The Healthy Heart Handbook for Women, Prevention A Personal

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	Prevention: A Personal Project

Preventing or controlling heart disease, by and large, means making changes in the way we live. For each individual, a healthy heart requires a personal action plan. But where does one begin? A complete medical checkup is a sensible first step, especially if you have multiple risk factors. Your doctor or other health professional can tell if you have cardiovascular disease or its risk factors, and if so, work out a practical treatment plan. Even if you don't have any risk factors now, you can discuss ways to lessen your chances of developing them.

Good communication with your health professional is very important. Choose someone you trust who will listen to your questions, answer them fully, and take your concerns seriously. (See "You and Your Doctor".)

But while advice from a health professional is important, the final responsibility for heart health lies with each woman. Only you can make the kinds of lifestyle changes--changes in eating, drinking, smoking, and physical activity--that will help protect against, or control, cardiovascular diseases. Remember, even if you have heart disease, you can help your heart become stronger and healthier.

To learn about the organizations and educational materials available to help you, see "Resources for a Healthy Heart." In the meantime, keep reading. The self-help suggestions that follow can help you get started on a personal program for a healthy heart.

To Do! The Healthy Heart Action Plan * Quit smoking * Cut back on foods high in fat, saturated fat, and cholesterol, and eat more fruits and vegetables * Check blood pressure and blood cholesterol levels * Be more physically active * Lose weight if you are overweight

Self-Help Strategies for a Healthy Heart Kicking the Smoking Habit There is nothing easy about giving up cigarettes. But as hard as quitting may be, the results are well worth it. One year after you stop smoking, your risk of coronary heart disease will drop by more than half. Within several years, it will approach, the heart disease risk of someone who has never smoked. This means that no matter what your age, quitting will lessen your chances of developing coronary heart disease. Meanwhile, for those who now have heart disease, giving up cigarettes lowers the risk of a heart attack. Quitting also reduces the risk of a second heart attack in women who have already had one.

Quitting will also save you money. Over 10 years, a two-pack-a-day smoker can spend more than $10,000 on cigarettes. And that price tag doesn't take into account the extra costs of smoking-related illnesses, such as doctors' bills, medicines, and lost wages.

Take some time to think about other benefits of being an ex-smoker. In addition to reducing your chances of heart attack and stroke, quitting will lessen your chances of developing lung cancer, emphysema and other lung diseases; result in fewer colds or flu each year; and give you more energy to pursue the physical actitivities you enjoy. In addition, if you have children living at home, they are likely to have fewer coughs, colds, and earaches once you stop smoking.

Take a few minutes now to write down all of the reasons you want to quit. Understanding what you and your family have to gain from quitting is an important first step in kicking the smoking habit.

GETTING READY TO QUIT

Once you decide to stop smoking, a few preparations are in order. Set a target date for quitting -- perhaps the first day of a month. Don't choose a time when you know you will be under a lot of stress. To help you stick to your quit date, you might want to write a brief contract that states your intention to quit, your quitting date, and some ways you plan to reward yourself for becoming an ex-smoker. Have someone sign it with you.

Consider asking your contract cosigner -- or another friend or family member -- to give you special support in your efforts to quit. Plan to get in touch with your supporter regularly to share your progress and to ask for encouragement. Give your "cheerleader" a copy of your list of reasons so that he or she can remind you of your goals. If possible, quit with a spouse or friend.

A Weighty Concern

Many women fear that if they stop smoking they will gain unwanted weight. But most ex-smokers gain less than 10 pounds. Weight gain may be partly due to changes in the way the body uses calories after smoking stops. Also, some people eat more when quitting because they substitute high-calorie food for cigarettes. Choosing more lower-calorie foods and increasing your level of physical activity can reduce the amount of weight you gain. If you do gain some weight, you can work on losing it after you have become comfortable as a nonsmoker. When you think about the enormous health risks of smoking, the possibility of putting on a few pound on a few pounds is not a reason to continue.

