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WHAT’S HAPPENING?  WHAT DO I DO?
A GUIDE TO MENOPAUSE
by Geoffrey Redmond, MD

WHAT IS MENOPAUSE?

Quick Reference
What is Menopause?
When does menopause happen?
How Menopause Feels
What is HRT?
Surviving  – and thriving – during menopause
The big question: HRT
HRT and Breast Cancer
HRT and Contemporary Lifestyles
The HRT Option
How is HRT taken:
The different forms of estrogen:
Estrogen as a skin patch:
The splendors and miseries of progesterone
What are SERMs?
If you've had a hysterectomy
Deciding about YOUR Menopause
I'm on HRT but I don't feel any better

Conclusion

The term “menopause” means the end of menstruation but what happens is much more than this. Menopause is a life passage whose approach often stirs apprehension. Yet the meaning of menopause has changed. The first thing to realize is that menopause is simply a decrease in estrogen; the idea that it is the equivalent of getting old is obsolete. While menopause used to mean withdrawal from active life for many women, this is fortunately no longer true. Yet women still worry about what will happen and what they should do when menopause arrives. And menopause often does bring considerable discomfort. Very effective treatments are available but require decisions to be made which are difficult ones for many women. For some, choosing the right treatment is almost as difficult as putting up with the symptoms themselves.

This article is intended to help in understanding what happens to a woman’s body at this time and also to prove that menopause need not take away achievement – or enjoyment. Women at this life stage may need to do things to keep their body feeling its best but there are many options; one is likely to be right for you. It may involve taking hormones but it may not.

All women’s ovaries eventually stop working because their supply of eggs becomes depleted (why we don’t know) as are the granulosa cells which make estrogen. It used to be imagined that menopause was a sudden event. One day the last egg was used up, two weeks later you had your last period and then you were in menopause. This picture does not describe what the experience of menopause is actually like. The ovary does not shut off suddenly but slows down gradually over a period of several years. The term “perimenopause” refers to this interval when symptoms have started but periods have not yet stopped. However menopause does hit suddenly when the ovaries are removed surgically. Fortunately there are ways to ease this abrupt transition.

In the lead up to menopause, referred to as perimenopause, the function of the ovary tends to be less consistent. Periods may come some months but not others. The hormonal swings in perimenopause are greater than at any other time in a woman’s life, even greater than in adolescence. If hormones are not quite as hard to deal with as they were in the teens, it is because by her forties, a woman has learned to live with them.

Menopause also marks the end of fertility and when it comes early can be a disappointment. But for women not wishing to conceive, reaching the forties or having occasional hot flashes does not necessarily mean contraception is no longer necessary. Deciding when contraception is no longer needed can be dicey. It is something to be careful about because many unwanted pregnancies occur when women are in their forties. It is hard for me to give guidelines here because they can all have exceptions. Generally, a physician can tell this based on your history, examination or blood tests.

When does menopause happen?
The average age when menstruation stops is supposedly 52 but any age after forty is considered normal and for a few women menopause occurs in their late thirties. However if periods stop before the mid forties, it is important to have a medical evaluation to find out the cause. Menopause also occurs when the ovaries are removed surgically or are damaged as can happen with some forms of chemotherapy.

Hot flashes are due to brief over-activity of the autonomic nervous system and often indicate that menopause is approaching. An occasional hot flash can occur without any hormonal trigger. This is like blushing and can be normal; it is particularly common in fall and spring with sudden temperature changes.

HOW MENOPAUSE FEELS
There is no question that the profound hormone changes of menopause make women feel different. For most women, menopause simply does not feel good. Many of these symptoms are so subtle as to be difficult to describe. As a result they were once dismissed as imaginary. We now know that they are very real and are the direct result of falling estrogen levels.

Here are some of the most common symptoms:

Body:
Changes – and eventual stopping of the menstrual cycle
Hot flashes and night sweats
Insomnia
Vaginal dryness – the vaginal tissues also become thinner and less blood flows through them. Sexual arousal may overcome these changes but not always.
Skin sensitivity – many previously unnoticed sensations like combing one’s hair can become uncomfortable.
Weight gain

Feelings:
Mood swings
Depression
Thinking slowed
Slight difficulty in memory 

I don’t want this to sound grim. Often these changes are mild and few women are so unlucky as to get all of them. However it is important to recognize them for what they are – specific effects of loss of estrogen – since even in this day and age they are still sometimes dismissed as “all in your head.”

