Menopause - Women Health Information Page

What Is Menopause

Estrogen Dominance

Women who have suffered from PMS and women who have suffered from menopausal symptoms will recognize the hallmark symptoms of estrogen dominance:

• Weight gain
• Bloating
• Mood swings
• Irritability
•  Depression
• Tender breasts
• Headaches
• Fatigue

Controlling The Symptoms of Menopause

Natural progesterone is derived from wild Mexican yam and other plant sources. Natural progesterone is identical in molecular structure to the progesterone produced by the human body. Phyto-estrogens are estrogens that are also derived from plan sources and when used in combination with phyto-progesterone are effective and safe.

A woman suffering from estrogen dominance can still be lacking in estrogen. Just not as much as with progesterone. For many women the best results are attained by using a combination 2 in1 cream. That contains both natural progesterone and plant based estrogens. Thousands of women have experienced relief from their menopausal symptoms by using a high quality, natural, phyto-progesterone/estrogen cream. The body is rebalance within 72 hours. What is most important is to listen to your own body. Optimum dosage is based on managing your symptoms.

You�ve had that feeling before, remember? It came in the form of a blaring alarm clock the night before when you did more weeping than sleeping. Your mate�s suggestion? See a psychiatrist. Good advice, wrong medical field; gynecologist, internist or general practitioner is more like it.

Menopause affects women in many different ways. Some feel they�re about to faint or experience a heart attack, while others will become overly sensitive, highly depressed and cry for no reason. You no longer feel desirable. And any compliment from your mate could send you right over the edge. All in all, the tremendous hormonal fluctuations during this confusing time are uncomfortable and disturbing sensations.

If you�re over age 40, you�ve just entered the Outer Limits. It�s not your fault your dysfunctional ovaries are now controlling the horizontal and vertical lines of your normal behavior pattern. About 80% of all menopausal women suffer, some more than others. This imbalance is more severe in women who do not sweat, whose menopause was surgically induced, and who are also enduring external stress.

Your gynecologist or internist can prescribe estrogen and progesterone to help you endure this change of life. However, there are quite a few natural remedies that can help you get through this difficult time.

If you are not diabetic, high doses of Vitamin E can be effective. Diet supplements containing black cohosh, unicorn root and ginseng have helped some women. Licorice root works to balance hormone levels. Japanese women report that a daily menu of rice and soy helps them control their hot flashes. There are numerous herbal and homeopathic remedies on the market aimed at balancing hormone levels.

Keep in mind the store attendant is not a medical expert and is not interested in whether you are diabetic or asthmatic; some of these remedies, like ginseng, could do you more harm than good. Be sure to ask your doctor about the supplements before you purchase them.

Some women report that moderate exercise and an active sex life help them because both activities raise important endorphin levels. Others may turn to meditation and visualization to promote a more positive mood.

Recent studies show that hormone levels do, in fact, affect sleep. Doctors have been looking closely at melatonin, a hormone secreted by the pineal gland. If you are disturbed by night sweats, melatonin has been proven successful in treating insomnia and jet lag. However, this supplement can cause depression in some women, which may defeat the purpose.

Chamomile tea and St. John�s wort with Kava Kava also help menopause-related insomnia. Sage, which contains plant estrogens, reduces excessive sweating and also helps reduce the frequency of night sweats.

Another safe way to get a good night�s rest is pamper yourself with a soothing, hot bath before bedtime. Take calcium in your preferred form and listen to soft music or a mood enhancement audio tape.

Yes, the new millennium has given the �M� word a name. So it�s okay to talk about your symptoms with mature family members and compassionate friends. Your mate, in particular, needs to understand this menopausal passage in order to help you get through it.

Written by Sharon Raiford Bush

Title: The safest ways to stop hot flashes
Description: Hot flashes are a reaction of menopause. The pulse races, skin reddens and then drenching sweats occur. That's what 80% of menopausal women experience. There are alternatives to hormone replacement therapy.

The main reason that a woman starts to experience changes is due to two factors: estrogen and progesterone. As a woman grows older, the balance of these two important chemicals may be changed. After age 35 estrogen production decreased enough to produce changes in the body. These changes are what perimenopause is all about.

The changes may start with irregular periods in the woman�s thirties. These can include periods of longer duration, shorter duration, too much bleeding, less bleeding, or no bleeding at all. These changes will increase as the woman enters her forties. According to the book, Perimenopause: Changes in Women�s Health After 35, by Dr. James Huston & Dr. Darlene Lanka, it is important to alert your doctor when your period becomes irregular. A period cycle that is less than 20 days long can be an indicator for endometrium disorders. Excessive bleeding may cause anemia or other problems. Women who wish to have more control over their cycle may opt for hormone replacements at this point.

Hot flashes are experienced by 85 percent of American Women according to research done by Dr. Fredi Kronenburg (1990). He reported that 75% of the women who report having hot flashes experience them for 1-2 years. 20-50% experience them for 5 years, and 10% report an indefinite time for experiencing this symptom. Hot flashes occur when blood vessels dilate and bring large amounts of blood to the surface. This causes the skin to appear red. Essentially, everyone has a heat conservation system. When it is cold, blood vessels constrict near the surface to maintain vital organs. In a hot flash this system is thrown off kilter, and heat is released even though it is not necessary to get rid of it. Typically this hot flash will last 3 to 5 minutes, but recovery from the hot flash can take up to a half hour.

Hot flashes can be dealt with through replacing estrogen, exercise, and alternative remedies. Some studies suggest that women who are very slim are missing levels of estrogen that are stored in fat cells. For some people putting on a few pounds will assist them in avoiding hot flashes. It is important to avoid trigger situations. A large meal can direct a great deal of blood to the digestive system, and that can trigger a heat release reaction. Avoid environments where you will not be able to escape excessive heat. Hot weather, overheated rooms, a hot tub, too many bedclothes, and too much clothing can make hot flashes harder to deal with.

Mood swings can be drastic during this transitional period. Phone commercials on television can reduce a woman to tears. Touching pictures or memories can make a normally stoic woman collapse into hysterical weeping. It is difficult for a woman to feel out of control in terms of her emotions. Women may feel they are suffering from a mental illness or depression. It is important to rule these out of course, but it is very possible these variable moods are the result of hormonal changes again. A doctor can check progesterone levels to make sure these are not too low. This is determined by blood tests done at various points of a woman�s cycle. Low progesterone can cause irritability, anger, weepiness, and generally unstable behavior. A progesterone supplement can reduce symptoms significantly within the first month of treatment. The risks of cancer are greater for a person with progesterone deficiencies. This is a wonderful treatment that can help a woman feel like herself again.

If you are experiencing the symptoms discussed or other symptoms that might be related to your reproductive health. The option of alternative healing techniques can be a consideration. Some traditional medical doctors are more receptive to alternative treatment than others. Talk with your doctor, or find a doctor that is willing to explore these methods with you. Homeopathy is a method that uses medicine that is highly diluted, and said to encourage the body�s own healing powers. Herbal treatments such as Ginseng, and Black cohosh have been tested and the results show they can be very effective in helping women with estrogen deficiencies. Patients of acupuncture and acupressure report relief from specific symptoms. These alternatives are other routes to take when seeking relief from perimenopausal symptoms.

It is frightening to consider going through menopause when a woman is in her mid-thirties. Even referring to it as perimenopause does not lessen the blow of a woman aging. It is better to regard menopause as a process. The early stages of menopause include symptoms such as menstrual changes and moodiness, and the later stages may include hot flashes, vaginal dryness, and ultimately the last menstrual cycle. Just as puberty was a process of development. Perimenopause and menopause are the process of closing the door on a reproduction. The transitions are certain to bring some chaos as most change does, but utilizing some of the methods described can make this movement to later life more smooth and enjoyable.

Written by sally nulph

Title: Information on perimenopause
Description: Women experience symptoms of perimenopause long before menopause. It is important to know what to expect in terms of emotional changes, hormones, and general health options.

These relatively new clarifications of the mythic nature of women�s heart treatment show that heart disease is actually the biggest killer of American women, with over 240,000 dying annually. At least 21,000 of these women are under the age of 65. Women with a negative heart history in the family, and particularly if high blood pressure is present, need to take proactive steps such as quitting smoking, reaching and maintaining a normal weight, and engaging in a healthful program of exercise to minimize their risk of serious coronary consequences.

Women who are postmenopausal should discuss the use of estrogen-replacing hormones. While further studies are being done, current data shows that women who take estrogen are half as likely to suffer heart attacks or die from heart disease. But there are risks associated with hormone replacement, such as elevated probability of acquiring breast cancer. How does a woman decide what to do?

The Harvard Medical School�s Harvard Heart Letter recommends that a balance be achieved between risks and benefits, when women are deciding whether or not to take estrogen replacements. The major benefits of postmenopausal estrogen therapy are a reduction in the risk of heart disease and osteoporosis, as well as the symptomatic relief from postmenopausal symptoms like hot flashes and vaginal dryness.

The potential risks are increased chances of breast cancer and endometrial cancer (cancer of the uterus), although the latter risk seems to disappear if the woman takes progesterone along with the estrogen 12 or more days a month.

What do current studies show? Assessing the risk factors of almost 50,000 nurses in the Nurses� Health Study verified that women taking estrogen replacements lowered their risk of coronary artery disease by half. A further �meta-analysis� by Harvard researchers who combined the results of 30 epidemiologic studies revealed that estrogen therapy reduced the risk of CAD by 44%--close enough to �half� to cause physicians to take notice.

The Harvard Heart Letter finds this study particularly compelling because as many as one-third of all women 65 and over have coronary artery disease, and CAD is the leading cause of death in this group. Some experts speculate that women who take estrogen replacements tend to be healthier in ways that decrease their heart-disease risk, such as engaging in additional exercise, eating healthier diets, or seeing their physicians more frequently. Some of these factors could be responsible for the lowering of heart disease risk, yet there are clearly biologic reasons why estrogen should be good for the heart. For one thing, women on estrogen therapy continually have a significant increase in HDL, the good cholesterol, and a comparable decrease in the bad cholesterol, LDL.

Studies have also shown the positive effects of estrogen on the reactivity of blood vessels. That is, women who received injections or powerful oral doses of estrogen showed a significant dilatation of their blood vessels in response to certain stimuli, a factor that might be expected to protect the heart by providing increased blood flow. Also, it is thought that estrogen replacement may possibly decrease blood clotting, one of the factors thought to precipitate a heart attack. For example, estrogen users show lower levels of fibrinogen, a protein involved in blood clotting. Also, estrogen may improve the body�s response to insulin; since insulin resistance is another independent risk factor for heart disease, this is an added benefit. Some studies show that women taking estrogen report a lowered blood pressure, although this is not a definitive finding at this time.

Physicians are currently calling for more studies to look at the combination of progestin-estrogen therapies on heart health in women, since most studies thus far have focussed on estrogen replacement primarily. But another big plus factor for taking estrogen replacements is estrogen�s amazing ability to prevent bone loss density, and possibly even to increase bone density in many women. Since one in six women has a hip fracture during her lifetime, and many more have vertebral fractures, the increased bone density could be a major health factor overall. Recently, other medications that are not estrogens have become available to treat women with osteoporosis who should not take female hormones.

Exactly who are the women who should consider avoiding female hormones? Postmenopausal women who still retain their uterus and take estrogen therapy by itself have six times the likelihood of incurring endometrial cancer, a powerful warning. But when progestin is added to the prescribed dosage of estrogen, the risk seems to disappear. Thus, the concomitant use of progesterone with estrogen appears to protect against endometrial cancer.

Breast cancer risk however remains controversial. One study showed that women on some sort of estrogen therapy have a 40% increased risk of incurring breast cancer, and the risk appears to increase when the hormones have been taken for five or more years, putting women in the 60-65 year old range at particular risk. This factor remained solid, whether the treatment was for estrogen alone or estrogen in combination with progestin.

Another study is more reassuring, although the study involved a smaller number of participants. In it, researchers argued that there was no increased risk of breast cancer among women who took hormones for more than eight years. Probably the most significant factor for women considering hormone therapy is their personal histories. With a clear cut family history of breast cancer, which affects one women in nine over a lifetime and accounts for 45, 000 deaths of US women each year, women should consider the statistics soberly.

With no family history of breast cancer, whether or not heart disease history is present, women should probably be encouraged to consider estrogen replacement. With heart disease history in the family, women should probably be strongly encouraged toward hormone replacement in postmenopausal years.

The Women�s Health Initiative, a massive study which is looking at many aspects of female health, should prove enlightening. In one branch of the study 27,500 postmenopausal women will be treated either with estrogen alone, estrogen with progestin or with a placebo over a nine-year period. Investigators hope to more clearly define the role of hormone therapy as regards heart disease, osteoporosis, breast and endometrial cancer. Until results are in and fine-tuned, women should carefully consider the possibilities with their medical care providers and make the wisest choice available to them at this time.

Written by Eleanor Sullo

Title: Hormone replacement for women at menopause
Description: What's the latest scoop on hormone replacement therapy for menopause? The positives and negatives and possible side effects are considered

A: As you correctly point out, hormone replacement therapy (HRT) has long been recommended for women entering menopause. The benefits included relief from the symptoms of menopause including sweating, hot flushes, and mood swings. The prevention of osteoporosis and heart disease were two of the more compelling medical reasons behind the long-term benefits of this recommendation. Prevention of heart disease was a particularly compelling reason, as it remains the number one cause by far of death in women. Some women also believe that HRT delays the effects of aging and helps them to look younger longer. The �down� side includes risks for stroke, blood clots, and the development of breast and uterine cancers.

As physicians, we were asked to look at this in the context of risk vs. benefit ratios. For example, the benefits of a reduced risk of heart disease or a hip fracture were believed to outweigh the statistically much smaller risks of cancer and strokes. Try as I may, I�ve never been able to convert that argument into very convincing terms for my patients, especially in light of this new information.

A recent study has determined that HRT should not be initiated for the prevention of cardiovascular disease either in women with a previous history of heart disease or those who are currently disease free. There is some concern that HRT in women with heart disease may actually place them at an increase risk for a cardiac event. There is as well not enough information to recommend that women begin HRT for the purposes of the prevention of heart disease.

If you are on HRT, ask your doctor to review the benefits for which the medication was initiated. If the main reason is the prevention of heart disease, you may want to discontinue therapy and instead consider lifestyle changes and aggressive treatment for high blood pressure and elevated blood lipids. If you have a history of heart disease, blood thinning agents and other medications used to lower the risk of heart disease might be a less risky substitute.

There are other medications to slow the progression of osteoporosis such as raloxifine, alendronate, and calcitonin to name a few that are all augmented by the use of 1000-1200mg of daily supplemental calcium.

There is still an indication for short-term use (3-6months) for the management of the symptoms of menopause. There are a number of herbal substitutes that in my reading so far provide few if any of the benefits of HRT and may lead to a false sense of security for women using them.