Three Aids for Quitting

As you prepare to quit smoking, give serious consideration to using a nicotine aid to help you stay off cigarette. Three products --nicotine gum, a nicotine patch, and a nicotine nasal spray -- can help you successfully quit by lessening your withdrawal symptoms. The gum and patch are now available over the counter, while the nasal spray is available only by prescription. However, nicotine aids are not for everyone. Pregnant women, nursing mothers, and people with serious heart problems cannot use them safely. Talk with your doctor about whether you should try any of these aids.

Breaking the Habit

* Surviving "Day One." On the evening before your quit day, "clean house." Throw away all cigarettes, matches, and lighters, and give away your ashtrays. Plan some special activities for the next day to keep you busy, such as a long walk or an outing with a friend. Ask family members and friends not to offer you cigarettes or to smoke in front of you. Your goal is to get through that first important day smoke-free. If you succeed on the first day, it will help give you the confidence to succeed on the second--and on each day after that.

* Know yourself. To quit successfully, you need to know your personal smoking "triggers." These are the situations and feelings that typically bring on the urge to light up. Some common triggers include drinking coffee, finishing a good meal, watching television, having an alcoholic drink, talking on the phone, or watching someone else smoke. Stress can also be a trigger. Make a list of the situations and feelings that particularly tempt you to smoke. Especially during the first weeks after quitting, try to avoid as many triggers as you can.

* Find new habits. Replace "triggers" with new activities that you don't associate with smoking. For example, if you always had a cigarette with a cup of coffee, switch to tea for awhile. If you always smoked at the table after dinner, get up as soon as the meal is over and go out for a walk. If you're feeling tense or angry, try a relaxation exercise such as deep breathing to calm yourself. (Take a slow, deep breath, count to five, and release it. Repeat 10 times.)

* Keep busy. Get involved in projects that require you to use your hands, such as needlework and jigsaw puzzles. When you feel the urge to put something in your mouth, have low-calorie substitutes on hand, such as vegetable sticks, apple slices, or sugarless gum. Some people find it helpful to inhale on a straw or chew on a toothpick until the urge passes.

* Be physically active. Walk, garden, or bicycle. Physical activity will make you feel better and help prevent weight gain.

* Know what to expect. During the first few weeks after quitting, you may experiences some temporary withdrawal symptoms, such as headaches, irritability, tiredness, constipation, and trouble concentrating. These symptoms may come and go, and be stronger or weaker on different days. While these feelings are not pleasant, it is important to know that they are signs that your body is recovering from smoking. Most symptoms end within 2 to 4 weeks.

* Help is available. A number of free or low-cost programs available to help you stop smoking. They include programs offered by local chapters of the American Lung Association and the American Cancer Society. Other low-cost programs can be found through hospitals, health maintenance organizations (HMOs), workplaces, and community groups. Some programs offer special support for women.

* Be good to yourself. Get plenty of rest, drink lots of fluids, and eat three balanced, healthful meals per day. If you are not as productive or cheerful as usual during the first several weeks after quitting, don't feel guilty. Give yourself a chance to adjust to your new nonsmoking lifestyle. Ask your friends and family to give you lots of praise for kicking the habit--and don't forget to pat yourself on the back. You are making a major change in your life, and you deserve a lot of credit.

If You "Slip"

A slip means that you have had a small setback and smoked a cigarette after your quit date. Most smokers slip three to five times before they quit for good. But to get right back on the nonsmoker track, here are some tips:

* Don't get discouraged. Having a cigarette or two doesn't mean you can't quit smoking. A slip happens to many, many people who successfully quit. Keep thinking of yourself as a nonsmoker. You are one.

* Learn from experience. What was the trigger that made you light up? Were you driving home from work, having a glass of wine at a party, feeling angry at your boss? Think back on the day's events until you remember what the specific trigger was.

* Take charge. Make a list of things you will do the next time you are in the particular situation--and other tempting situations as well. Sign a new contract with your support person to show yourself how determined you are to kick the habit. Reread your list of all the reasons you want to quit. You're on your way.

Becoming Physically Active

Regular exercise can help you reduce your risk of coronary heart disease. Staying active helps take off extra pounds, helps to prevent and control blood pressure, boosts the level of "good" HDL-cholesterol, and helps to prevent diabetes. Some studies show that inactive people are more likely to have heart attacks.