WHAT IS HRT?
I’ll have a lot more to say more as we go on but since I’ll be using this abbreviation a lot I need to give you the definition here at the beginning. HRT is hormone replacement therapy. The hormones in question are estrogen and progesterone, which are the two female hormones. It is referred to as “replacement” because the idea is to give the body back something it should make but is now unable to. Other hormones, the thyroid for example, sometimes need to be replaced but the term HRT always refers to replacing the female hormones. Women who’ve had a hysterectomy  usually take estrogen only; this is referred to as ERT, for “estrogen replacement therapy”.

The decision as to whether or not to use HRT is a difficult one for many women. I’ll do my best to cover the factors you need to consider to arrive at a decision you will be comfortable with.

SURVIVING – AND THRIVING – DURING MENOPAUSE
Despite the problems menopause brings, the years afterwards are the most productive and satisfying for many women. It is worth repeating, Menopause does not mean getting older; it just means your estrogen levels are lower. In past generations the usual reaction was resignation but now there are many things that you can do about it.

What can you do about menopause. First, let go of whatever pessimism you’ve heard. Menopause is a challenge but need not be an overwhelming one. A menopause program is drawn from the four areas of lifestyle, nutrition, supplements and herbs and (sometimes) prescription medications.

Lifestyle: Menopause resets women’s thermostats. Often someone who has felt cold most of her life, starts to feel hot. Now it’s her husband, not her, who wants to turn up the thermostat. If this is happening, it’s best just to accept it. Your wardrobe may have to change toward lighter clothes and perhaps, if you can persuade your family to accept a cooler house temperature, they may need more sweaters. If you have night sweats, you may have to be prepared to change nightgowns during the night.

Exercise is just as valuable at this life stage as it is before. The better shape you keep yourself in , the better you will feel. However, exercise while good for you, will not take all symptoms away, nor will it completely protect your bones.

Nutrition:  Some women tend to flush when they eat spicy foods. If so, you may need to avoid these or save them for situations in which sweating and flushing will not be embarrassing, for example, when you are having lunch with your best friend who is having the same experience.

Adequate calcium is key. Too little calcium can make bone loss worse. You need about 1,500 mg of calcium daily. Calcium citrate is a good choice. Also, your body cannot absorb calcium unless it has enough vitamin D. You need 600 to 800 units a day - more than used to be thought. You can get this by taking two rather than one multiple vitamins a day or by getting calcium tablets which have D in them.

Nutrition is essential for maintaining bone health but not always sufficient by itself. Some women continue to lose bone despite adequate calcium and D intake and regular exercise.

Supplements and vitamins: However there are some alternative possibilities to try first. One is soy. Lately some have tried to cast doubt on its safety but this is part of the prejudice in our culture against using nutrition to prevent disease. Considering that Japanese women eat gobs of the stuff and are among the world’s healthiest with very low rates of breast cancer, it must be doing something good. However you need real soy, not capsules or powders, many of which do not have the healthy substances in them. Two ways to get it are tofu (1 ounce per day) and fresh soy milk ( one glass per day); both are available in dairy areas of supermarkets.

Various herbs have been tried for hot flashes; the best studied is black cohosh. There is also good evidence that soy can  the edge off hot flashes and other symptoms. Both can be used in combination. The herbal approach gives adequate relief for some but not for all. Or it may work better at first when your ovaries are still making some estrogen. They seem to work best for women whose symptoms are relatively mild but that does not mean you shouldn’t try them if your symptoms are more severe. You probably need to use them consistently for at least two months to see how well they will work for you.

When these measures are not enough by themselves, HRT becomes a consideration.

THE BIG QUESTION: HRT
Let’s look at reasons for considering HRT and then look at the major issue: breast cancer.

It is helpful to keep in mind that there are two kinds of benefits from HRT — immediate, and long term. The long term benefits are probable decreases in the risk of heart disease, osteoporosis, colon cancer and Alzheimer’s disease. However estrogen is not the only medication available to protect heart and bones.

What estrogen does that other medications cannot is to relieve symptoms and restore well-being. Unpleasant effects of estrogen deficiency which replacement can relieve include hot flashes, night sweats, insomnia, vaginal dryness and more subtle but just as real changes such as skin discomfort and mood swings.

A few women do not find their well-being restored by estrogen. Generally this happens when the treatment is not adjusted to her individual needs. Fortunately many forms of estrogen and progesterone are available and so customized regimens can be developed for women who are hormonally vulnerable. But before I go into the details, I want to take up the issue which is on everyone’s mind.

HRT and Breast Cancer
At the heart of women’s uncertainty about HRT is the vital question of whether it increases the risk of breast cancer. There have been many studies attempting to answer this question but they simply do not agree. The studies finding an association get the most attention but there are many studies which have not found any increase. Let’s look at the worst case interpretation first. These studies find an increased risk overall of about 30% starting after five years on HRT. However, breast cancer found in women on HRT has a better prognosis -- one theory is that there is not more breast cancer but that it is diagnosed earlier. This means that breast cancer found in women on estrogen is more likely to be curable – but it does not guarantee that it will be.