Russell G. Robertson, MD

Keyword: Women's Health, estrogen, hormone replacement, HRT, menopause, hot flashes, heart disease, osteoporosis, breast cancer, uterine cancer, stroke, blood clots, hip fracture, cardiovascular disease

Perimenopause is the two to fifteen year span before menopause during which a woman experiences changes due to declining levels of estrogen and progesterone. For some women, the perimenopausal time can be more troubling than actual menopause.

Hormone Changes During Perimenopause

A woman may notice changes in her menstrual cycle several years before true menopause. The ovary has a finite number of eggs, and these begin to run out. The hypothalamus stimulates the pituitary to make more FSH in an attempt to cause the remaining eggs to mature. FSH and LH levels rise. Estrogen levels may vary. FSH levels can help determine whether a woman is entering menopause.

During perimenopause, ovulation occurs intermittently. If there is no ovulation, the progesterone does not increase and the estrogen production may continue. This may cause the uterus to build up a thicker lining. The menstrual period may occur irregularly and may be quite heavy. Other cycles may produce a light menstrual period. As perimenopause moves into menopause, the ovaries produce much less estrogen and progesterone and the menses cease.

Symptoms of Perimenopause

Hot flashes are experienced by up to two-thirds of perimenopausal women. They usually occur one to five years before the end of menstruation. These symptoms are more severe in women who have had their ovaries surgically removed. It is thought that low levels of estrogen cause the brain to release a surge of Gonadotropin-releasing hormone. This may be the cause of the hot flash. A woman suddenly feels hot and may perspire profusely. She may then have a cold chill. They are more common at night but can occur at any time of day. They last from a few seconds up to an hour.

Changes in menstrual cycles: Menses may be heavier, or lighter. There may be increased or decreased cramping. Eventually, menses lighten, become less frequent and then stop.

Increased PMS symptoms

Difficulty with memory and attention span: Some women report difficulty with concentrating or remembering specific words. A woman with attention deficit disorder may first come for treatment at this age because declining estrogen level has exacerbated her ability to concentrate.

Insomnia is a common complaint of women in perimenopause or menopause itself. Night sweats may disrupt sleep. Irritability and depression can impair sleep. Reduced sleep can lead to tiredness and irritability during the day.

Vaginal dryness: Before and after menopause, lowered estrogen levels cause the lining of the vagina to become drier and thinner. This may lead to painful intercourse and decreased interest in sexual relations.

Urinary leakage: Some urinary symptoms may be related to pelvic floor changes that occurred years ago during labor and delivery.  As the estrogen level drops, further changes can occur. Low estrogen levels may weaken the urethral sphincter that helps hold in urine. If the woman has gained weight, it may put more strain on the bladder.

Skin and hair changes

Dealing Actively With Your Midlife Changes

Healthy Lifestyle Changes: Regular exercise may decrease depression and irritability. Good muscle tone can also improve energy level and decrease aches and pains. Some forms of exercise may help decrease bone loss. Yoga or Tai Chi decrease stress and may reverse the decreased flexibility often associated with aging. Regular Tai Chi has been shown to decrease the incidence of hip fractures in older individuals. A diet high in complex carbohydrates, including multiple small meals may reduce irritability and improve one�s feeling of well-being.

Social support: Many women experience menopause as a time of increased freedom and new possibilities. As their own children grow up, they may have more time and flexibility. However, some women experience the empty nest as the loss of their central role in life. Loss of a spouse through death or divorce can increase isolation. The physical changes associated with hormonal fluctuations can be confusing. Menopause may cause some women to start to think about the finite nature of life. Supportive friends and family can help a woman understand and cope with life changes. Reading about menopause or talking to one�s doctor can help make the changes less mystifying. A return to spirituality can spur growth at this phase of life.

Hormone Replacement Therapy (HRT) Taking estrogen and progesterone can help some of the symptoms associated with approaching menopause. The decision to take hormones is an individual one. A woman considering HRT needs to consider the severity of her symptoms, her health history and her family history. She may also have personal preferences about taking medications. Estrogen is the hormone that seems to relieve many of the symptoms of approaching menopause. If a woman has already had her uterus removed, she may take estrogen by itself.  However, if a woman with an intact uterus takes estrogen without progesterone, the lining of the uterus may build up, and the woman may be at increased risk of uterine cancer. Thus HRT often requires a combination of estrogen and progesterone. The doses of estrogen and progesterone used for HRT are generally lower than the doses used for birth control pills. Often, women only need HRT for a limited number of years after menopause. There can be benefits and drawbacks to the use of HRT. Estrogen can relieve hot flashes, vaginal dryness, urinary problems, and sometimes insomnia. It can also promote a feeling of well-being. Some women feel that it improves memory and concentration. HRT can reduce the chance of osteoporosis. Estrogen may help prevent heart disease, but recent data has suggested that this effect may not be as dramatic as previously thought. For some women there may be drawbacks to HRT. Some studies have suggested a link between HRT and an increased incidence of breast cancer. Estrogen may elevate blood sugar, cause headaches, weight gain, or other side effects.

Psychological support: For some women, social support, healthy lifestyle changes and hormone replacement therapy are not enough. The death of loss of a spouse, heath changes and other stresses may cause stress. Depression and mood swings are more common during perimenopause than after menopause is well established. However, a woman with a history of anxiety or major depression may have a reoccurrence during either of these periods.  Counseling may help some women deal with losses. Counseling may also help a woman review her life and make decisions about new directions and interests. If a woman has a persistent depression or experiences sleep, appetite and energy changes, or has suicidal thoughts, she may want to consider a psychiatric consultation and antidepressant medication.

Passage through this life transition may leave one with a larger view of the rhythm and flow of life.

- By Gayatri Devi, M.D.

Menopause symptoms, due to estrogen deficits, include memory problems, trouble finding words, inability to pay attention, mood swings and irritability, in addition to the more well known symptoms.

These symptoms are often overlooked or left untreated but should be addressed. Treatment will not only result in symptom remission but may also, in my opinion, have preventive value.

Some common questions I have encountered in my practice about estrogen and memory loss include the following:

Q: Do I have Alzheimer's disease?

A: This unspoken fear is often the reason why women suffer in silence when they have cognitive symptoms of menopause. Scared about what they may find out, many women opt not to seek treatment. However, menopause related memory and cognitive disturbances are being increasingly described in scientific literature and are generally responsive to treatment. They should be addressed and treated, so that symptom resolution occurs.

Q: Does estrogen have an impact on functions of the mind?

A: Yes. Estrogen influences language skills, mood, attention, and a number of other functions in addition to memory.

Q: How does estrogen affect the mind?

A: Estrogen receptors are present in several regions of the brain, including those involved in memory (such as the hippocampus). When activated by estrogen, these receptors, in turn, activate processes that are beneficial to the brain. In addition, estrogen may, in effect, raise levels of certain chemicals (neurotransmitters) within the brain. These include the neurotransmitters acetylcholine (implicated in memory), serotonin (implicated in mood), noradrenaline (implicated in mood and other autonomic functions), and dopamine (implicated in motor coordination). Thus, estrogen facilitates networking between nerve cells, promoting their ability to "talk to" one another.

Q: Does this mean that my recent irritability, apathy, 'foggy' state of mind, trouble finding words, constantly losing my keys, inability to function at my job, etc. may be related to estrogen deficit?

A: Given estrogen's myriad role in brain processes, it should come as no surprise that it can influence many of the mind's functions. However, a careful history and a thorough examination are needed to sort through symptoms. You should plan to spend about an hour to an hour and a half with your physician to discuss the issues related to menopause, symptoms and treatment options.

Q: If estrogen replacement corrects my memory and other cognitive symptoms, do I need to do anything more?

A: Generally, if hormone replacement treats one's difficulties, your physician may decide that further work-up is not necessary.

Q: I am on hormone replacement and my symptoms persist. What next?

A: If your symptoms do not resolve with hormone replacement, you may need to discuss the dosage and type of hormone replacement you are on with your doctor. Sometimes, changing to another preparation is helpful. If problems still persist, you might want to seek further help from a physician who specializes in this area.

Q: What are other treatment options for my problems?

Estrogen related cognitive deficits may be differentiated from those associated with other conditions through a careful history, examination and testing. During this time in a woman's life, many problems coexist, including treatable causes (e.g.: depression, hypothyroidism). Focused neuropsychological testing is useful in this regard to delineate the nature of the problem. Testing will also establish a cognitive baseline for future comparison. Thus, treatment options will depend on the cause(s) of the memory loss.

Q: Ideally, what areas should be covered in neuropsychological testing?

A: As estrogen affects various cognitive functions, comprehensive testing should assess all aspects of language (reading, naming, understanding, word fluency), memory (both short and long term memory, visual and verbal memory), and other cognitive functions (problem solving skills, visuospatial skills, etc). Simple screening tools, such as the mini mental status examination, will most often remain normal in peri- and post-menopausal cognitive loss. A good neuropsychological battery of tests should establish a cognitive baseline for future comparison, answer the questions asked and allow monitoring of treatment response.

Q: Will my depression get better if I go on estrogen?

A: If the mood changes are related to estrogen deficiency, they usually will respond to hormone or estrogen treatment. If the mood changes persist, you need to discuss this with your physician.

Q: Is estrogen useful for preventing memory loss?

A: Various naturalistic studies have suggested a preventive role for hormone replacement with estrogen for memory loss. However, more rigorous trials to investigate this are now under way and need to be concluded before consensus recommendations can be made.

Q: I have heard that estrogen prevents Alzheimer's disease. Is this true?

A: The results of several naturalistic studies suggest that estrogen may reduce risk for Alzheimer's by up to 50% although other studies did not find this benefit. The more significant of these studies involved looking at risk in large populations (epidemiological studies). However, controlled clinical trials are needed to confirm this observation before a decision of estrogen's benefit in this regard can be reached.

Q: My friend's mother has Alzheimer's disease. Will estrogen or hormone replacement help in this case?

A: There is a body of evidence to suggest that estrogen or hormone supplementation helps to slow progression of Alzheimer's. Further work still needs to be done in this area. As of the present time, the opinions of experts vary in this regard.

Q: What about the naturally occurring estrogens found in substances like soy milk?

A: There is not enough data on the use of these naturally occurring hormones for treatment of cognitive symptoms of menopause.

Q: Why do I need hormone replacement? Isn't it the natural order of life that women go into menopause?

A: The average age of menopause is 52.3 years and has not changed much over the years. However, a century ago, life expectancy was much less for a woman than it is today. Today, the average woman will spend from a fourth to up to half of her life without the protective and beneficial effects of estrogen.

Q: What is the difference between hormone replacement and estrogen replacement therapy (HRT vs. ERT)?

A: Hormone replacement therapy is a combination of estrogen and progestogen and is generally given to women who have not undergone hysterectomies.

Q: If there is a family history of breast cancer, should I not take estrogen?

A: A family history of breast cancer does not preclude treatment with estrogen. Every person needs to be evaluated on an individual basis. Risk in each person varies and you will need to discuss this with your doctor.

Q: Does my risk for breast cancer increase if I am on estrogen?

A: The data in this area is conflicting. Some studies have noted an increased risk, while others have found an increase in certain types of breast cancer. You need to discuss this issue with your physician. Additionally, every woman on estrogen or hormone replacement should undergo periodic breast self examinations and mammograms as determined by her physician.

Q: What is the difference between a patch and an oral preparation?

A: Skin patches are often used when oral estrogen is not tolerated. Skin absorption bypasses the liver circulation and is more easily titrated.

Q: If my hormone levels are normal on testing, but I am having all these symptoms of menopause, what next?

A: Hormone levels fluctuate and may need to be rechecked if your symptoms are attributable to menopause (or estrogen deficit). You would need to discuss this with your physician.

Q: How does estrogen affect other organ systems?

A: Estrogen keeps bones healthy and prevents osteoporosis. It may also be helpful with cardiovascular diseases, although studies in this area are less unanimous.

Q: What are the risks of taking estrogen or hormone replacement therapy?

A: The most common concern for women deciding on estrogen or hormone replacement therapy is fear of increased risk for breast cancer. Several large, prospective studies have yielded varying results, including increased risk for certain kinds of breast cancer, although some studies found that the total risk for breast cancer of all kinds may not be increased. This is an area that you would need to discuss carefully with your physician. Other more common side effects include spotting, some bloating, breast tenderness and mood changes.

Q: Should I take estrogen or hormone replacement?

A: This is a question that every peri- and post- menopausal woman needs to discuss with her physician. Pros and cons of estrogen use in an individual woman vary.

Hot flashes, vaginal dryness and the onset of osteoporosis (the slow loss of calcium by bones) are physical side effects of menopause. Many emotional changes such as nervousness, fatigue or depression are also common. To ease the side effects of menopause, hormone replacement therapy (HRT) might be recommended by your doctor. Synthetic hormones are substituted for what your body no longer produces. HRT is not without risks and is not recommended for every woman.

Today, HRT differs greatly from the large doses of estrogen that were given to women until the 1970s. The lowest effective dose of estrogen is combined with progesterone. A large dose of progesterone may be given once a month, or a small dose of progesterone may be given daily.

Estrogen replacement therapy can be started during menopause if the woman is experiencing severe symptoms or if her ovaries have been removed.  

THE POSITIVE SIDE OF HORMONE REPLACEMENT THERAPY

• Hot flashes occur less often and are less severe.
• Vaginal dryness and discomfort are relieved.
• The progression of osteoporosis may be delayed.
• Depression and fatigue occur less often.
• The risk of heart disease and stroke are decreased.
• It protects against uterine cancer.
• It may reduce the risk of colorectal cancer.

THE NEGATIVE SIDE OF HORMONE REPLACEMENT THERAPY

• A menstrual cycle may occur.
• Use of estrogen by itself has been liked to cancer of the endometrium.
• Estrogen alone can cause swollen breasts, nausea, high blood pressure and fluid retention.

ESTROGEN THERAPY SHOULD NOT BE UNDERTAKEN IF YOU HAVE:

• cancer of the breast or uterus.
• estrogen-dependent ovarian cancer.
• a history of blood clots in the legs, pelvis or lungs.
• gallstones or gall bladder disease.
• large uterine fibroids.

Objectives

• Describe changes in androgens in aging, menopause, and following oophorectomy.
• Define patients who might be appropriate for testosterone therapy.
• Discuss alternative medical therapy versus prescription medical therapy.

WOMEN AND LIBIDO-IS THERE A ROLE FOR TESTOSTERONE?

Decreasing testosterone may be one of many possible causes of decreasing sexual desire; however, disorders of desire are complex and require careful, non-judgmental history taking. Testosterone replacement/supplementation may be appropriate in a small percentage of women who complain of decreased desire.3 Many women experiencing the clinical symptoms of androgen deficiency and low free testosterone levels respond well to testosterone replacement therapy.