For those who have heart disease, regular, moderate physical activity lowers the risk of death from heart-related causes. However, if you have heart diesase, check with your doctor first to find out what kinds of activities are best for you.

Physical activity has many other benefits. It strengthens the lungs, tones the muscles, keeps the joints in good condition, improves balance, and helps many people cope better with stress and anxiety.

Older women, in particular, can benefit from physical activities that strengthen bones and promote coordination and balance. Exercises such as T'ai Chi can improve balance and may be done alternately with healthy-heart physical activities. The National Institute on Aging has a list of physical activities that are particularly helpful for older individuals.

The good news is that to reap benefits from physical activity, you don't need to train for a marathon. You need only engage in about 30 minutes per day of moderate-level activity on most --and preferably all--days.

Some examples of everyday activities that can improve heart health are brisk walking, bicycling, housecleaning, raking leaves, and gardening. You can engage in any of these activities for 30 minutes at one time, or you can do them in shorter periods of at least 10 minutes each, as long as you total approximately 30 minutes per day.

It is important to know that the people likely to reap the most health benefits are those who are just starting to become physically active. If you have not been physically active until now, gradually build up to approximately 30 minutes per day of moderate-level activity.

If you are already engaging in this recommended level of physical activity, you may receive extra health and fitness benefits from doing these activities for a longer period each day, or by becoming involved in more vigorous activity.

Some people should get medical advice before starting a program of physical activity. for example, if you have heart trouble or hace had a heart attack, if you are over 50 years old and are not used to moderate energetic activity, or if you have a family history of developing heart disease at an early age, check with your doctor before you start.

Once you get started, keep these guidelines in mind:

* Go slow. Before each activity session, allow a 5-minute period of stretching and slow movement to give your muscles a chance to warm up. At the end of your activity, take another 5 minutes to "cool down" with a slower, less energetic pace.

* Listen to your body. A certain amount of stiffness is normal at first. but if you hurt a joint or pull a muscle or tendon, stop the activity for several days to avoid more serious injury. Most minor muscle and joint problems can be healed by rest and over-the-counter painkillers.

* Pay attention to warning signals. While physical activity can strengthen your heart, some types of activity may worsen existing heart problems. Warning signals include sudden dizziness, cold sweat, paleness, fainting, or pain or pressure in your upper body just after engaging in physical activity. If you notice any of these signs, call your doctor immediately.

* Keep at it. Unless you have to stop your program of physical activity for a health reason, stay with it. If you feel like giving up because you think you're not going as fast or as far as you "should," set smaller, short-term goals for yourself as well as grander ones. If you find yourself becoming bored, try engaging in an activity with a friend. Or switch to another activity. The health rewards of regular, moderate-level physical activity are well worth the effort.

Eating for Health

The health of your heart has a lot to do with the food you eat. Following the "Dietary Guidelines for Americans" lessens your risk of heart disease in three ways:

* It helps reduce high blood cholesterol levels.

* It helps control high blood pressure.

* It helps take off extra pounds.

As a bonus, the kinds of eating habits that are good for your heart may also help prevent cancer and a number of other health problems.

Lowering Blood Cholesterol

Reducing your blood cholesterol level can greatly lessen your chances of developing heart disease. For those who have heart disease, lowering blood cholesterol is still more important. If you have angina or have had a heart attack, keeping your blood cholersterol low will help lessen your risk of having a future heart attack and may well prolong your life.

In general, each 1 percent reduction in blood cholesterol produces a 2 percent reduction in the risk of a heart attack. This means that if you lower your blood cholesterol by 25 percent, you may cut your risk of heart attack in half.

For most people, blood cholesterol can be lowered by being more physically active, maintaining a healthy weight, and by eating less saturated fat, total fat, and cholesterol. Use the guide in the "Meal Planning:A Change of Heart" section. However, the particular diet tat will work best for you depends on your current health status. Here are some specific guidelines for heart-healthy eating:

The eating pattern recommended for healthy Americans who do not have a cholesterol problem that needs a doctor's attention is:

* Less than 10 percent of day's total calories. from saturated fat.