Not long ago, I attended a medical symposium at which one speaker got up and said “There is now no doubt, HRT increases the risk of breast cancer”. At a later session, a different speaker got up and said, “There is now no doubt, HRT does not increase the risk of breast cancer”. If the experts do not agree, how can women decide who is correct? Obviously no one can. The honest answer is: “There is no doubt that we do not know if HRT increases the risk of breast cancer.” No one likes to admit that we don’t know something so important. But I think it is better to be up front about the limits of our knowledge.

Given this uncertainty, how can a woman make a decision? There are certain considerations which do help. First, studies suggest that because HRT does have health benefits, on average it increases women’s life spans by about a year. Some experts question the way the studies were done but no study has shown a decrease in lifespan. HRT decreases the risk of osteoporosis, and colon cancer. Most evidence suggests that it reduces overall heart disease risk but not in women who have already had a heart attack and possibly not in a few other women. This is being actively researched now.  Estrogen probably has other benefits not yet pinpointed. If there is an increased risk of breast cancer, it is small –which is why it has been so hard to tell if it is real.  And as I have discussed, the breast cancer found in women on HRT is more often curable. Since the overall effect on health and life expectancy  is positive, many women opt for HRT and feel comfortable doing so.

Still, many may still be asking: why would I consider taking it? The answer is of course, quality of life. Studies have shown that many women who have decided not to use HRT change their minds once menopause hits. They just do not feel well enough. Not long ago I was speaking to a prominent female physician who is an expert on menopause. She told me she is not entirely convinced that estrogen lengthens lifespan but she uses HRT anyway because she just does not feel well enough without it. This is a person who is extremely well informed  and highly regarded in her field who has no intention of slowing down because she has reached menopause.

HRT and Contemporary Lifestyles
Sometimes I am asked, “If HRT is so important, why didn’t my mother need it?” I think the reason is that women’s lives have changed greatly over the last decades. In past generations, women in their 50s often did not work and their children were grown. Now a woman in her fifties is likely to have adolescent children still at home, needs to contribute to paying for their college, and has a responsible, demanding job. And on top of that, she cannot sleep because of night sweats, is irritable because of mood swings, or has embarrassing flushing and sweating in the middle of a business presentation. The difficulties are considerable. A generation ago she might have felt just as uncomfortable but had relatively few demands on her. And she may have felt that nothing could be done anyway, an opinion that most doctors also subscribed to.

Unfortunately, the attitude that if you have a woman’s body you are destined to not to feel well still survives. Before women were taught not to complain and so often did not ask for help, which is very sad. Most women now take an active role in finding the kind of medical help they need. So two things have changed: women’s lives are more demanding (the price paid for being more interesting) and women expect, rightly, that they are entitled to medical help for their discomforts.

Even now, not all doctors understand the discomfort that menopausal symptoms can produce and how much they can interfere with normal activity. Women’s complaints, especially vague ones such as “overall achiness” or “mood swings” are still not always taken seriously and women, knowing this, sometimes feel that they are not being listened to. Though these were once dismissed as “in your head,” the more we know about them, the more we find that they have physical causes. You are entitled to be cared for by a professional who understands the hormonal basis of these problems, takes them seriously, and is willing to treat them.

THE HRT OPTION
This section is for women who are taking estrogen or seriously considering it and want to know the pros and cons of the many different forms. The bad news is that the great variety can be confusing. The good news is that because there are many different preparations, if you want HRT there is almost certain to be one which agrees with you. This section is a brief guide to the different forms.

Progesterone or a form of it is given as part of HRT to protect the endometrium (lining of the uterus) from over stimulation by estrogen. This over stimulation can lead to cancer but this does not occur if adequate progesterone is taken. 

How is HRT taken
Until recently, women on HRT took two separate pills: estrogen every day and progesterone or a form of it for part of the month. Now there are fixed dose combinations which are quite convenient. The main ones are Prempro®, FemHRT and Ortho Prefest ®. With these you get both hormones throughout the month. In theory, women using these should not bleed at all but in actuality, spotting and breakthrough are common, particularly in women who are recently menopausal. This extra bleeding is usually light and does not cause harm but can get tiresome. If you experience unpredictable bleeding and it has not gone away after a few weeks, another regimen may work out better for you. Also women who are hormonally vulnerable often need customized regimens with individualized adjustments of the estrogen and progesterone.