Androgen Production

Menopause and Disorders of Desire

What is the nature of the patient's current sexual activity? Is there an identifiable event associated with loss of desire? How much disparity is there between the patient's desire and her partner's? It is the issues surrounding a woman's autoerotic behavior, her own sexual thoughts, dreams and fantasies, and masturbation, which define a woman's libido that need to be examined. Is the problem really lack of interest or is it anger, fear of rejection, or negative messages partners give to one another? Is the lack of desire selective? Is the underlying effort to remain sexually aloof a way to punish or control the partner? Have there been attempts to solve the problem?

It is important to determine if there is a surgical event connected to loss of desire. Women who can clearly define their sexual \drive through issues of fantasy and desire, and who can say there was a specific drop associated with a specific medical event, are very likely to respond to androgen therapy.8

There are a number of medical causes of decreased libido. These include acute and chronic illness, fatigue, malnutrition, alcohol, drugs, stroke, pituitary disease, renal disease, depression, and testosterone and estrogen deficiency. Traumatic deliveries can also result in chronic dyspareunia and incontinence, both affecting sexual relations and satisfaction.

Possible Medical Causes of Decreased Libido

• Illnesses Virtually any illness (genital or general; physical, emotional, or both): liver, renal, cardiac or hormonal disease, cystitis,
• anemia, hypertension, stroke, cancer, neurologic disease, colostomy, neostomy, bladder surgery, incontinence, herpes virus or
• HIV infection, gonorrhea, venereal warts.

• Medications Antihypertensives, antineoplastic drugs, some antidepressants, (including selective serotonin reuptake inhibitors),
• major or minor tranquilizers (depending on dose), diuretics, antihistamines.

• Treatments Major surgery (hysterectomy, mastectomy, cardiac bypass, organ transplant), dialysis, radiotherapy, chemotherapy.

In disorders of desire, 90 percent of it has to do with the relationship. However, 10 percent of it may be related to decreasing levels of testosterone. The biggest question to ask in evaluating disorder is whether the patient has had desire in the past, including autoerotic behavior and fantasies.

Androgen Therapy

For menopausal women who have never had much sexual desire, or who experience no change in libido, testosterone would probably not be the right therapy. But for those women who have felt sexual desire and wonder where it went, testosterone may be helpful.

During menopause, low estrogen levels lead to vulvar and vaginal atrophy,11 which can cause discomfort. This can have a dampening effect on libido, although lubricants can help. Estrogen replacement therapy can increase vulvar sensation and decrease dyspareunia, but it does not do anything for desire.12

Non-androgenic progestins in oral contraceptives, with the addition of ethinyl estradiol, can drive free testosterone to very low levels. This will eliminate the mid-cycle surge of androgens and accompanying surge of autoerotic and sex-seeking behavior in humans related to ovulation.

There is no convincing evidence that adding physiologic doses of androgens consistently enhances libido in menstruating women. Naturally menopausal women over 50 still produce a fair amount of androgens, for at least five to 10 years. For 35- to 60-year-old women who have had oophorectomies, there may be an increase in libido with the addition of androgens.13 Evidence that this is the case comes from a study, comparing estrogen-only, estrogen-testosterone, and placebo therapy in women who have had oopherectomies.14 The levels of testosterone used in the study were, however, superphysiologic, sometimes four to five times the average in males.Testosterone and estrogen combined may increase bone density more than estrogen alone.15 Recent studies have also shown estrogen-androgen therapy to contribute to the prevention of osteoporosis and reduce serum levels of total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.16,17 Finally, there appears to be some connection between testosterone and an elevated sense of well being in some patients, although this is difficult to assess given the powerful placebo effect.18

For women who might be candidates, there are a number of androgen therapies available: combined oral conjugated estrogens, injectables, subcutaneous testosterone pellets, transdermal patches (in development), and creams and gels.

Androgens and Estrogens

Conjugated Estrogens and Methyltestosterone
1.25 mg conjugated estrogens/10 mg methyltestosterone
1x day for 21 days (7 days off)

Esterfied Estrogens and Methyltestosterone
0.625 to 2.5 mg esterfied estrogens and 1.25 to 5 mg methyltestosterone
1x day for 21 days (7 days off)

Fluoxymesterone and Ethinyl Estradiol
1 to 2 mg fluoxymesterone and 0.02 to 0.04 mg ethinyl estradiol
2x day for 21 days (7 days off)

Injection Dosages (not recommended or commonly used in the United States)

Testosterone Cypionate and Estradiol Cypionate
50 mg testosterone cypionate/2 mg estradiol cypionate
1x every 4 weeks

Testosterone Enanthate and Estradiol Valerate
90 mg testosterone enanthate/4 mg estradiol valerate
1x evey 4 weeks

Testosterone Enanthate Benzilic Acid Hydrazone, Estradiol Dienanthate, and Estradiol Benzoate
150 mg testosterone enenthate benzilic acid hydrazone/7.5 mg estradiol dienanthate/1 mg estradiol benzoate
1x every 4 to 8 weeks or less

Oral preparations are difficult to evaluate because their androgen delivery cannot be measured; only secondary effects can be measured. So it is hard to tell whether patients are receiving a lot or not enough testosterone. Transdermal preparations can vary in application effectiveness and dosing, but can achieve very high testosterone levels.

Androgen therapy does have side effects. These include hirsutism, increased facial oiliness, acne, deepening voice, hostility, weight gain, alopecia,19 elevated liver functions, lower HDL levels, and (rarely) epedicellular carcinoma.20 Finding the right balance that will help women with their libido without causing adverse side effects is very difficult. How much is too much or too little testosterone has yet to be determined.

Other potential indications for androgen therapy in women are currently being evaluated. These include use in women with premature ovarian failure, premenopausal androgen deficiency symptoms, postmenopausal and glucocorticosteroid-related bone loss, alleviation of wasting syndrome secondary to human immunodeficiency virus infection, and management of premenstrual syndrome  

WHAT IS PERIMENOPAUSE?

SIGNS OF PERIMENOPAUSE

• Menstrual cycles become shorter, longer, or unpredictable
• Flow becomes heavier or lighter
• Low blood sugar
• Fatigue several days before menstruation
• Weight gain
• Decreased sex drive
• Headaches - from mild to migraines with aura and visual distortions
• Dry and/or itchy vulva, clitoris
• Increased incidence of yeast infections

NATURAL SUPPLEMENTS

If you find yourself frequently light-headed, experiencing headaches or fatigue, stabilize your blood sugar by eating at regular intervals. Do not skip meals - especially breakfast.

Consider natural supplements. These are said to work wonders for many women, and do not have the side effects or high cost of medications. Add one supplement per month to your diet so you can observe its effects. By this sort of experimentation you can find out what combination really does or doesn't work for you.

DONG QUAI

PHYOTESTROGENS

AVENA SATIVA and SEX

BLACK COHOSH

RED CLOVER

OTHER SUPPLEMENTS

What is continuous hormone replacement therapy?

Are there different types of hormone replacement therapy?

In the past, women taking these two hormones would take estrogen for the first part of the cycle and progestin during the latter part of the cycle. But this form of hormone replacement therapy may cause bleeding every month, much like having a menstrual period. Many women quit taking the hormones because of this monthly bleeding.

Taking both of the hormones every day throughout the month seems to fix this problem for many women - most women taking continuous estrogen and progestin therapy quit having bleeding after three to six months.

How is continuous hormone replacement therapy taken?

Take both pills every day. You don't have to stop on certain days of the months. If you have bleeding, tell your doctor. The dose of progestin may need to be increased.

What are the benefits of hormone replacement therapy?

• It can reduce your risk of osteoporosis, a condition that causes the bones to become porous and thin and more likely to break.
• It can relieve symptoms of menopause, such as flushing, night sweats and vaginal dryness.
• It can decrease your risk of heart attacks.

What are the risks of hormone replacement therapy?

Progestin can cause tender breasts, fluid retention, swelling, moodiness and cramps. These side effects seem to be less for some women who take continuous hormone replacement therapy. Progestin may also reduce how well estrogen works to protect against heart disease. Studies are still being done on the use of progestin.

Generally, women who have had endometrial cancer, breast cancer, blood clots, stroke, unexplained vaginal bleeding or liver disease shouldn't take hormone replacement therapy.

Are there any signs of problems I should look for?

Yes. If you bleed after you haven't had any periods for several months, call your doctor. Also call your doctor if you notice any breast lumps or pain, or if you have any questions.  

Management of the climacteric

Options abound to relieve women's midlife symptoms

Douglas R. Morrissey, MD; Jeffrey T. Kirchner, DO

VOL 108 / NO 1 / JULY 2000 / POSTGRADUATE MEDICINE

CME learning objectives

• To become familiar with the main symptoms of the climacteric
• To identify currently available options, including alternative or complementary therapies, for treatment of symptoms of the climacteric
• To understand that counseling about lifestyle changes may allow women to forego both traditional and nontraditional therapies

The authors disclose no financial interests in this article.

This page is best viewed with a browser that supports tables

Sixth in a series of articles on women's health coordinated by Jeffrey T. Kirchner, DO, associate director, Family Practice Residency Program, department of family and community medicine, Lancaster General Hospital, Lancaster, Pennsylvania.

Preview: The transition out of the reproductive years can often be accompanied by uncomfortable and disruptive symptoms, one of the most common of which is hot flashes. Drs Morrissey and Kirchner describe this and other typical menopausal symptoms, as well as pharmacologic, hormonal, and lifestyle options that can bring relief and enable a smooth midlife passage.
Morrissey DR, Kirchner JT. Management of the climacteric: options abound to relieve women's midlife symptoms. Postgrad Med 2000;108(1):85-100

The term "climacteric" comes from the Greek word for rung of a ladder and refers to the period of passage out of the reproductive stage of life and into the nonreproductive phase. In women, it encompasses perimenopause, menopause, and the early postmenopausal years.

The climacteric can be accompanied by wide-ranging symptoms that are quite bothersome. However, physicians who understand the hormonal symptoms, who can differentiate these symptoms from age-related changes, and who are familiar with hormone replacement therapies, alternative therapies, and effective life-style modifications can help their patients gain relief.

Patterns of hormonal change

Perimenopause, or premenopause, is the period of years in which normal ovulatory cycles give way to cessation of menses. This time is marked by irregular menstrual cycles (1). Cycle length begins to increase (figure 1), and ovulation and fertility decrease. In the United States, average age at onset of perimenopause is 46 years (range, 39 to 51 years), and mean duration is about 5 years (range, 2 to 8 years).

Menopause is typically defined as the point, after the loss of ovarian activity, when permanent cessation of menstruation occurs (1). The average age at which this occurs is 51 years (range, 44 to 56 years). Cessation of menses before age 40 is considered secondary amenorrhea. Differential diagnosis of secondary amenorrhea includes premature ovarian failure, or early menopause, which occurs in 1% of women in the United States.

Women tend to experience menopause at the same age their mothers did. Risk factors for early menopause are higher socioeconomic class and smoking (2). Alcohol use, parity, and meat consumption have a dose-response relationship to later menopause (2).

Hormonal changes during perimenopause include a decrease in inhibin and an increase in follicle-stimulating hormone (FSH). Surprisingly, estradiol levels increase initially in response to rising FSH levels and then begin declining 6 to 12 months before menopause. After menopause, the ovaries no longer make significant amounts of estrogen. Instead, androstenedione from the adrenal glands and ovaries is converted to estrone, which is in turn converted to estradiol. Proportionally, estradiol levels decrease more than do estrone, testosterone, and androstenedione levels.

Hormone-related symptoms

Symptoms that are related to midlife hormonal changes include abnormal bleeding, vasomotor flushes (hot flashes), and urogenital discomfort. Treatment options include various hormonal, pharmacologic, herbal, and nutritional agents (tables 1 through 4) and lifestyle changes.

Table 1. Equivalent dosage and cost comparison of estrogen formulations
Formulation	Daily dose	Monthly cost*
Conjugated estrogens, natural (Premarin)	0.625 mg	$15
Conjugated estrogens, synthetic (Cenestin)	0.625 mg	$14
Estradiol, micronized (Estrace)	1.0 mg	$14 (brand) $10 (generic)
Estradiol, transdermal	50 micrograms	$24-33
Esterified estrogens (Estratab, Menest)	0.625 mg	$15 (brand) $8 (generic)
Estropipate (Ogen, Ortho-Est)	1.25 mg	$12-18 (brand) $13 (generic)
Ethinyl estradiol (Estinyl)	5.0 micrograms	$11**
*Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards. **Cost for 20 micrograms.

Table 2. Equivalent dosage and cost comparison of selected progestin formulations
Formulation	Daily dose	Cyclic dose	Monthly cost*
Medroxyprogesterone acetate	2.5 mg	5 mg	$9 (brand) $6 (generic)
Norethindrone (Micronor)	3.5 mg	7 mg	$38 (brand) $35 (generic)
Progesterone, micronized (Prometrium)	100 mg	200 mg	$18
*Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards.

Table 3. Cost of selected vaginal estrogen replacement formulations
Product (ingredient)	Monthly cost*
Estrace cream (estradiol, 0.1 mg/g)	$42
Estring ring (estradiol, 2 mg)	$26
Ogen cream (estropipate, 1.5 mg/g )	$51
Premarin cream (conjugated estrogens, 0.625 mg/g)	$50
*Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards.

Table 4. Dosage, common side effects, and costs of selected agents used in treatment of hot flashes
Agent	Dosage	Common side effects	Monthly cost
Conjugated estrogens, natural	0.625 mg qd	Nausea, breast tenderness, endometrial and breast cancer risk, headache	$15*
Medroxyprogesterone acetate	20 mg qd	Irregular bleeding, bloating, weight gain, depression	$26* (brand) $16* (generic)
Methyldopa (Aldomet)	500 mg bid	Sedation, headache, gastrointestinal upset	$47* (brand) $37* (generic)
Clonidine HCl (Catapres)	0.1-0.2 mg bid	Dry mouth, constipation, central nervous system depression	$45-67* (brand) $12-19* (generic)
Soy protein	60 g qd	Gastrointestinal upset	$15-30**
Black cohosh (Remifemin)	2 mg bid	Gastrointestinal upset	$10-15**
Tibolone***	2.5 mg qd	Nausea, edema, breast tenderness	NA
Veralipride***	100 mg qd	Galactorrhea, breast tension, gastrointestinal upset	NA
Bellergal-S	1 tablet bid	Dry mouth, dizziness, sleepiness	$40**
NA, not available. *Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards. **Average cost based on quotes from local retailers. ***Not currently available in the United States.

Abnormal uterine bleeding
Anovulation in the perimenopausal years leads to unopposed estrogen and dysfunctional uterine bleeding. However, abnormal bleeding may also be a sign of endometrial hyperplasia or cancer. Transvaginal ultrasound revealing an endometrial stripe of less than 5 mm is reassuring and essentially rules out cancer (3). An endometrial stripe greater than 4 mm necessitates endometrial sampling, preferably with in-office use of a Pipelle endometrial suction curette or similar device. Endocrine tumors, liver disease, obesity, hyperthyroidism, hypothyroidism, and ovarian tumors may also cause abnormal uterine bleeding and should be considered in the differential diagnosis.