* 30 percent or less of the day's total calories from fat.

* Less than 300 mg of dietary cholesterol per day.

If you have high blood cholesterol, your doctor will first prescribe a diet similar to the one above, but have you take special care to limit calories from saturated fat to 8-10 percent of the day's calories. If you follow this Step I eating pattern for about 3 months and your blood cholesterol does not drop enough, you may need to cut back still more on satureated fat and cholesterol and follow a step II eating pattern.

If you have heart disease, you will need to adopt an eating pattern that is especially low in saturated fat and cholesterol. Specifically, you should follow the Step II diet:

* Less than 7 percent of the day's total calories from saturated fat.

* 30 percent or less of the day's total calories from fat.

* Less than 200 milligrams of dietary cholesterol a day.

When starting the Step II diet, you should get help from a registered dietitian or other qualified nutrionist.

Fat-Finding

Now, let's get practical. Which fats are found in which foods?

* Saturated fat is found mainly in foods that come from animals. Whole-milk dairy products such as butter, cheese, milk, cream, and ice cream all contain high amounts of saturated fat. The fat in meat and poultry skin is also loaded with saturated fat. A few vegetable fats--coconut oil, cocoa butter, palm kernel oil, and palm oil--are also high in saturated fat. These fats are sometimes found in cookies, crackers, coffee creamers, whipped toppings, and snack foods. Because fats are invisible in many foods, it is very important to read food labels. Remember: Saturated fat boost you blood cholesterol level more than anything else in your diet. Eating less saturated fat is the best way to lower your blood cholesterol level.

* Unsaturated fat does not raise blood cholesterol levels, but like all fats it has 9 calories a gram. One type of polyunsaturated fat, which is found in many cooking and salad oils, such as safflower, corn, soybean, cottonseed, sesame, and sunflower oils, and in some margarines. Another type is monounsaturated fat, which is found in olive canola, and peanut oils.

* Cholesterolis found only in foods that come from animals. Egg yolks and organ meats (liver, for example) are very high in cholesterol. Meat and poultry have similar amounts of cholesterol. Eating less cholesterol will help lower blood cholesterol levels in most people.

Now You're Cooking

Planning and cooking meals aimed at reducing blood cholesterol don't have to be complicated. Here are some suggestions:

* Choose fish, poultry, and lean cuts of meat, and remove fat from meats and skin from chicken before eating. Eat up to 6 ounces per day.

* Broil, bake, roast, or poach foods rather than fry them.

* Cut down on sausage, bacon, and processed high-fat cold cuts.

* Limit organ meats such as liver, kidney, or brains.

* Instead of whole milk or cream, drink skim or 1 percent milk. Try nonfat low fat yogurt in place of sour cream. Use nonfat low fat cheeses. Sherbet and nonfat or low fat frozen yogurt can be delicious replacements for ice cream.

* Instead of butter, use liquid or tub margarine or liquid vegetable oils high in poly or mononsaturated fats. All fats and oils should be used sparingly.

* Eat egg yolks only in moderation. Egg whites contain no fat or cholesterol and can be eaten often. In most recipes, substitute two egg whites for one whole egg.

* Eat plenty of fruits and vegetables, as well as cereals, breads, rice, and pasta made from whole grains (for example, rye bread, whole wheat spaghetti, bran cereal). These foods are good sources of starch and fiber, and usually contain no cholesterol and little or no saturated fat.

* Liquid vegetable oils are a good choice for sautéing vegetables, browning potatoes, popping corn, and for making baked goods, pancakes, and waffles. Use small amounts. or try using a vegetable oil cooking spray.

* Many store-bought baked goods, snacks, and other prepared foods have hidden saturated fats because they are made with hydrogenated vegetable oils, or palm kernal or coconut oil. They may also contain lard, butter, or cream. Get in the habit of reading product labels, and choose products that are lowest in fat and saturated fat. New baked goods have been developed that contain no cholesterol and very little fat. But keep in mind that they may still be high in calories.