The different forms of estrogen
For decades the main form of estrogen given to women was conjugated equine estrogens (CEE) or Premarin®. As the name suggests, this is derived from horses. Other forms of estrogen come from plant sources, most commonly from yams. However, yams themselves contain only tiny amounts of estrogen or progesterone, so a large number of yams must be used to get enough purified hormone. Nutritional supplements made from yams do not contain enough to have any hormone-like effects on the body.

In addition to CEE, there are a variety of other estrogens available in pill form, such as esterified estrogens (Estratab®), micronized estradiol (Estrace®), and generic versions. The latter, estradiol, is the main estrogen made in a woman’s body. However, it is converted to another estrogen when it is absorbed through the GI tract. A newer oral estrogen is Cenestin®, which contains the same hormones as Premarin® but is made from soy and yam rather than from the urine of pregnant mares. It has very predictable absorption. All of these preparations can work well. Estradiol is the most natural form but really works better if divided into two doses rather than a single one. Cenestin gives very predictable absorption.

Some combination forms use ethinyl estradiol which is the form used in birth control pills but the dose is much lower. While these pill forms of estrogen give perfectly good results for many women, newer non-oral forms have some advantages.

Estrogen as a skin patch
Estrogen patches are small bits of translucent plastic, which supply estrogen through the skin. This gives a very smooth level in the blood whereas with pills, levels go way up after taking the pill, but drop down later. Estrogen shifts can set off mood swings, breast tenderness, hot flashes and more. Many menstrual cycle problems are due to swings in estrogen levels. You don’t want to keep having these fluctuations after menopause; the patch avoids them.

When estrogen is absorbed from the GI tract, it first has to travel through liver. Here two things can happen: the estrogen may be chemically altered and it tends to increase the liver’s production of some proteins, such as those involved in blood clotting (a potentially harmful effect). Not all these effects are bad; estrogen also increases the production of HDL, the good cholesterol. New preparations of estrogens, which are absorbed through the skin, have much less effect on the liver.

All patches use estradiol, the natural female hormone. They are like a little piece of tape which is placed out of sight on the back or lower abdomen where it releases estrogen into the body in a steady trickle. The patches can be worn while swimming or showering. They are changed once or twice a week. A gel form of estrogen that can be applied to the forearms once a day ,may become available soon.

The key to being happy with hormone replacement therapy (HRT) is to be sure it is customized for your body.

THE SPLENDORS AND MISERIES OF PROGESTERONE
Progesterone does some great things. It prepares the uterus for pregnancy or menstruation, and protects its lining against cancer. The wild card is its effect on mood. It sometimes helps PMS but when taken as part of HRT it can make mood worse, sometimes much worse. The main culprit is a synthetic version called MPA (medroxyprogesterone acetate.) Brand names include Provera ® and Cycrin® and it is also contained in Prempro ®. Many women feel fine on MPA but some get PMS feelings from it: mood swings, irritability and bloating. If the HRT that was supposed to settle your moods has made them sway more, consider this as a possible cause. The forms of progesterone in FemHRT and OrthoPrefest seem less likely to affect mood although they sometimes can. Natural progesterone is now available in micronized form as Prometrium®. Previously it had to be compounded by a pharmacist. Progesterone is much less likely to cause PMS-like symptoms, and may be better in its effects on cholesterol. If you have mood problems on your HRT or are vulnerable to mood swings generally, natural progesterone often is gentler with your emotions. Most women prefer progesterone to MPA, but a small number prefer MPA. This is why I have emphasized having an HRT regimen developed for your individual needs.

Not only is the dose of progesterone important, how many days you take it is too. The current view is that women on HRT need it at least 12 days in a row at least every two months. When you take progesterone like this, you may have period-like bleeding. This tends to be light and it is predictable. Also you can control when it happens by timing when you take your progesterone – the bleeding usually starts about two days after you finish the 12 day course. In the fixed dose forms, a form of progesterone is taken every day in a smaller dose.

What are SERMs?
These oddly named medications are designed to have the wanted effects of estrogen without the unwanted ones. (SERM stands for selective estrogen receptor modulator.) Only one is available now, raloxifene (Evista®), but more are being developed. Raloxifene acts on bone and blood vessels but not on breasts, uterus or vagina. Initial research suggests that it protects against breast cancer, but further studies are needed to know how fully it does so. It also has some protective effect on the bones, and possibly on the heart, though probably not quite as much as estrogen itself. The great drawback of raloxifene is that it does not help the symptoms of menopause, in fact it may make them worse. Its use is mainly for women that are well past menopause, feel fine off estrogen and only need the long-term health protective effects.