Even if pathologic causes have been ruled out, dysfunctional uterine bleeding remains a sign of unopposed estrogen and, in general, should be treated. Treatment options include low-dose oral contraceptives and cyclical or continuous progestogen.

Hot flashes
Hot flashes, or flushes, begin with a sudden reddening of the skin of the head, neck, and chest accompanied by a feeling of intense body heat and conclude with perspiration that may be profuse. These episodes last for a few seconds to several minutes or, rarely, up to an hour. When they occur during sleep, often women say they have night sweats.

During a hot flash, skin temperature increases but core body temperature actually decreases. Hot flashes occur in 10% to 40% of premenopausal and 50% to 85% of postmenopausal women. Episodes occur daily in 15% to 20% of postmenopausal women. In most women, the episodes occur over a period of 1 to 2 years, but in 20% to 25% they continue for more than 5 years (1). Differential diagnostic considerations include pheochromocytoma, carcinoid, leukemias, pancreatic tumors, thyroid abnormalities, and psychosomatic disorders.

An elevated FSH level supports, but does not absolutely confirm, that symptoms are related to menopause. Measurement of the serum estrogen level is not generally useful for determining whether menopause is the cause of hot flashes.

Because hot flashes are not inherently dangerous, treatment is symptomatic only. Standard first-line treatment is hormone replacement therapy (HRT), usually taken orally or administered as a transdermal patch. Second-line therapy is a progestin. Oral medroxyprogesterone acetate at doses of 20 mg/day was found to reduce the frequency of hot flashes by 90% in one study (4) and by 74% in another (5). Depot medroxyprogesterone given at a dosage of 150 mg/week for 4 weeks (6) was found to relieve 90% of vasomotor symptoms and at a dosage of 100 to 150 mg/week for 12 weeks, relieved 100% of symptoms (7). Megestrol acetate, a synthetic derivative of natural progesterone, relieved at least 50% of symptoms in 75% of women when given at a dosage of 20 mg twice daily for 4 weeks (8). For all progestins, the side effects of irregular bleeding, bloating, weight gain, and depression can be limiting.

Third-line therapy should be based on comorbid conditions. For example, patients with hypertension may benefit from methyldopa (Aldomet) or clonidine hydrochloride (Catapres). Methyldopa, 250 to 500 mg twice daily, reduced the frequency of hot flashes by 65% compared with a 38% reduction with placebo (9). A single evening dose of 375 to 750 mg was not statistically better than placebo at reducing hot flash frequency (80% versus 65%) but was preferred over placebo by 63% of women (10).

Use of clonidine has had variable results. A standard gynecology textbook states that transdermal clonidine is more effective than the oral form (11). However, studies (12-24) suggest that oral clonidine is just as good or possibly better. In the largest trials, the oral formulation was effective, with reductions of 43% to 88% in hot flash frequency (12,14), but transdermal clonidine was unimpressive, with only a 20% reduction in frequency (23). In the latter study, only 31% of women given clonidine reported that they were feeling better, compared with 24% given placebo (23). Side effects of clonidine include dry mouth, constipation, and central nervous system depression.

Fourth-line therapies for hot flashes include proven alternative therapies, such as soy protein and black cohosh. In a trial of 104 women (25), 60 g of isolated soy protein per day reduced the number of hot flashes by 45%, versus 30% with placebo. However, 25% of the women dropped out of the study because of gastrointestinal side effects. In another study (26), hot flashes decreased in 23 (40%) of 58 women who received dietary supplementation with soy flour and in 8 (25%) of 30 who consumed wheat flour. Another trial compared soy protein at 20 g/day in a single dose or 10 g twice a day with placebo (27). Soy was no more effective than placebo for controlling night sweats, and hot flash severity was improved over placebo in only the twice-a-day group. These data collectively suggest that a dose higher than 20 g daily should be used.

Black cohosh is an herbal supplement that contains phytoestrogens. A review of eight clinical trials (28) concluded that black cohosh is safe and effective for treating hot flashes. All eight studies used the brand Remifemin as drops or tablets. Patients took 40 drops or two 2-mg tablets twice a day. However, these forms of black cohosh may not be readily available. For example, one national retailer carries Remifemin only as 20-mg tablets (cost, $15/month). Another national retailer does not offer Remifemin but has a different brand available as 500-micrograms tablets. Herbal products are not regulated by the US Food and Drug Administration and may vary in strength.

Fifth-line therapy should be guided by a concept called "the trial of one," in which harmless but unproven therapies are given a trial on a patient-by-patient basis. The physician and patient can experiment with successive agents until relief is found. This strategy is appropriate for hot flashes because many safe treatments are available. Moreover, there may be a 20% to 50% response to placebos.

Vitamin E is commonly prescribed for hot flashes. A MEDLINE search identified only one randomized, controlled trial of this therapy (29). In it, vitamin E (800 IU/day) resulted in only one less hot flash per day. Furthermore, patient preference for vitamin E over placebo (32% versus 29%) was not statistically significant. However, vitamin E is low in cost and may provide some additional cardiovascular benefits (30).

Dong quai is popularly considered an estrogenic herb. However, a study to detect its estrogenic effect on endometrial thickness, vaginal maturation, and vasomotor flushes found no difference from placebo (31). Other agents that have been reported to relieve hot flashes include vitamins B and C, zinc, ginseng, bee pollen, angus castus, red sage, fenugreek, gotu kola, sarsaparilla, licorice root, wild yam root, and beth root (32).

Bellergal-S (a combination of belladonna, ergotamine, and phenobarbital) has been used for many years for treatment of hot flashes but has generally gone out of favor. In one older study (33), this formulation reduced symptom severity scores by 66%, versus 22% with placebo. A more recent study (34) found Bellergal-S to be ineffective. More important, Bellergal-S has many contraindications for use. Ergotrates are contraindicated in patients with peripheral vascular disease, coronary vascular disease, hypertension, and impaired hepatic or renal function. Belladonna is contraindicated in patients with glaucoma, asthma, and obstructive uropathy. Phenobarbital sodium (Bellatal, Luminal Sodium, Solfoton) is sedating and potentially addictive and should not be used for long periods of time (32). It may be useful at bedtime for hot flashes that disturb sleep.

A final but very important approach is to counsel women about lifestyle changes that can attenuate hot flash severity. Patients can be told to keep a diary of triggers or avoid such inducers as hot weather, warm rooms, alcohol, caffeine, and hot or spicy foods. They should wear layered clothing, preferably made of cool, breathable, natural material, such as cotton. Regular exercise has also been reported to help (32).

Urogenital discomfort
Dysuria is a result of mucosal thinning of the bladder and urethra and is common in postmenopausal women. It responds very well to HRT. Dysuria can also signify a urinary tract infection, and this diagnosis should routinely be ruled out. A 1993 study by Raz and colleagues (35) found that recurrent urinary tract infections were effectively prevented (0.5 versus 5.9 episodes per year) by postmenopausal treatment with intravaginal estriol.

Women with urge, stress, or mixed urinary incontinence may improve with HRT, but the current evidence is contradictory. In a study of 629 postmenopausal women (36), both urge and stress incontinence improved with topical estriol. A smaller, placebo-controlled study of oral conjugated estrogens (37) found no significant benefit. Many investigators have suggested that topical estrogen therapy is more effective than oral therapy for this condition.

Dyspareunia results when estrogen deficiency reduces vaginal lubricating fluid and vaginal elasticity. Consistent sexual activity helps prevent this decline. Vaginal lubrication with nonprescription formulations (eg, K-Y, Replens) is also effective. Oral, transdermal, and topical estrogens are all effective for dyspareunia, as noted by Speroff and colleagues (1).

If systemic estrogen is contraindicated, vaginal creams should probably be avoided, since they are rapidly absorbed by atrophic epithelium (38). The estradiol ring (Estring), however, does not produce significant levels of serum estradiol. It is less expensive, more convenient (lasting 3 months), and better tolerated (having 78% compliance at 1 year) (39). After the vaginal epithelium has been restored with use of the ring for 3 to 6 months, it is acceptable to switch to a vaginal cream that can be used two to three times per week.

Estrogen replacement does not effectively treat all urogenital disorders. Opinions differ about which conditions deserve a trial of estrogen therapy. However, in general, conditions such as cystocele, rectocele, uterine prolapse, and vulvar dystrophy are not caused by estrogen deficiency and thus do not respond to estrogen replacement (1).

Other estrogen-deficiency disorders
Hirsutism is usually a consequence of a decreased estrogen-androgen ratio. In perimenopause, this should be evaluated and treated as in premenopause. In postmenopausal women, HRT increases the levels of estrogen and sex hormone-binding globulin. The sex hormone-binding globulin decreases the free testosterone level. As a consequence, the estrogen-androgen ratio will increase and growth of new hair will decrease. Electrolysis, waxing, or bleaching may be necessary to treat established hairs, even if HRT prevents new growth. Adrenal and ovarian tumors are a possible concern in women with persistent hirsutism or other signs of virilization.

Skin loses collagen content and thickness with age and estrogen deprivation. This leads to tissue sagging and wrinkles. Topical estrogen cream improves facial wrinkles (40), and oral HRT is associated with a lower prevalence of skin wrinkling and dryness (41). Unfortunately, this benefit is offset by smoking, which can be another reason to encourage patients to quit smoking (41).

Central (android) obesity is a consequence of estrogen deficiency. In midlife, women tend to gain weight whether they are menopausal or not. However, after menopause, this weight is distributed more in the abdomen than in the thighs and hips. HRT effectively prevents this redistribution of body fat (42) but does not prevent weight gain itself (43).

Decreased libido is common in menopause. Although this symptom does not seem to respond to HRT, many studies have suggested a benefit from androgen replacement. Multiple studies of parenteral administration of androgen, which were recently reviewed (44), have shown increases in various sexual parameters. A study comparing use of daily doses of combined esterified estrogens and methyltestosterone (45) (1.25 mg and 2.5 mg, respectively) with use of esterified estrogens alone or placebo showed increased sexual sensation and desire in the estrogen-androgen group relative to those receiving the other treatments. However, the review suggests choosing parenteral formulations over oral forms to avoid negative hepatic and lipid side effects. The investigators also suggest measuring testosterone levels before considering replacement and limiting doses to physiologic levels (44). It is important to discuss with patients other possible causes of diminished libido, including depression, dyspareunia, alcohol, and use of psychotropic medicines.

Insomnia is a common complaint of postmenopausal women. Hot flashes often contribute to this problem; however, hot flashes are not the sole explanation, since HRT improves sleep in women who have insomnia without hot flashes (46). Behavioral therapy and use of a pharmacologic adjunct such as Bellergal-S, a sedative-hypnotic, an antihistamine, or a low-dose tricyclic anti-depressant may also be prescribed.

Nonhormonal midlife changes

Several common problems of the climacteric do not seem to be due to estrogen deficiency and do not respond to HRT. Weight gain, as previously mentioned, is a function of age, diet, and exercise, not estrogen deprivation (43). Fatigue, nervousness, headaches, irritability, joint and muscle pain, dizziness, and palpitations are common in both men and women in midlife and are probably not attributable to hormonal changes (1).

Menopause is not associated with an increased risk of depression. On the contrary, depression is less common among middle-aged women (1). Therefore, if a woman in the climacteric has any of these nonhormonal symptoms, a cause should be sought from among the common changes of midlife other than menopause (eg, the loss of a parent, a change of employment, a child leaving for college or moving out of the house).

Despite these facts, mood symptoms do improve with HRT (47). Most authorities attribute this to relief from hot flashes. However, such relief with use of veralipride did not result in the same improvement in quality of life that resulted from HRT (48). In fact, a group of asymptomatic women showed improvement on the Beck Depression Inventory after starting HRT (49). Therefore, if a woman is not receiving HRT for other reasons, it seems prudent to suggest HRT for persistent, nonhormonal emotional symptoms that are not attributable to other causes.

Conclusion

A crucial role of the primary care physician is to counsel and educate perimenopausal patients about the diverse and often bothersome changes that can accompany the climacteric. For most of these patients, standard therapy remains HRT. The benefits of HRT extend to protection against osteoporosis and coronary disease. However, many women have medical contraindications or are simply averse to using HRT. Fortunately, for these patients there is a growing armamentarium of new estrogen products and alternative therapies that are effective for relief of symptoms associated with the climacteric.

References

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24. Loprinzi CL, Goldberg RM, O'Fallon JR, et al. Transdermal clonidine for ameliorating post-orchiectomy hot flashes. J Urol 1994;151(3):634-6
25. Albertazzi P, Pansini F, Bonaccorsi G, et al. The effect of dietary soy supplementation on hot flushes. Obstet Gynecol 1998;91(1):6-11
26. Murkies AL, Lombard C, Strauss BJ, et al. Dietary flour supplementation decreases post-menopausal hot flushes: effect of soy and wheat. Maturitas 1995;21(3):189-95
27. Washburn S, Burke GL, Morgan T, et al. Effect of soy protein supplementation on serum lipoproteins, blood pressure, and menopausal symptoms in perimenopausal women. Menopause 1999;6(1):7-13
28. Lieberman S. A review of the effectiveness of Cimicifuga racemosa (black cohosh) for the symptoms of menopause. J Womens Health 1988;7(5):525-9
29. Barton DL, Loprinzi CL, Quella SK, et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. J Clin Oncol 1998;16(2):495-500
30. Emmert DH, Kirchner JT. The role of vitamin E in the prevention of heart disease. Arch Fam Med 1999;8(6):537-42
31. Hirata JD, Swiersz LM, Zell B, et al. Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. Fertil Steril 1997;68(6):981-6
32. Hendrix SL. Nonestrogen management of menopausal symptoms. Endocrin Metab Clin North Am 1997;26(2):379-90
33. Lebherz TB, French L. Nonhormonal treatment of the menopausal syndrome: a double-blind evaluation of an autonomic system stabilizer. Obstet Gynecol 1969;33(6):795-9
34. Bergmans MG, Merkus JM, Corbey RS, et al. Effect of Bellergal Retard on climacteric complaints: a double-blind, placebo-controlled study. Maturitas 1987;9(3):227-34
35. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 1993;329(11):753-6
36. Schmidbauer CP. [Vaginal estriol administration in treatment of postmenopausal urinary incontinence.] Urologe A 1992;31(6):384-9 (Ger)
37. Fantl JA, Bump RC, Robinson D, et al. Efficacy of estrogen supplementation in the treatment of urinary incontinence. Obstet Gynecol 1996;88(5):745-9
38. Rigg LA, Hermann H, Yen SS. Absorption of estrogens from vaginal creams. N Engl J Med 1978;298(4):195-7
39. Henriksson L, Stjernquist M, Boquist L, et al. A one-year multicenter study of efficacy and safety of a continuous, low-dose, estradiol-releasing vaginal ring (Estring) in postmenopausal women with symptoms and signs of urogenital aging. Am J Obstet Gynecol 1996;174(1 Pt 1):85-92
40. Creidi P, Faivre B, Agache P, et al. Effect of a conjugated oestrogen (Premarin) cream on ageing facial skin: a comparative study with a placebo cream. Maturitas 1994;19(3):211-23
41. Dunn LB, Damesyn M, Moore AA, et al. Does estrogen prevent skin aging? Results from the First National Health and Nutrition Examination Survey. Arch Dermatol 1997;133(3):339-42
42. Reubinoff BE, Wurtman J, Rojansky N, et al. Effects of hormone replacement therapy on weight, body composition, fat distribution, and food intake in early postmenopausal women: a prospective study. Fertil Steril 1995;64(5):963-8
43. Wing RR, Matthews KA, Kuller LH, et al. Weight gain at the time of menopause. Arch Intern Med 1991;151(1):97-102
44. Basson R. Androgen replacement for women. Can Fam Physician 1999;45(Sep):2100-7
45. Sarrel P, Dobay B, Wiita B. Estrogen and estrogen-androgen replacement in postmenopausal women dissatisfied with estrogen-only therapy: sexual behavior and neuroendocrine responses. J Reprod Med 1998:43(10):847-56
46. Polo-Kantola P, Erkkola R, Helenius H, et al. When does estrogen replacement therapy improve sleep quality? Am J Obstet Gynecol 1998;178(5):1002-9
47. Wiklund I, Karlberg J, Mattsson LA. Quality of life of postmenopausal women on a regimen of transdermal estradiol therapy: a double-blind placebo-controlled study. Am J Obstet Gynecol 1993;168(3 Pt 1):824-30
48. Limouzin-Lamothe MA, Mairon N, Joyce CR, et al. Quality of life after the menopause: influence of hormonal replacement therapy. Am J Obstet Gynecol 1994;170(2):618-24
49. Ditkoff EC, Crary WG, Cristo M, et al. Estrogen improves psychological function in asymptomatic postmenopausal women. Obstet Gynecol 1991;78(6):991-5