For more meal ideas, see "Recipes for a Healthy Heart" and "Meal Planning: A Change of Heart" at the back of this book.

EATING SMART AWAY FROM HOME

Following a heart-healthy diet is a bit more challenging when you're away from home, but there are many ways to eat right when eating out. Choose restaurants that have low fat, low cholesterol menu choices, and ask that gravy, butter, and rich sauces be served on the side. If the restaurant offers a salad bar, load up on vegetables and limit food such as eggs, bacon, and cheese. Go easy on the salad dressing, and choose low-calorie types when they are offered.

Even at fast-food restaurants, you can make healthy choices. Choose grilled (not fried or breaded) chicken sandwiches, regular-sized hamburgers, or roast beef sandwiches. When ordering pizza, ask for vegetable, toppings such as green pepper, onions, and mushrooms, instead of meat toppings and extra cheese.

PREVENTING AND CONTROLLING HIGH BLOOD PRESSURE

More than half of American women will develop high blood pressure at some point in their lives. Women who have the highest risk include those who are African American, have a family history of high blood pressure, are overweight, or have "high-normal" blood pressure. (130-139 over 85-89 mmHg). Blood pressure tends to get higher as you age - but it need not. By taking preventitive steps, a healthy blood pressure can be maintained throughout life.

Especially if you have heart disease, controlling high blood pressure will improve your health. For example, women who have had a heart attack are less likely ot have another one if they take steps to reduce high blood pressure.

To prevent high blood pressure-- or to help control blood pressure if it is now too high -- take these steps:

* Lose weight, if you are overweight.

* If you drink alcohol, have no more than one drink per day--that means no more than 12 ounces of beer, 5 ounces of wine, or 1 1/2 ounces of hard liquor.

* Try to engage in 30 minutes of moderate physical activity on most or all days of the week. Physical activity also helps weight control and is good for your entire cardiovascular system.

* Use salt and sodium in small amounts, if at all.

* If your doctor prescribes medication, be sure to take it exactly as directed. High blood pressure medicine must be taken in the right amounts and at the right times in order to work properly.

Losing Weight: Four Ways to Win

If you are overweight, taking off pounds can lower the chances of developing cardiovascular disease in several ways. First, since overweight raises the risk of heart disease, losing weight will directly lower your risk. Secondly, weight loss will also help control diabetes. Third and fourth, shedding pounds can lower both high blood pressure and cholesterol. In fact, for some people, weight loss along with other dietary changes may be the only treatment needed. But even if medication is required, for one of the above conditions, the healthier your weight, the less medication you may need.

In a society so concerned about thinness, it may be hard to listen to yet more advice about the need to take off pounds. But too often, women are pressured to lose too much weight and for the wrong reasons: to look better in trendy clothes, to attract male attention, to have today's super-slim athletic look. The aim here is not to promote the false and discouraging idea that "thin is beautiful," but to show the link between reasonable weight and good health--especially the health of your heart. Weight loss is advised only to reach a healthy weight, not to drop to an extreme level.

Taking off pounds, and especially keeping them off, can be quite a challenge. Here are some suggestions for making weight loss an easier, safer, and more successful process:

*Eat for health. Choose a wide variety of low-calorie, nutritious foods in moderate amounts from the basic food groups. Include pasta, rice, bread, and other whole-grain foods, and fruits and vegetables -- and other foods low in fat, since fat is the richest source of calories. But keep in mind that while more low-saturated fat food products are now available, many of them are still loaded with sugar and therefore high in calories. To make every calorie count,cut down on snack foods that are high in calories but provide few other nutrients.

*Make a plan. If you have a lot of weight to lose, ask your doctor, a registered dietitian, or a qualified nutritionist to help you develop a sensible, well-balanced plan for gradual weight loss. To lose weight you will need to take in fewer calories than you burn. That means that you must either choose food with fewer calories or become more physically active--and preferably, do both.

*Take if slowly. The safest course is to take off weight gradually -- no more than 1/2 to 1 pound per week. Don't think of weight control as a quick fix, but as a healthful, lifelong habit.