IF YOU’VE HAD A HYSTERECTOMY
Actually the term hysterectomy refers to removal of the uterus. Often the ovaries are removed with it but not always. If the ovaries are left in, they will eventually cease to make estrogen as they do in all women. Of course there are no periods to stop but otherwise, the symptoms are the same. When the ovaries are taken out, the symptoms are likely to come on right away and are often quite uncomfortable. As with natural menopause, the discomfort can be helped with estrogen. Higher doses of estrogen may be needed right after the surgery but often can be tapered down later. When the ovaries are removed at a young age, estrogen replacement is particularly important to prevent problems with bones and also to keep the vaginal and pelvic tissues in a youthful state.

DECIDING ABOUT YOUR MENOPAUSE
While I cannot tell you what you should do, I can offer some guidelines to help in your decision making. While I do not suggest that any particular approach to menopause is right for all women, I do think that all women should develop a plan for themselves  --  with the help of their health care professional.

Of course, some women do nothing and live to be over 100. But unless you have such lucky genes, it’s better to do all you can to maintain your health. Here are  the main elements of a personalized menopause plan:

Calcium and vitamin D supplements should be started beginning in the thirties. If you are one of the many women who didn’t, you can start now. Even women with strong bones should take these supplements.

Assess your risk for osteoporosis by getting a DXA bone scan as soon as you have any menopause symptoms but no later than age 50. If your bones are OK – you’ll need medical help in interpreting the report; they were designed by computer jockeys and are needlessly complex – then stay on the supplements and get a repeat DXA at least every 5 years.

If your bone density is low, you may need treatment to prevent further bone loss and restore some of what you have lost. Estrogen is one option but a group of medications called bisphosphonates (Fosamax® and Actonel®) work at least as well. They are unrelated to estrogen but for that reason do not help with menopause symptoms. They are only to help your bones. Calcium and vitamin D by themselves will not fully prevent bone loss.

Women are not exempt from heart disease; in fact over half eventually die from it. Check if you have specific risk factors. Family history can’t be changed but cholesterol levels, high blood pressure, smoking, and diabetes can. If you do have risk factors, take action to correct them: lower cholesterol with diet or medication or both, be sure your blood pressure is normal or get it normal, if you have diabetes, have it treated aggressively with the new medications which actually work.

Get a yearly breast exam and mammogram but also do monthly breast self-exam yourself.

Now you’ve done the standard things to protect your long term health. The next decision is based on symptoms – how you feel. If symptoms are uncomfortable you can try soy and supplements. If these do not give adequate relief, you may want to consider HRT.

Here are some of the things HRT does: reduce hot flashes and night sweats, improve sleep, help mental quickness and memory, decrease discomfort in skin and muscles and joints, maintain vaginal tissues and lubrication. These are significant benefits and are the reason millions of women do choose to go on HRT. If you cannot enjoy your life without HRT that is a good reason to take it. On the other hand, if you feel perfectly fine without it, there are other ways to get the same long term health benefits as I discussed above.

Finally, if you decide to start HRT, you are not committed to taking it for life. You can always reassess and change your mind whenever you like. If you do decide to stop, then you need to consider other ways to protect bones and heart.

I’M ON HRT BUT I DON’T FEEL ANY BETTER
It is not unusual for women on hormone replacement therapy (HRT) to be somewhat dissatisfied with the effects. This is one of the most common reasons I see women in my practice for menopause difficulties. The trend in menopause treatment has been, unfortunately, to a one-size-fits-all approach. Hormones are part of what makes us individual. This implies that no one hormone regimen will work out for all women. The preparations with fixed doses - Prempro®, OrthoPrefest® and FemHRT® work fine for some.

Some women need higher or lower doses than the standard ones. Those who are hormonally vulnerable or who have been estrogen deficient for more than a year often need to start at a tiny dose and increase it gradually so their body can get used to estrogen again. The various oral estrogen differ from each other and for many, patches with their smooth estrogen levels give a more comfortable feeling. If HRT has not helped your mood, check which form of progesterone you are on and consider a switch to a more natural version. Here too, there is likely to be a form that will work for you.

If HRT has not been working for you, my suggestion is that you find a physician who is familiar with the diverse forms of estrogen and progesterone and who will take the time to work with you to develop a customized form of HRT that your body likes.

CONCLUSION
Menopause is not the onset of old age but simply a developmental stage you will find your are quite capable of dealing with. The alternative and conventional treatments I’ve discussed help millions of women. Don’t let yourself be swayed by any pessimistic misinformation you have heard. There are several good options. Help is there. If you have trouble finding it at first, don’t get discouraged because you can find it if you look hard enough.

 

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