Dr Morrissey is a third-year resident and Dr Kirchner, coordinator of this series, is associate director, Family Practice Residency Program, department of family and community medicine, Lancaster General Hospital, Lancaster, Pennsylvania. Correspondence: Jeffrey T. Kirchner, DO, Department of Family and Community Medicine, Lancaster General Hospital, 555 N Duke St, PO Box 3555, Lancaster, PA 17604-3555. E-mail: jtkirchn@lha.org.

A Natural Passage through Menopause

The current medical view of menopause is that menopause is a disease rather than a normal physiological process. The medical response to the disease is to treat it with drugs. The most popular estrogen drug in the United States is Premarin which contains estrogens derived from the urine of pregnant mares. Other popular estrogen drugs are Estrace and Estraderm.

Reports of increases in endometrial cancer (cancer of the lining of the uterus) being linked to estrogen began surfacing as early as 1961. In 1975 and 1976 three studies reported such strong links between estrogen and endometrial cancer that the FDA (Food and Drug Administration) issued a recommendation that pharmaceutical companies place warnings on estrogen package inserts. In response to these studies, doctors began prescribing a progestin (synthetic form of progesterone) called Provera as an adjunct to Premarin to help prevent estrogen-induced uterine cancer. Progesterone, when occurring naturally, counteracts the tumor-stimulating effects of estrogen in the body; it does not, however, reduce the risk of estrogen-induced breast or ovarian cancers.

In addition to the increased cancer risks, estrogen and progestin drugs have well-documented side effects such as weight gain, thrombosis (abnormal blood clot formation), nausea, headaches, irritability, fluid retention, increased risk of gallstones, fibroid tumors and adult-onset asthma.

Why would women consider taking these drugs?

Despite their unpleasant and sometimes dangerous side effects, HRT (hormone replacement therapy) can produce true anti-aging effects such as smoother, firmer skin, better muscle tone, reduced genital atrophy and vaginal dryness and relief from menopausal symptoms such as hot flashes, dizziness and mood swings. HRT has been reported to slow the loss of bone density, help prevent osteopororis, improve memory and the ability to concentrate and support the immune system.

Another supposed benefit of HRT is reduced risk of heart disease and strokes. New research, however, is showing that HRT may not be effective in preventing heart disease. According to Ellen Kahmi, Ph.D., R.N and co-author of Cycles of Life: Herbs and Energetics for Women, in a recent interview on WebMD a study called HERS (the Heart Estrogen/Progestin Study), 2,763 women with heart disease were found after four years of HRT to have just as many heart attacks as women not on hormones. During the first year of treatment, more women had heart attacks and other cardiovascular problems than those who were given the placebo. The American College of Cardiology (ACC) discussed at a meeting in March that HRT again showed no protective effect for heart disease. On the other hand, HRT is related to a slight increased risk in deep vein thrombosis and clots in the lungs as well as clots in the cardiovascular system.

Is there another, more natural way to achieve the benefits of HRT without the risks?

Recent studies show that changes in diet, regular exercise and supplementation with certain vitamins and plant-derived estrogens or phytoestrogens can relieve the symptoms of menopause and protect your heart and bones without the side effects of synthetic hormones.

Diet

Adhering to a low-fat, high fiber diet with at least 5 to 9 daily servings of fruits and vegetables while limiting animal protein is one of your best defenses against heart disease, stroke, cancer, diabetes, arthritis and cataracts.

While you should reduce the amount of saturated fat in your diet, �good fats� such as the Omega 3�s found in flaxseed, flaxseed oil and cold water fish are highly beneficial. Eating several servings a week of tuna, salmon, sardines, herring or mackerel can reduce cholesterol and the risk of heart disease and stroke, relieve the pain associated with inflamed arthritic joints and even combat depression.

Animal protein, especially red meat, is high in phosphorous as are carbonated drinks such as colas and other sodas. Phosphorous can cause the excretion of calcium from your bones. Try to limit the intake of animal protein and eliminate sodas if at all possible.

For Asian and Latin women, menopause is a relative nonevent, both physically and emotionally. This smooth transition from one age to another is due partly to a culture that values the experience that comes with age rather than fearing it. Researchers attribute the lack of physical symptoms in Asian and Latin women, however, to a diet consisting largely of legumes such as lentils, soy, and chickpeas that are rich in phytoestrogens. Phytoestrogens are plant hormones that are accepted by our bodies because they closely mimic human hormones. They are classified into groups - the flavones, flavanones, flavonols, chalcones, lignans, and isoflavones.

The most common types of phytoestrogens are flavones and lignans, the most potent are the isoflavones. Lignans and flavones are found in most cereals and fruits and vegetables. Isoflavones, however, are only found in legumes such as soy, lentils, chickpeas, and beans. Most American women will have modest levels of lignans and flavones in their blood but very low levels of isoflavones.

Adding soy to your diet can relieve many of the symptoms associated with menopause. Soybeans are rich in isoflavones and phytosterols. Consuming 300 mg. of soy isoflavones would be roughly equivalent to taking a .45 mg. tablet of Premarin. There is one big difference however, while synthetic hormone replacement has been linked to increasing cancer, studies have shown that Japanese women who eat an average of 30-50 grams of soy a day (150-200 mg of isoflavones) enjoy a relatively low rate of hormone-related cancers.

Soy products have been attributed to reducing the risk of breast cancer, lowering cholesterol and protecting the heart. Studies have also shown that the phytoestrogens in soy can help increase bone density and bone mineral content. If you wish to incorporate soy into your diet, you are not limited to soy beans. Soy milk, tempeh, tofu and soy cheese are all rich sources of isoflavones.

Exercise

The most important effect of regular exercise, especially weight bearing exercises such as strength training and walking, is the increased mineralization of your bones. A study was devised to measure the effectiveness of exercise on bone density. A group of postmenopausal women were given a program of exercise comprising of a fast, one-hour walk three times a week alternating with a one hour series of back extensions and posture exercises two times a week. At the end of the study, the women who followed the exercise program while taking medications to combat osteoporosis showed a 4.4 percent increase in spinal bone density as opposed to the women on medication alone who experienced a bone density increase of only 1.6 percent.

Regular exercise has also been shown to reduce the frequency and severity of hot flashes, improve circulation, reduce blood cholesterol levels and relieve stress.

Menopause 101

With record number of baby boomers now reaching mid-life, menopause has become the news hot flash of the 1990�s. Yet much of what we hear or read about menopause is alarmist, misleading or downright confusing.  Dr. Donnica explains that menopause is a transitional time characterized by the end of the menstrual cycle-and the beginning of the final third of a woman�s life. She also discusses what menopause is, what its consequences are, and what is available to treat them.

Each day, 4,000 women in the United States and Canada reach menopause, which is simply the end of a woman's menstrual cycle. During the perimenopausal period (up to 10 years before menopause), the ovaries decrease production of the "female hormones" estrogen and progesterone, the hormones which allow a woman to become pregnant and to menstruate.  Yet these hormones also affect many other functions in a woman�s body such as the circulatory system, urogenitary system, nervous system, skeletal system, memory, sexuality, skin, vision, and teeth.

The average age for menopause in American women is 51. However, when menopause begins and the length of time it lasts varies for every woman. Menopause means more than just losing your periods.  This is a syndrome with clinical symptoms as well as long term consequences.  Estrogen loss can have wide-ranging effects--from menopausal symptoms (such as hot flashes) to increased risk of heart disease and osteoporosis, which can be life threatening.  Because most women will live a third of their life after menopause, it is important to be aware of the symptoms, systemic effects, and available treatment options associated with estrogen loss. 

The term "menopausal" usually refers to the year preceding the end of menstruation and the five years following.  "Postmenopausal" refers to the time thereafter.  "Perimenopause" is the 2-10 year time period preceding menopause; it is this period we are now learning more about.  "Premature menopause" is defined as menopause occurring for whatever reason before age 40.  It is also called "premature ovarian failure".

An important definitional distinction here is that women who have had a hysterectomy (surgical removal of the uterus) but whose ovaries function normally won�t have periods, but they are not "in menopause."  They will go into menopause naturally when their ovaries cease functioning.  Many women who have a hysterectomy also have their ovaries removed (ovariectomy or oophorectomy) at the same time; it�s important to find out which category you are in if you have had either type of surgery.

Interestingly, up to a third of women report no disruptive menopausal symptoms; in others the symptoms may last several years, usually between ages 40 and 55.   The most common symptom is that menstrual periods appear less and less frequently, or, in some cases, "irregularly irregular" until they stop altogether.  Many women have the typical symptoms of menopause: hot flashes, night sweats, irritability, moodiness, sleep disturbances, vaginal dryness, decreased libido, and hair coarseness/loss

Learning Center - Menopause Overview

An Ending and a Beginning
In the history of the world, menopause is a relatively recent condition � before the twentieth century most women did not live long enough to experience this biological change. Advancements in medical science during the last 100 years have increased life expectancy, so that menopause is now a normal life event for women. In fact, it is estimated that by the year 2020, there will be over 45 million women older than age 55. While menopause signals the end of fertility, it also marks the beginning of a time when growth and transformation are possible.

What is Menopause?
Menopause is the result of a gradual biological process (a phase called perimenopause) when the ovaries decrease production of female sex hormones, most notably estrogen, and menstruation eventually stops. Menopause may occur as the natural result of aging or may be induced as a result of surgical or medical intervention.

• Begins sometime in the decade before menopause (late 30s to early 40s).
• Menstrual cycles may become irregular and menstrual flow may become unusually light or heavy.
• Irregular hormone levels may be associated with symptoms such as hot flashes, breast tenderness, night sweats, fatigue, and concentration and memory changes.

• Identified as the last normal period in a woman�s life.
• Menopause is reached when a woman has not experienced a menstrual period for one full year.
• The average age of menopause in the United States is 51 years, 4 months.

• Hereditary factors
• Whether or not a woman smokes
• Whether any medical procedures, such as a oophorectomy (removal of both ovaries), have been performed

• Irregular bleeding before the last period
• Hot flashes
• Changes in sexual desire
• Weight gain
• Mood swings
• Reported memory loss and concentration changes
• Secondary insomnia
• Vaginal dryness
• Incontinence
• Hair loss or growth of facial hair

• Estrogen replenishment for osteoporosis
• Regular exercise that includes weight training and weight-bearing exercise
• A healthy diet with adequate calcium intake
• A no-smoking lifestyle

Each is more useful with a good working partnership with your clinician.

Knowledge is Power
As menopausal women make up more of our society � "Baby Boomers" are reaching middle age � information, treatments and support for women are increasing. It is vital for you to be knowledgeable about your risks, and all the options available to make informed decisions about your long-term health.

If you reach midlife understanding the process during menopause, you may experience the transition with less anxiety, allowing you to make effective decisions in partnership with your clinician.

Hormone replacement for women at menopause

Charlotte Libov, M.D., physician advocate for women�s heart health, explores the myths concerning women and heart disease which were promulgated in medical schools throughout most of the past century. First, women are NOT largely "immune" to heart disease. Second, if a woman DOES suffer a heart attack, she may not be elderly, as previously assumed.

These relatively new clarifications of the mythic nature of women�s heart treatment show that heart disease is actually the biggest killer of American women, with over 240,000 dying annually. At least 21,000 of these women are under the age of 65. Women with a negative heart history in the family, and particularly if high blood pressure is present, need to take proactive steps such as quitting smoking, reaching and maintaining a normal weight, and engaging in a healthful program of exercise to minimize their risk of serious coronary consequences.

Women who are postmenopausal should discuss the use of estrogen-replacing hormones. While further studies are being done, current data shows that women who take estrogen are half as likely to suffer heart attacks or die from heart disease. But there are risks associated with hormone replacement, such as elevated probability of acquiring breast cancer. How does a woman decide what to do?

The Harvard Medical School�s Harvard Heart Letter recommends that a balance be achieved between risks and benefits, when women are deciding whether or not to take estrogen replacements. The major benefits of postmenopausal estrogen therapy are a reduction in the risk of heart disease and osteoporosis, as well as the symptomatic relief from postmenopausal symptoms like hot flashes and vaginal dryness.

The potential risks are increased chances of breast cancer and endometrial cancer (cancer of the uterus), although the latter risk seems to disappear if the woman takes progesterone along with the estrogen 12 or more days a month.

What do current studies show? Assessing the risk factors of almost 50,000 nurses in the Nurses� Health Study verified that women taking estrogen replacements lowered their risk of coronary artery disease by half. A further �meta-analysis� by Harvard researchers who combined the results of 30 epidemiologic studies revealed that estrogen therapy reduced the risk of CAD by 44%--close enough to �half� to cause physicians to take notice.