*Keep milk on the menu. Don't cut out dairy products in trying to reduce calories and fat. Dairy products are rich in calcium, a nutrient that is particularly important for women. Instead, choose non- or low fat dairy products. For instance, if you are used to drinking whole milk, gradually cut back to 2 percent milk, move to 1 percent, and then to skim milk. This way the calories are reduced while the amount of calcium remains the same. There are other ways to keep up your calcium. Try canned fish with soft bones, such as salmon and sardines, dark green leafy vegetables, broccoli, tofu processed with calcium sulfate, and tortillas made with lime-processed corn.

*Beyond dieting. To keep the pounds off, change your basic eating habits rather than simply "go on a diet." Keep a food diary of what, when, and why you eat to help you understand your eating patterns and what affects them. Learn to recognize social and emotional situations that trigger overeating and figure out ways to cope with them. Set short-term goals at first.

*Forget the fads. Tempting as their promises are, fad diets are not the answer. Most provide poor nutrition and cause a many side effects, especially those with less than 800 calories. a day. Although fad diets can give quick and dramatic results, much of the weight loss is due to water loss. The weight returns quickly once you stop dieting.

*Get a move on. Physical activity can help burn calories, tone muscles, and control appetite. (It also gives you something to do when you feel that familiar urge for a slice of chocolate fudge cake.) Even moderate activity, such as brisk walking, will burn up calories and help control weight.

*Ask for support. Tell your family and friends about your weight loss plans and let them know how they can be most helpful to you. You might also want to join a self-help group devoted to weight control. These groups provide support and practical suggestions on changing eating habits and long-term weight loss.

Hormones and Menopause

Should menopausal women use "hormone replacement therapy"?

There is no simple answer to this question.

Menopause is caused by a decrease in estrogen produced by a woman's ovaries. It happens naturally in most women between the ages of 45 and 55, and it also occurs in women of any age whose ovaries are removed by an operation.

As estrogen levels begin to drop, some women develop uncomfortable symptoms such as "hot flashes" and mood changes. Hormone replacement therapy (HRT) --a term for prescription hormone medications -- can be used to relieve these symptoms. Some women are prescribed medication that contain only estrogen. Others take estrogen combined with a second hormone called progestin, a synthetic form of progesterone.

HORMONE THERAPY AND HEART HEALTH

The latest research indicates that HRT may have important heart benefits for women after menopause. The National Institutes of Health supported a study on HRT called the Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. It studied postmenopausal women who took one of four kinds of hormone therapy -- a daily dose of estrogen alone, daily estrogen plus daily progestin, daily estrogen plus progestin 12 days per month, and daily estrogen plus progesterone 12 days per month. The most important results include:

*All four treatments raised levels of HDL, or "good" cholesterol. The best results occurred with the estrogen-only and estrogen-plus-progesterone treatments.

*All four treatments lowered levels of LDL, or "bad" cholesterol. Each treatment lowered LDLs by about the same amount.

*All four treatments lowered levels of fibrinogen. Fibrinogen is a substance in the blood that allows clots to form more easily, which in turn increases the risk of heart attack and stroke.

*None of the hormonal treatments increased blood pressure, caused weight gain, or changed insulin levels.

*All of the treatments caused a rise in triglyceride levels, which are fatty substances carried through the blood to the body's tissues. Their link to heart disease risk is unclear.

OTHER HEALTH BENEFITS

In addition to the effects of HRT on heart disease risk factors reported by the PEPI study, other research has found that hormone therapy helps to prevent osteoporosis, a thinnning of the bones that makes them more likely to break in later life. As women age, they lose mineral density in their bones, This loss is believed to happen most rapidly during early menopause, but to continue more slowly after that.

The PEPI study found that all of the hormonal treatments increased bone density, regardless of a woman's ethnic or racial background, alcohol intake, weight, degree of physical activity, or whether she had undergone a hysterectomy. The hormone treatments were particularly helpful for smokers, who lost bone mass more quickly than nonsmokers if they did not use HRT.

The researchers concluded that HRT can slow the bone loss associated with menopause, as well as increase bone mass, a decade and more after menopause.

