with those on placebo.

In 2004, researchers published results of the WHI study of estrogen-only therapy, taken for about seven years by women who had had their uteruses surgically removed. (Progesterone is added to hormone therapy to protect the uterus lining from a risk of cancer seen with estrogen alone.) The trial, also stopped early, reported a decreased risk of hip fractures and breast cancer, but an increased risk of stroke. The study didn’t change the narrative that hormone therapy wasn’t safe.

Timing is everything
Since the turn away from hormone therapy, follow-up studies have brought nuance not initially captured by the first two reports. Researchers were finally able to tease out the results that applied to “the young women — and I love saying this — young women 50 to 59 who are most apt to present with symptoms of menopause,” says Cynthia Stuenkel, an internist and endocrinologist at the University of California, San Diego School of Medicine in La Jolla.

In 2013, Manson and colleagues reported data from the WHI grouped by age. It turned out that absolute risks were smaller for 50- to 59-year-olds than they were for older women, especially those 70 to 79 years old, for both combined therapy and estrogen alone. For example, in the combined hormone therapy trial, treated 50- to 59-year-olds had five additional cases of heart disease and five more strokes per 10,000 women annually compared with the same-aged group on placebo. But the treated 70- to 79-year-olds had 19 more heart disease cases and 13 more strokes per 10,000 women annually than women of the same age taking a placebo. “So a lot more of these events that were of concern were in the older women,” Stuenkel says.

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A Danish study reported in 2012 of about 1,000 recently postmenopausal women, ages 45 to 58, also supported the idea that timing of hormone treatment matters. The randomized controlled trial examined the use of different formulations of estrogen (17β-estradiol) and progesterone than the WHI. The researchers reported in BMJ that after 10 years, women taking hormone therapy — combined or estrogen alone — had a reduced risk of mortality, heart failure or heart attacks, and no added risk of cancer, stroke or blood clots compared with those not treated.

These findings provide evidence for the timing hypothesis, also supported by animal studies, as an explanation for the results seen in younger women, especially in terms of heart disease and stroke. In healthy blood vessels, more common in younger women, estrogen can slow the development of artery-clogging plaques. But in vessels that already have plaque buildup, more likely in older women, estrogen may cause the plaques to rupture and block an artery, Manson explains.

Recently, Manson and colleagues published a long-term study of the risk of death in women in the two WHI hormone therapy trials — combined therapy and estrogen alone — from the time of trial enrollment in the mid-1990s until the end of 2014. Use of either hormone therapy was not associated with an added risk of death during the study or follow-up periods due to any cause or, specifically, death from heart disease or cancer, the researchers reported in JAMA in September 2017. The study provides reassurance that taking hormone therapy, at least for five to seven years, “does not show any mortality concern,” Stuenkel says.

Both the Endocrine Society and the North American Menopause Society state that, for symptom relief, the benefits of FDA-approved hormone therapy outweigh the risks in women younger than 60 or within 10 years of their last period, absent health issues such as a high risk of breast cancer or heart disease. The menopause society position statement adds that there are also benefits for women at high risk of bone loss or fracture.

Today, the message about hormone therapy is “not everybody needs it, but if you’re a candidate, let’s talk about the pros and cons, and let’s do it in a science-based way,” Pinkerton says.

Hormone therapy is the most effective treatment for hot flashes, night sweats and genital symptoms, she says. A review of randomized controlled trials, published in 2004, reported that hormone therapy decreased the frequency of hot flashes by 75 percent and reduced their severity as well.

More than 50 million U.S. women will be older than 51 by 2020, Manson says. Yet today, many women have a hard time finding a physician who is comfortable prescribing hormone therapy or even just managing a patient’s menopausal symptoms, she says.

Stuenkel, who says many younger doctors stopped learning about hormone therapy after 2002, is trying to play catch up. When she teaches medical students and doctors about treating menopausal symptoms, she brings up three questions to ask patients. First, how bothersome are the symptoms? Some women say “fix it, get me through the day and the night, put me back in order,” Stuenkel says. Other women’s symptoms are not as disruptive. Second, what does the patient want? Third, what is safe for this particular woman, based on her health? If a woman’s health history doesn’t support the use of hormone therapy, or she just isn’t interested, there are nonhormonal options, such as certain antidepressants, and also nondrug lifestyle approaches.

Menopause looms large for many women, Povar says, and discussing a patient’s expectations as well as whether hormone therapy is the right approach becomes a unique discussion with each patient, she says. “This is one of the most individual decisions a woman makes.”