The Harvard Heart Letter finds this study particularly compelling because as many as one-third of all women 65 and over have coronary artery disease, and CAD is the leading cause of death in this group. Some experts speculate that women who take estrogen replacements tend to be healthier in ways that decrease their heart-disease risk, such as engaging in additional exercise, eating healthier diets, or seeing their physicians more frequently. Some of these factors could be responsible for the lowering of heart disease risk, yet there are clearly biologic reasons why estrogen should be good for the heart. For one thing, women on estrogen therapy continually have a significant increase in HDL, the good cholesterol, and a comparable decrease in the bad cholesterol, LDL.

Studies have also shown the positive effects of estrogen on the reactivity of blood vessels. That is, women who received injections or powerful oral doses of estrogen showed a significant dilatation of their blood vessels in response to certain stimuli, a factor that might be expected to protect the heart by providing increased blood flow. Also, it is thought that estrogen replacement may possibly decrease blood clotting, one of the factors thought to precipitate a heart attack. For example, estrogen users show lower levels of fibrinogen, a protein involved in blood clotting. Also, estrogen may improve the body�s response to insulin; since insulin resistance is another independent risk factor for heart disease, this is an added benefit. Some studies show that women taking estrogen report a lowered blood pressure, although this is not a definitive finding at this time.

Physicians are currently calling for more studies to look at the combination of progestin-estrogen therapies on heart health in women, since most studies thus far have focussed on estrogen replacement primarily. But another big plus factor for taking estrogen replacements is estrogen�s amazing ability to prevent bone loss density, and possibly even to increase bone density in many women. Since one in six women has a hip fracture during her lifetime, and many more have vertebral fractures, the increased bone density could be a major health factor overall. Recently, other medications that are not estrogens have become available to treat women with osteoporosis who should not take female hormones.

Exactly who are the women who should consider avoiding female hormones? Postmenopausal women who still retain their uterus and take estrogen therapy by itself have six times the likelihood of incurring endometrial cancer, a powerful warning. But when progestin is added to the prescribed dosage of estrogen, the risk seems to disappear. Thus, the concomitant use of progesterone with estrogen appears to protect against endometrial cancer.

Breast cancer risk however remains controversial. One study showed that women on some sort of estrogen therapy have a 40% increased risk of incurring breast cancer, and the risk appears to increase when the hormones have been taken for five or more years, putting women in the 60-65 year old range at particular risk. This factor remained solid, whether the treatment was for estrogen alone or estrogen in combination with progestin.

Another study is more reassuring, although the study involved a smaller number of participants. In it, researchers argued that there was no increased risk of breast cancer among women who took hormones for more than eight years. Probably the most significant factor for women considering hormone therapy is their personal histories. With a clear cut family history of breast cancer, which affects one women in nine over a lifetime and accounts for 45, 000 deaths of US women each year, women should consider the statistics soberly.

With no family history of breast cancer, whether or not heart disease history is present, women should probably be encouraged to consider estrogen replacement. With heart disease history in the family, women should probably be strongly encouraged toward hormone replacement in postmenopausal years.

The Women�s Health Initiative, a massive study which is looking at many aspects of female health, should prove enlightening. In one branch of the study 27,500 postmenopausal women will be treated either with estrogen alone, estrogen with progestin or with a placebo over a nine-year period. Investigators hope to more clearly define the role of hormone therapy as regards heart disease, osteoporosis, breast and endometrial cancer. Until results are in and fine-tuned, women should carefully consider the possibilities with their medical care providers and make the wisest choice available to them at this time.

Written by Eleanor Sullo

Title: Hormone replacement for women at menopause
Description: What's the latest scoop on hormone replacement therapy for menopause? The positives and negatives and possible side effects are considered.

Continuous Hormone Replacement Therapy After Menopause

What is continuous hormone replacement therapy?

Continuous hormone replacement therapy involves taking hormones every day after menopause, when the ovaries stop making enough of the female hormones estrogen and progesterone, or after surgery to remove the ovaries.

Are there different types of hormone replacement therapy?

Yes. There are different types of hormone replacement therapy. One type involves taking estrogen alone, but hormone replacement therapy with estrogen alone can increase the risk of cancer of the uterus (womb) and endometrium (lining of the uterus). Adding progestin, a synthetic form of progesterone, to your treatment seems to keep the risk of these two cancers down.

In the past, women taking these two hormones would take estrogen for the first part of the cycle and progestin during the latter part of the cycle. But this form of hormone replacement therapy may cause bleeding every month, much like having a menstrual period. Many women quit taking the hormones because of this monthly bleeding.

Taking both of the hormones every day throughout the month seems to fix this problem for many women - most women taking continuous estrogen and progestin therapy quit having bleeding after three to six months.

How is continuous hormone replacement therapy taken?

Your doctor will probably start you on the estrogen and progestin at the same time. He or she will probably start you on a low dose of progestin to see if you have bleeding on the lowest dose.

Take both pills every day. You don't have to stop on certain days of the months.

If you have bleeding, tell your doctor. The dose of progestin may need to be increased.

What are the benefits of hormone replacement therapy?

Hormone replacement therapy can be beneficial in many ways:

• It can reduce your risk of osteoporosis, a condition that causes the bones to become porous and thin and more likely to break.
• It can relieve symptoms of menopause, such as flushing, night sweats and vaginal dryness.
• It can decrease your risk of heart attacks.

As mentioned before, estrogen taken alone can increase the risk of cancer of the uterus and endometrium.

Progestin can cause tender breasts, fluid retention, swelling, moodiness and cramps. These side effects seem to be less for some women who take continuous hormone replacement therapy. Progestin may also reduce how well estrogen works to protect against heart disease. Studies are still being done on the use of progestin.

Generally, women who have had endometrial cancer, breast cancer, blood clots, stroke, unexplained vaginal bleeding or liver disease shouldn't take hormone replacement therapy.

Are there any signs of problems I should look for?

Yes. If you bleed after you haven't had any periods for several months, call your doctor. Also call your doctor if you notice any breast lumps or pain, or if you have any questions.

Menopause

Menopause is the ending of a woman's monthly menstrual periods and ovulation. It also signals other changes to the body and mind, brought on in part because the body begins producing smaller amounts of the hormones estrogen and progesterone (among others). The menopausal period is different for each individual woman. Menopause typically occurs between the ages of 45 and 55.

Menopause is not a disease. It is a natural process in a woman's life. How a woman views this time of her life can have a lot to do with how frequent and severe her symptoms are. If menopause is viewed as the end of youth and sexuality, this time will be much more difficult than if it is viewed as the next, natural phase of life. With a proper diet, nutritional supplements, and exercise, most of the unpleasant side effects of menopause can be minimized, if not eliminated.

Although menopause is one of the greatest physical milestones in a woman's life, many women lack concrete information about what is taking place and what are their options. Here is all the information you need to make an intelligent decision.

Menopause

by Sidra Vitale

Haven't been through it? I haven't. Want to know more about it? Me too.

Here's what we've got

• Literature A couple references on and off-line for you.
• Hopefully Helpful Sites Please, feel free to recommend a site you found especially useful.
• Online Support You are not alone!
• Organizations Other Organizations
• Other Women's Experiences Please share with us.

Literature

• NIH National Institute on Aging: Menopause
• Hot Flashes, by Christine Chuppa
• Estrogen and Osteoarthritis
• The Menopause Time Of Life
• PostMenopausal Hormone Therapy and Mortality
• Re-Assessing Hormone Therapy
• Managing Your Menopause, Wulf H. Utian, M.D., Ph.D., and Ruth S. Jacobowitz. New York: Prentice Hall/Simon & Schuster, 1990.
• The Menopause Self-Help Book, Susan M. Lark, M.D. Berkeley: Celestial Arts, 1990.
• Ourselves Growing Older, Paula Brown Doress and Diane Laskin Siegal. New York: Simon and Schuster, 1987 (in cooperation with the Boston Women's Health Book Collective).
• Estrogens: The Facts Can Save Your Life, Lila Nachtigall, M.D., and Joan Rattner Heilman. New York: Harper & Row, 1986.
• Choice Years, Judith Paige and Pamela Gordon. New York: Villard Books, 1991.
• Change of Life: The Menopause Handbook, by Susan Flamholtz Trien. New York: Fawcett, 1986.
• Menopause: A Positive Approach, Rosetta Reitz. Penguin Books, 1977.
• The Menopause, Hormone Therapy, and Women's Health-Background Paper. 'Congress of the United States, Office of Technology Assessment, May 1992.
• Who, What, Where? Resources for Women's Health & Aging, National Institute on Aging, March 1992.

Links

• Power Surge Support network and online community for women experiencing menopause.
• Atlanta Reproductive Health Centre Infertility, IVF, Endometriosis Homepage -- Includes Menopause
• ARHP: The Association of Reproductive Health Professionals
• The North American Menopause Society
• 50 Tips to Surviving Menopause Naturally By Joan Stark.

Wanna talk about it online?

Online Groups

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Want more info?

Organizations

National Institute on Aging (NIA)

9000 Rockville Pike
Bethesda, MD 20892
800-222-2225

North American Menopause Society (NAMS)

University Hospitals
Department of OB/GYN
2074 Abington Road
Cleveland, OH 44106
fax: 216-844-3348
(written requests)

National Women's Health Network

1325 G Street, NW
Washington, DC 20005
202-347-1140

American College of Obstetrics and Gynecologists (ACOG)

409 12th Street, SW
Washington, DC 20024
202-638-5577

Alliance for Aging Research

2021 K Street, NW, Suite 305
Washington, DC 20006
202-293-2856

Older Women's League (OWL)

666 11th Street, NW
Suite 700
Washington, DC 20001
202-783-6686

National Women's Health Resource Center (NWHRC)

2440 M Street, NW
Suite 201
Washington, DC 20037
202-293-6045

Wider Opportunities for Women (WOW)

National Commission on Working Women
1325 G Street, NW
Lower Level
Washington, DC 20005
202-638-3143

American Dietetic Association (ADA)

216 West Jackson Boulevard
Suite 800
Chicago, IL 60606
312-899-0040

American Heart Association (AHA)

7320 Greenville Avenue
Dallas, TX 75231
214-373-6300

National Heart, Lung, and Blood Institute (NHLBI)

9000 Rockville Pike
Bethesda, MD 20892
3014964236

National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse

Box AMS
9000 Rockville Pike
Bethesda, MD 20892
301-495-4484

National Osteoporosis Foundation (NOF)

2100 M Street, NW
Suite 602
Washington, DC 20037
202-223-2226

Sex Information and Education Council of the U.S. (SIECUS)

130 West 42nd Street
Suite 2500
New York, NY 10036
212-819-9770

DEPRESSION Awareness, Recognition, and Treatment Program

National Institute of Mental Health
D/ART Public Inquiries
5600 Fishers Lane
Room 15C-05
Rockville, MD 20857
301-443-4513

National Mental Health Association (NMHA)
Information Center

1021 Prince Street
Alexandria, VA 22314-2971
703-684-7722/800-969-6642

National Cancer Institute

Cancer Information Service
9000 Rockville Pike
Bethesda, MD 20892
800-4-CANCER
(800-422-6237)

American Cancer Society

National Headquarters
1599 Clifton Road, NE
Atlanta, GA 30329 800-ACS-2345
(800-227-2345)

Managing Menopause WITH Hormones

Objectives:

1. Evaluate the effects of a phytoestrogen rich diet on common menopause related experiences and concerns.
2. List common food sources of phytoestrogens.
3. Describe at least three basic concepts that should be considered in evaluating and/or initiating herbal therapies.
4. Define the new Dietary Reference Intakes (DRI's) for calcium and related nutrients.
5. Describe at least two concerns related to wild yam that should be shared with women who are seeking information about these products.
6. Describe at least three lifestyle strategies that can help minimize hot flashes and enhance the menopausal experience.

INTRODUCTION

I wish I had a dollar for every time a woman asked me for alternatives to estrogen in managing menopause! Several years ago it occurred to me that the best way to approach this request is to start with a few specific questions, similar to the assessment I would begin with if a woman wanted to use estrogen supplements:

What are your concerns?
What do you need help in managing?
What kind of effect are you looking for?

The goal is important to define because it helps to define the specific management, regardless of whether that involves use of an estrogen supplement, a particular diet or a specific herb. The following are some of the more common goals women have during this transition:

Decrease hot flashes
Decrease vaginal dryness
Improve sleep
Decrease risk for osteoporosis
Decrease risk for heart disease
Decrease risk for breast cancer

When a woman chooses to use estrogen, many of these common goals are addressed whether or not they are specific to her individual experience of menopause. However, with alternatives to estrogen, management strategies need to be fine-tuned to the specific outcome that is desired, since there isn't a single strategy that reproduces the exact effects of estrogen. That's not to say they are less than estrogen in terms of their effects - in fact, in my opinion, some are better than estrogen! With this in mind, this review will also be helpful in considering some of these strategies as adjunct to estrogen supplementation, in those situations where women prefer to use estrogen.

There are many ways a review like this can be organized, but I decided to be guided by the goals which women are seeking to address rather than to simply create a list of herbs and other substances. I begin with an overview of phytoestrogens, (this can get academically heavy at times, so I've tried to inject a bit of myself in some comments throughout) then proceed to strategies which are helpful for achieving specific outcomes.

Once last, but very important point�..THERE IS SO MUCH WE DON'T KNOW!

There are many researchable topics that emerge from this review, many of these can and should be done by nurses in collaboration with middle years women!

Before beginning this fascinating topic, take a look at one woman's artistic expression of menopause.
Birthing The Crone

PHYTOESTROGENS

General overview:

Phytoestrogens include:

1. isoflavones,(genistein and daidzein - commonly found in soybeans)
2. coumestans,(found in red clover and alfalfa sprouts) and
3. lignans. (found in oil seeds such as flaxseed) (16)

They have both estrogenic and anti-estrogenic effects in humans. The plant lignan and isoflavonoid glycosides are converted by intestinal bacteria into hormone-like compounds. (29)

There has been a lot of talk about phytoestrogens being the wonderful new option for menopausal women. It sounds simple, increase the phytoestrogen content in your diet and manage your menopause "naturally". However, it may not be that simple! There are, various estrogenic compounds that exist in our environment - and not all of them are beneficial to the human female. Some are "natural (phytoestrogens ) and some are synthetic (pesticides and industrial contaminants). All have the capability of interacting with estrogen receptors in the human body and stimulating estrogen-associated responses. In fact many synthetic estrogens appear to persist for months or years in body fat. They also have an antiestrogenic effect by competing with other estrogens and binding at estrogen receptor sites in the body - producing less opportunity for stronger estrogens to bind at these sites. (25)

Our knowledge base about these substances is complicated by the fact that some researchers tend to speak about these environmental estrogens as if they were all the same. I have found the term "phytoestrogen" used when speaking about industrial contaminants! Here are some examples of the confusion I found in the literature:

-Olea et al (4) describe phytoestrogens as "estrogenic xenobiotics or xenoestrogens", further defined as "endogenous disruptors", substances that cause adverse health effects in an intact organism or it's progeny, secondary to changes in endocrine function. During the 1960's and 70's, studies showed that a number of industrial compounds and pesticides produced an estrogen -like effect in humans. These included: DDT, kepone, methoxychlor, phenolic derivatives and polychlorinated biphenyls (PCB's).