THE RISKS OF HORMONE THERAPY

The PEPI study also reported one troubling result: The estrogen-only treatment caused several types of hyperplasia, which are abnormal cell growths in the lining of the uterus. The most serious type, called atypia, increases the risk of uterine cancer. One-third of women with a uterus who took estogen alone developed either atypia or a less serious type of hyperplasia. Women who had had a hysterectomy, which is the surgical removal of the uterus, could not develop hyperplasia.

While the PEPI study could not examine breast cancer risk, some other research suggests tat HRT may be linked to a small increased risk of breast cancer, especially among women who have used hormone therapy for 5 or more years. Other research suggests that hormone replacement therapy also may increase the likelihood of headaches, including migraines, in some women.

also reported one troubling result: The estrogen-only treatment caused several types of hyperplasia, which are abnormal cell growths in the lining of the uterus. The most serious type, called atypia, increases the risk of uterine cancer. One-third of women with a uterus who took estogen alone developed either atypia or a less serious type of hyperplasia. Women who had had a hysterectomy, which is the surgical removal of the uterus, could not develop hyperplasia.

SHOULD YOU USE HORMONE REPLACEMENT THERAPY?

Together with your doctor, you must decide whether the benefits of hormone therapy are worth the risks. Keep in mind that women are much more likely to die of heart disease than from uterine, breast, and ovarian cancers combined. Nonetheless, if you are considering HRT, you will need to consider your own particular health needs as well as your personal and family history of heart disease; uterine, breast, and ovarian cancers; and osteoporosis.

*If you have not had a hysterectomy, consider taking a therapy that combines estrogen with progestin, or estrogen with natural progesterone. If you decide to take estrogen alone, you should have a yearly examination of your uterine lining because of the risk of hyperplasia.

*If you have had a hysterectomy, there is no benefit in adding a progestin. Estrogen alone appears to be the best choice. Since your uterus has been removed, using estrogen alone poses no risk of abnormal changes in the uterine lining. Also, the addition of a progestin will not increase bone density more than estrogen alone.

When choosing a particular type of hormone replacement therapy, postmenopausal women and their health care providers should consider these guidelines:

IF YOU DECIDE TO USE HRT

If your decision to use HRT is related to an expected improvement in cholesterol levels, you should have your total, HDL, and LDL cholesterol levels measured before you begin hormone therapy. You can then compare those numbers with those of later tests to help you determine the effects of hormone therapy on your cholesterol levels.

Every 6 to 12 months, you and your doctor should discuss whether you need to continue treatment. Be alert for signs of trouble, particularly abnormal bleeding, extreme dizziness, or severe headaches. While these symptoms could be caused by factors other than HRT, you should report them immediately in any case. See your doctor at least once a year for a complete physical examination.

ASPIRIN

The research on aspirin is promising: This well-known "wonder drug" may help to both prevent and treat heart attacks.

A study of more than 87,000 women found that those who took a low dose of aspirin regularly were less likely to suffer a first heart attack than women who took no aspirin. Women over age 50 appeared to benefit most. While earlier research has shown that aspirin can help prevent heart attacks in men, this was the first study to suggest a similar result for women.

Other recent research suggests that only a tiny daily dose of aspirin may be needed to protect against heart attacks. One study found that for both women and men, taking only 30 mg of aspirin daily--one-tenth the strength of a regular aspirin--helped prevent heart attacks as effectively as the usual 300 mg dose. The smaller dose also caused less stomach irritation.

Aspirin also reduces the chances that women who have already had a heart attack or stroke will have, or die from, another one. Aspirin may also increase the chances of survival after a heart attack, if it is taken quickly. A major study showed that taking a low dose of aspirin within the first hours of an attack reduced deaths by 23 percent.

However, you should not take aspirin either to treat or prevent a heart attack without first discussing it with your doctor. Aspirin is a powerful drug with many side effects. It can increase your chances of getting ulcers, kidney disease, liver disease, and stroke from a hemorrhage. Only a doctor who knows your complete medical history and current health can judge whether the benefits you may gain from aspirin outweigh the risks.

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