WHAT IS MENOPAUSE?
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thing to realize is that menopause is simply a decrease in estrogen; the idea that it is the equivalent of getting old is obsolete.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?
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
Here are some of the most common symptoms:
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?
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
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.
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
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
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
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
The different forms of estrogen
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
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
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?
IF YOU’VE HAD A HYSTERECTOMY
DECIDING ABOUT YOUR MENOPAUSE
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
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.
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