-Safe and Gaido (7) describe xenoestrogens separately from phytoestrogens (dietary sources of estrogens) as chemical contaminants that act like estrogens and are generally harmful. The authors of this article call for more research regarding these estrogenic compounds, stating that their effects will depend on the following factors:

-metabolism and pharmacokinetics
-compound potency
-serum concentrations
-relative binding to serum proteins
-levels of exposure during critical periods

-Other authors (20) describe these substances as xenohormones - materials that modify hormonal production which, depending on the periods and extent of exposure, work through either genetic or hormonal paths. Genetically, they can modify DNA structure or function. Hormonally, beneficial xenohormones may reduce the growth of abnormal breast cells.

A two-edged sword: Animal studies have shown that specific phytoestrogens can have a beneficial effect. However, it's possible that the increased number of hormone-related diseases occurring in the environment are associated with some of these pseudo-estrogens - whether they are man made chemicals or naturally occurring phytochemicals. (10)

-Murkies et al. reported on a Medline review of the literature for the years 1975-1996, regarding the known biological effects of phytoestrogens in humans.(5) They concluded the following:

-phytoestrogens exhibit physiological effects in humans
-mild estrogenic changes occur in postmenopausal women
-there are some benefits related to high blood cholesterol
-further evidence is needed regarding cancer prevention

-A different Medline review (1980-1995) was done by Knight and Eden (27) and resulted in similar conclusions.

-Rudel (21) discusses two major assumptions associated with experimental data reporting on the effects of phytoestrogens. These are:

1. estrogenic potency found in the laboratory can predict the relative potency and effect in humans
2. all estrogenic substances act using the same mechanisms to produce these effects

The author identifies a need to address these methodologic concerns including issues related to pharmacokinetics, the role of timing and duration of exposure and possible interactions with other substances.

-Whitten and colleagues (35) emphasize the same concern, namely that phytoestrogens have a broad range of action and variability in their potencies. This variability demands that each phytoestrogen be studied in terms of it's sites of action, balance of agonist and antagonist properties, natural potency and short-term and long-term effects.

-In an earlier study conducted in 1994, the amount of isoflavones among various tofu products was variable from brand to brand. (36)

-The methodological concerns raised by the above authors reminds me of the historical "mess" found in research on postmenopausal estrogen use. Years of data becomes difficult to compile in any meaningful way for the following reasons:

1. The studies were done using different kinds and dosages of estrogens
2. The women involved in the studies were often mixed in terms of the type of menopause they were experiencing (women experiencing surgical menopause were often randomly included even though they had a very different hormonal pattern)

-A recent study has shown that the effect of a specific dietary phytoestrogens, such as flaxseed (the richest source of lignan precursors) can vary depending on harvest location and the harvest year. (22) This clearly adds to the difficulty in establishing research-based conclusions about their effects on humans.

-There may be possible problems and variances with the absorption of phytoestogens in different women. For instance, in one study using a cross over design, a fiber rich diet produced 55% lower plasma genistein levels 24 hours after ingesting soy. (40) The researchers believe that highly insoluble wheat fiber reduced the absorption of genistein probably by it's bulking effect and hydrophobic binding to this compound. It's clearly important to study the bioavailability of these substances in order to understand the range of doses that will result in the desired effect. I spoke by phone with Suzanne Henrich, one of the researchers on this team at the University of Iowa, because I wanted to clarify what, if any, practical implications this research offered. In particular, I wanted to know whether women would obtain less benefit from phytoestrogens if they had a high wheat diet. Suzanne said they were not prepared to offer that kind of practical assistance at this time based on their findings, however, she stressed the importance of recognizing individual variations which possibly decrease absorption in some individuals. She said it is possible (and these are current questions in their research), that women who have rapid gut motility obtain better availability and that meat eaters have less. Stay tuned!

-In another report (41) researchers presented their findings regarding the intestinal half life of daidzein and genistein, which may be as little as 7.5 and 3.3 hours respectively. This data was dependent on the relative ability of gut microflora to break down these compounds. This is important data to understand, especially if women are using these foods to try and minimize some of the common experiences of menopause such as hot flashes. The effect of foods that are consumed in the morning or the afternoon may not effect hot flashes which occur during the night. Something to think about!

-Soybeans also contain compounds that inhibit thyroid peroxidase which is essential in order to make thyroid hormone. When this happens in laboratory rats, it can produce a goiter and thyroid cancer. (9) More needs to be known about this effect!

Concerns about soy-based infant formulas:
(although not specific to menopause, it was too interesting not to include in this review!)

Sheehan (3) describes infant based soy formula as appearing to provide the highest of all phytoestrogen doses. Intake occurs during early growth and development - the life-stage that is especially vulnerable to toxicity. Setchell and colleagues (17) analyzed the isoflavone composition from 25 randomly selected samples of soy-based infant formulas from five major commercial brands and found the following:

"The daily exposure of infants to isoflavones in soy infant formulas is 6-11 fold higher on a bodyweight basis than the dose that has hormonal effects in adults consuming soy foods. Circulating concentrations of isoflavones in the seven infants fed soy based formula were 13000-22000 times higher than plasma estradiol concentrations in early life, and may be sufficient to exert biological effects. (The amount of isoflavones in breast and cow milk is negligible.)"

Consider some of these possible research questions:

Is there any correlation between women who were fed soy-based formulas as infants and the occurrence of breast cancer? Infertility? Endometriosis? Sound crazy? Maybe not�

Effect of phytoestrogens on the menstrual cycle

Researchers examined the effects of soy consumption in six healthy pre menopausal women aged 22-29 years.(28) They drank a 12 0z glass of soy milk with each of three meals for one month. Serum estradiol levels decreased significantly during the follicular phase (days 12-14, prior to ovulation) and serum progesterone levels also decreased during the luteal phase (second half of cycle). Menstrual cycle length increased, in the soy milk group, to 31.8 days (plus or minus 5.1 days), from the baseline of 28.3 days (plus or minus 1.9 days). An earlier study reported in the British Journal of Nutrition, produced similar findings. I would love to see a study like this designed with peri-menopausal women who are having great difficulty with shortened and erratic cycles due to fluctuating hormone levels. Any one game?

An interesting note;
In animal husbandry research, ewes that were fed estrogenic forage suffered from impaired ovarian function, often resulting in reduced conception rates and increased fetal losses. (Some ewes who were fed for prolonged periods suffered from a permanent form of infertility which caused the cervix to loose it's ability to store sperm even though ovarian function remained normal!!!! Could there be any possible connection between phytoestrogen intake and in premenopausal women and infertility? It seems to me that this little bit of trivia should be shared with this population. And that's another avenue of study for nursing research!

Effect of phytoestrogens on hot flashes and vaginal dryness

Last summer a group of researchers reported on the effect of dietary phytoestrogens in reducing hot flashes and vaginal dryness. (19) 145 women with these concerns and others related to their menopausal experience, where randomly assigned to a phytoestrogen-rich diet group or a control. Serum levels of phytoestrogens were obtained from both groups during the study and those on a phytoestrogen-rich diet had significant increases as opposed to those in the control group who were eating considerably less amounts of these foods. Although there appeared to be an overall greater improvement in the phytoestrogen fed group, it was not statistically significant. However, when their concerns were evaluated separately, the women in the phytoestrogen group had significant reductions in hot flash and vaginal dryness scores. It should be noted that historically, there has been a large placebo effect in studies evaluating hot flashes.

"I have been drinking a soy milk product product approximately 8oz a day and I try to eat tofu at least 3-4x per week in my stirfrys, salads etc.I was originally taking 3 different levels of estrogren on  alternate daysranging from .9mg to 1.25 of Premerin.  I am now only taking the .9 onalternate days and I can honestly say that my hot flashes are almost gone."
J. R. Ontario

-Using rats that had their ovaries removed, researchers found that dietary soybean estrogens did not produce the same effects in either the vagina or the uterus as conjugated equine estrogens (1). There was also no evidence of an additive effect when both soybean protein and these estrogens were used together.

-In a study with postmenopausal women supplementing their diet for four weeks with soy, 19% showed an increase in the percentage of vaginal superficial cells (can be measured during a pap smear and is known as a maturation index -see April's ALLWISE topic). These cells require a sufficient amount of estrogen in order to survive and some women shed these cells during menopause if their estrogen levels are very low. Only 8% of the women in this study who were not taking soy demonstrated an increase in these cells. The FSH and LH levels, which are usually high during menopause when estrogen levels are low, did not decrease significantly. The researchers concluded that soy intake had a small estrogenic effect on the vagina. (33)

-Hot flushes significantly decreased in a randomized, double blind study that enrolled 58 postmenopausal women who were experiencing at least 14 hot flushes per week.(34) Some of the women were given soy products and some were given wheat. The decrease appeared in both groups (40% and 25% respectively) with the soy group having a significant rapid response that continued. Once again the placebo effect is strong when studying hot flushes which may explain the response in the wheat group.

Effect of phytoestrogens on breast cancer risk:

-Phytoestrogens have both a weak estrogenic effect and an anti-estrogenic competitive effect, thus reducing the potential carcinogenic action on estrogen breast receptors.(8)

-Wang and Kurzer (11) found a biphasic effect while studying the role of phytoestrogens in cancer prevention. In the laboratory, human breast cancer cells which were estrogen -dependent, stopped reproducing when high levels of phytoestrogen were introduced but the cells were stimulated when exposed to levels that more closely matched what humans might consume! This biphasic effect was not apparent with breast cancer cells that were not estrogen sensitive.

-In trying to find an association between phytoestrogen intake and the risk of breast cancer, Ingram et al.(12) measured the urinary excretion of phytoestrogens from women with newly diagnosed breast cancer. A comparison group of women who did not have breast cancer were also recruited for the study. After adjusting for age at menarche, number of biological children, alcohol intake, and total fat intake, the authors found a substantial reduction in breast cancer risk among those women with high levels of the phytoestrogen equol and enterolactone, a lignan.

- When compared with control subjects, the risk of breast cancer decreased with increased tofu intake among Asian American women born in Asia. The protective effect was evidenced in both pre and post menopausal women even after adjusting for menstrual and reproductive factors. (24) The researchers caution that soy intake in this population may just be a marker for some other protective aspect in the Asian diet or lifestyle.

-Low breast cancer rates among postmenopausal Hispanic women may be associated with increased dietary intake of phytoestrogens, in spite of the tendency to have increased body fat in this population (a known risk factor for breast cancer). (30)

Effect of phytoestrogens on colon cancer risk

Similar to recent studies showing a decrease in the risk of colon cancer when estrogen supplements are taken, flaxseed (a rich source of lignan) has been shown, over the short term, to decrease some early markers of colon cancer risk. (26)

-Effect of phytoestrogens on bone:

Using laboratory rats without ovaries, Draper et al.(13) studied the effect of three phytoestrogens (coumestrol, zearalanol, and a mixture of isoflavones) on estrogen-dependent bone loss. An estrogen treated group as well as an untreated group was used for comparison. Compared with the control group, rats receiving coumestrol and zearalanol had significantly reduced bone loss at all sites measured. The estrogen group had greater bone density than the control group and also had greater bone density in the spine when compared with the coumestrol group.

-After conducting a review of the research in this area, Anderson and Garner (14) concluded that isoflavones, particularly genistein and daidzein, modestly improve bone mass. However, the authors discuss a biphasic effect - a negative impact on bone when using very high doses. High levels of genistein caused a loss of normal cell function. Although it is unlikely that humans would consume this high amount through normal dietary sources, it highlights the potential harm that could result if genistein was marketed in pill form at these doses!

Phytoestrogens and Cardiovascular Risk Factors

-In the laboratory, female monkeys without ovaries were studied for 7 months. They were divided into the following four groups:(18)

1. fed casein (cow's milk) as the major protein source
2. fed casein plus 17 beta-estradiol
3. fed soybean as the major protein source
4. fed soybean plus 17 beta-estradiol

The researchers found that both estrogen and dietary soybean protein had beneficial effects on cardiovascular risk factors (reduced total body weight and amounts of abdominal fat, reduced fasting insulin levels and insulin to glucose ratios, and produced smaller LDL particles.) There was an interesting and beneficial combined effect. Animals that ate soy protein plus estrogen had the lowest arterial cholesterol ester content. This is at least one argument for combining a phytoestrogen rich diet with estrogen supplements.

Phytoestrogens and uterine cancer:

-In a case-control study of the multi-ethnic population of Hawaii, a high consumption of soy products and other legumes was associated with a decreased risk of uterine cancer. (15) This is an important risk to define since some pseudo-estrogens may have potentially harmful effects on the uterine lining (see ginseng, below).

Cultural variations regarding dietary phytoestrogen intake

-When comparing the phytoestrogen intake of white women with the intake of Latina and African American women, researchers found white women to have the highest levels of coumestrol and the lignans. (23) Genistein levels, however, were highest in Latina women.

-In a population based case control study of women with primary breast cancer, intake of tofu was found to be more than twice as high among Asian-American women born in Asia compared to those born in the United States.(24) Among immigrants, the intake of tofu decreased with years of residence in the United States.

Sources of phytoestrogens

Isoflavonoids: genistein, biochanin A and formononetin
Most popular source is soy and various seeds.

-Analyzing 26 samples of bottled beer, Lapcik et al (6) concluded that beer contains significant amounts of active isoflavonoid phytoestrogens. Something occurred to me as I was reading this article - if alcohol increases estrogen levels in postmenopausal women taking estrogen supplements (refer to the April ALLWISE topic), then what happens when beer is consumed by this group? Does it's phytoestrogen status create protective or harmful effects on estrogen receptors? If you find the answer, let me know! Oh, by the way, phytoestrogens are also found in bourbon, however, they are less potent than those found in beer! (37)

-Zava et al (2) found the following to be the most commonly consumed estrogen binding (phytoESTROGEN) herbs: licorice, red clover, thyme, turmeric, hops and verbena. -The six most commonly consumed progestin binding (phytoPROGESTINS) herbs include: oregano, verbena, turmeric, thyme, red clover, and damiana. Little, if anything, is known about phytoprogestins.

NOTE: For an amazing list of the phytoestrogen content of various foods, refer to the following journal article: (44)
"Phytoestrogen content of foods - A compendium of literature values"
Nutrition and Cancer 1996, Vol. 26, No 2. Pages 123-148.

If you would like to see what else these foods offer in terms of nutrition, check out this USDA site:
Search the USDA Nutrient Database for Standar... Just insert the name of a food in the search box and you will get a complete nutritional evaluation! I think it's a great resource!

- With all of the hype now surrounding phytoestrogens, it was only a matter of time before a company would emerge with a pill form. Novogen is a new Australian pharmaceutical company that focuses on phytoestrogens. One of their products is called Promensil. It's made from red clover and contains 4 isoflavones: genistein, daidzein, formononetin, and biochanin. Each tablet contains 40 mg. of biologically available isoflavones and retails for $24.95 in health food stores.
promensil.html at www.novogen.com

Great Internet Resources!

The Indiana Soybean Board has a wonderful web site that provides a description of various soy foods (tofu, tempeh, miso and many more!) and also recipes!!
Soyfoods Descriptions
Recipes For Tofu, Tempeh, Textured Soy Protei...

HERBS

In my search for intelligent information regarding this subject (!), I finally found an article that every nurse, indeed, anyone interested in this topic, should have! I was delighted to find that it was co-authored by a Pharm.D. and a Nurse!! Here is the reference: (45)

"Herbal Therapies for Perimenopausal and Menopausal Complaints"
Debra Israel, Pharm.D. and Ellis Quinn Youngkin Ph.D., R.N.C
Pharmacotherapy Volume 17, Number 5, 1997. Pages 970-983.

This section summarizes what I've learned from this article except where I've noted a different reference. I've focused on some of the herbs that I seem to get the most inquiries about when discussing alternative therapies with women. I want to emphasize, however, that there is a great deal we don't know about these substances. Our information today may be entirely different tomorrow! Also, I am always careful not to dismiss a woman's experiences with an herb based solely on our current level of information - she may indeed know something that science has not yet recognized!

Some basic concepts related to herbal therapies:

1. Herbs are drugs
2. Herbs are not necessarily safe
3. Herbs can only be sold as food products and by law cannot claim to prevent or treat disease.
4. Consumers will use herbs regardless of the above if they think they will benefit from them.
5. Herbs are important sources of therapy and should not be ignored.
6. There are no standards regarding the quality of herbs.
7. The longer teas are steeped, the stronger the dose.
8. Different parts of a plant can have different effects.
9. Currently there is no way to know the exact amount or quantity of the specific components which constitute an herbal product.

Isreal and Youngkin list specific menopausal concerns and associated herbal therapies currently being marketed by the lay press. They then discuss whatever is known from the scientific literature - in many cases, very little, - finishing with adverse effects and intelligent recommendations based on all of these variables. Much of their data comes from Commission E, which is a panel of experts formed in Germany in 1978 to review the safety and use of over 1400 herbal drugs! Since it is not my desire to replicate this fine article for the purpose of this review, I will summarize some key points that I found interesting and once again, encourage you to read the entire article!

Black Cohosh

There is much discussion about this herb in alternative menopausal circles. It is marketed as a progesterone precursor with estrogen-like actions. When an alcoholic extract of this herb was used, it was found to reduce LH but not FSH in menopausal women. It has been used in Europe for many years in the treatment of PMS, dysmenorrhea and menopause related experiences. There is some scientific data that supports its use in reducing hot flashes, however, data on toxicity is limited. Potential drug interaction with antihypertensive agents has also been noted (additive hypotensive effects). Commission E recommends daily doses of 40-200mg - not to exceed 6 months!

NOTE:

There are two new products on the market that have Black Cohosh as the main ingredient. These are:
Estroven

Remifemin

"Hi, I am 43 years old and just starting menopause. I found the hot flashes during the day (6 to 10) and at night (4 - 6) to be annoying and embarrassing, but I did not want to go on HRT. Anybody looked up Premarin on the Internet and discovered how it is made? Please do! Although we have no history of breast or endometrial cancer in my family there is still no guarantee of not getting it. What I did discover is that not many doctors know a lot about menopause and so I did my own research. Years ago I would have popped pills to relieve anything, headaches, stomach aches, colds, flu, etc. and not really care if they might in some way be harmful. Not now, I would prefer to use more natural methods whenever possible. I found 100% relief in a product called "Remifemin"($17.95 CAN) which apparently has been used by women in Germany and the U.S.A. for 30-40 years with great success. You must be patient when first starting it because they recommend taking it for a month before noticing any changes. I found that after 2 weeks my symptoms improved by 60 % and before I had finished a months supply they had improved by almost 100%. The odd hot flash I did experience was in no way comparable to when I first started, and I had to ask myself if in fact it was a hot flash. Check your local health food store or pharmacy. Its your body, get educated, be informed." KDJ, Ontario, Canada

Chamomile

Approved by Commission E for GI complaints but no evidence exists to support it's use as an anti-anxiety agent. Of particular interest: a cross sensitivity to ragweed pollens may occur in susceptible individuals.

Chaste Tree, Chasteberry

There is scientific evidence that this herb inhibits the secretion of prolactin by the pituitary gland although its exact effects on menopause have not been established. There is a possible interaction with dopamine-receptor antagonists. It can cause an itchy rash and GI discomfort but little else is known in terms of adverse effects.

Dong Quai:

This herb is a type of angelica but should not be used interchangeably. It contains several coumarin derivatives which may be responsible for adverse effects associated with it. A dermatitis can result due to photosensitization and the essential oil contains a carcinogenic substance! Citing several sources, Isreal and Youngkin recommend that "all unnecessary exposure to dong quai should be avoided."

-Seventy-one post menopausal women showed no statistically significant differences in the vaginal maturation index, number of hot flushes experienced or thickness of the uterine lining after using dong quai for 24 weeks. (38)

Ginkgo (Ginkgo biloba)

Used in China since 2800 BC, this herb is known to increase vasodilation and peripheral blood flow. In 1988, it was the drug most widely prescribed by German physicians as well as being available over the counter. It's used for memory disturbances, mood swings, Side effects include headache, GI disturbances and allergic skin reactions.

Ginseng

Over the years, I've had some interesting clinical experiences with women who have used this root/herb. I'll share two of them with you:

1. About 10 years ago, a woman in her forties came to my office for a consultation regarding the skin changes that were occurring on her face. She was a healthy woman who was still menstruating and experiencing some of the common changes associated with perimenopause. She was interested in homeopathy and took many supplements (I had no idea what most of them were!) in addition to several vitamin and mineral supplements. When I first saw her, I knew immediately that she had chloasma - a patchy, macular, hyperpigmentation of the face that is often associated with increasing estrogen levels (as in pregnancy). She was not pregnant nor was she on birth control pills. I had a hunch that something she was taking was estrogenic but I didn't really have a clue where to start. One supplement had ginseng as it's main ingredient, one of the few substances that I recognized, at least, by name. I knew we had to start somewhere, so we agreed that she would eliminate this supplement and return in two weeks. When she returned in two weeks, there was a fifty percent improvement and at the end of a month, most of the patchiness was gone.

2. A nurse colleague was consulting with me regarding some perimenopausal changes she was experiencing - irregular bleeding and shortened cycles. She went to a naturopath just prior to seeing me. He gave her some gelatin like capsules called pearls that he said would regulate her menses. I shared with her the little that I knew about ginseng and my concerns about its estrogenic effects. She viewed it as a more "natural" approach to her problem and decided to give it a try. Two months later, she came to see me and told me that her menses were completely back to her normal! There was no more erratic bleeding and the last two cycles were 27-29 days.

There are some other interesting case studies in the literature regarding ginseng.

-A case study reported in the Canadian Medical Journal describes a 74 year old man taking the same dose of digoxin for many years with no sign of any toxic effects. When he started using Siberian ginseng, his digoxin level increased. When he stopped using the ginseng, his serum digoxin levels returned to normal, acceptable levels. The authors of this report are not clear whether part of the ginseng was converted to digoxin when consumed in the human body, whether it interfered with digoxin elimination from the body or simply caused a false serum assay report. (39)

-A 44year old woman who stopped menstruating at age 42, experienced vaginal bleeding which was attributed to ginseng facial cream from China (Fang Fang). (47) Ginseng was determined to be the cause of bleeding by rechallenge combined with measurements of FSH levels, which decreased with the use of the cream. This is really something to think about! As early as 1971, there was a brief journal article which focused on chemical compounds and plant derivatives in cosmetics. (48). This includes phytoestrogens as well as herbs!

-Ginseng can be very confusing. Packages that contain this herb may be labeled with any one of the following: Wild Red American Ginseng, Korea Ginseng, Oriental Ginseng, Chinese Ginseng. In addition to labeling concerns, it's difficult to know what you are getting since there are several varieties. Authentic ginseng is difficult to get and can cost more than $20.00 an ounce!

-Ginseng was approved by Commission E to treat fatigue, diminished work capacity and loss of concentration. However, its use was recommended for no more than 3 months!

I have some serious concerns about women who are using ginseng because they believe it is safer to use than estrogen. Two years ago, I met some of these women in a breast cancer support group. They were told by their moderator that ginseng was a natural estrogen supplement and therefore, safe to use. Having had estrogen receptor positive breast cancer, these women were placing themselves at potential risk without realizing it! I have similar concerns for postmenopausal women who use this substance instead of estrogen and without a progestin. There are some obvious benefits that should be investigated but women deserve data from well designed clinical trials in order to make informed choices! Isreal and Youngkin do not support the use of ginseng for perimenopausal or menopausal complaints.

Licorice Root

Although the lay press promotes this substance as having estrogenic properties, there is no scientific evidence to support this claim. Commission E approved licorice for limited use (4-6-weeks) for the treatment of upper respiratory tract infections.

St. John's Wort

Isreal and Youngkin believe that this herb should be classified as an antidepressant based on four published clinical trials since 1987. However, they advise caution with its use since there appears to be potential food and drug interactions which are similar to traditional MAO inhibitors.

Valerian

This herb was approved as a sedative and sleep inducer by Commission E. Isreal and Youngkin tell us that it's been used as a tranquilizer for over a thousand years. Although generally thought to be safe with low toxicity, some rare adverse effects include liver and cardiac damage.

Toxicity of herbal medicines.

Compared to the drugs we use, we know very little about the toxicity of herbal medicines and phytoestrogen-containing products. There is also very little information from animal experimentation (usually conducted during the early phases of research.) Most of what we know comes from information gathered during acute toxic reactions after human exposure. Sheehan (3) states that it's very difficult to associate a substance with toxicity, especially those substances that need to be consumed over a long period of time, even after wide scale exposure. Some examples include: diethylstilbestrol and reproductive tract cancers and abnormalities, tobacco smoking and lung cancer, fetal alcohol exposure and birth defects. We have a long history in women's health in terms of learning too late about the consequences of substances we put into our bodies. Other examples include: the dalkon shield, thalidomide, and estrogen (initially unnecessarily high doses were used for birth control as well as during menopause). When using herbs, we clearly need to use caution in balance with intellectual openness.

VITAMINS AND MINERALS

Vitamin E

In a recently reported placebo-controlled, randomized, cross-over study (Feb, 1998),
researchers found that women had a statistically significant reduction in hot flashes when taking 800 units of Vitamin E daily. Diaries were used to measure potential toxicities and number of hot flashes. Although there was numerical significance, the reality appeared less significant: those taking Vitamin E experienced one less hot flash per day than those taking placebo! The women themselves did not notice any difference. No evidence of toxicity was found. (43)

As I read through this study, I wondered whether the absorption of Vitamin E was a possible variable. It did not appear that physiologic evidence was obtained at any time during the study.

Magnesium

Magnesium helps to improve gastrointestinal absorption of calcium. Other benefits include increased gastrointestinal motility and stool softening. (42) Some call this mineral "nature's tranguilizer."

"I'm a 54 yr old RN from FL. The hot flashes got real bad. I went & got a Homeopathic remedy from a practitioner & it worked! I take various suppl.including various antioxidants, eve primrose oil, minerals, etc. It was when I went to a Gyn dr (after 10 yrs) that I got a period again & I've had two in a row every 9 months for 2 yrs since then. And after each of these 2 mo.interludes, the hot flashes start up again - but not as severe. Loss of libido was also a problem. 1/4% testosterone creme took care of that - a dab a day to the private area. I also use Progest creme to protect my bones as I'm not very active & my mother has osteoporosis. I hope to avoid ERT but if I do take it (Mother also has Alzheimer's) it will be later in life - maybe starting at age 75 or so. B."

Sometimes, as in the above situation, a woman trys many different vitamins, minerals and other substances and it becomes difficult to know what is causing which effect! Something or some combination of things is helping this particular woman but it's hard to know exactly what that is. I encourage women to try one thing at a time and give it about two weeks before trying something else. I've had to do this myself and although one needs patience, in the long run it results in better outcomes!

Calcium

There are several different kinds of calcium on the market and selecting one is often confusing. The Tufts University Health and Nutrition Newsletter has an excellent guide in its 1997 Special Report entitled: "Yes, but which calcium supplement?" (1997; 14: 4-5) Generally it's better to choose a supplement which is chewable since absorption is enhanced with increased surface area. Taking calcium with meals or in the evening also helps absorption.
IMPORTANT: after many years (since 1941), the RDA's (Reccomended daily allowances for vitamins and minerals) are being revised based on current knowledge and research. In the spirit of change, they will no longer be referred to as RDA's, but rather DRI's (Dietary Reference Intakes). This work is being conducted by:
The Standing Committee on the Scientific Evaluation of Dietary Reference Intakes of the Food and Nutrition Board, Institute of Medicine, National Academy of Sciences, with help from Health Canada.
There will be seven reports. The first one was published in August 1997 and covers nutrients related to bone. Dietary
The revised reccomendations for calcium, magnesium, Vit. D, phosphorus and fluoride:

For a list of non-dairy food sources of calcium, in addition to a list of different kinds of calcium found in supplements:

OTHER ALTERNATIVE SUBSTANCES

Wild Yams

"I have used a natural product made by AMS in FDA approved labs called Mexican wild yam cream....this creates a balance in ones system of the main two hormones, estrogen and progesterone. I was around 35 y.o.a. when I first noticed problems such as PMS, mood swings, irregular cycles, hot flashes, weeping jags, cramps, plus others I couldn't figure out what was happening.....after using this high quality cream my symptoms started to disappear. While the symptoms were gone I kind of forgot about the cream I did o.k. for about 4 months then it all came back needless to say I don't forget anymore to use the cream at least once a day sometimes more. This stuff is wonderful"
CA in Virginia

I wish I had a dollar for every inquiry I receive regarding these wild yam creams! I have also heard from many women, like the one above, who swear by it! It's hard to find traditional scientific sources of information on this product but I will share some insight from Dr. Maida Taylor (whom I personally know as a long time advocate in women's health) who shares the following in an excellent article she published recently in Comprehensive Therapy (42):

1. In order to have a significant biological effect, yams would need to be eaten raw and in large quantities.
2. After reviewing many of the papers distributed by producers and promoters of these products, Dr. Taylor found that claims that were made about progesterone were frequently referenced from studies that used medroxyprogesterone acetate (provera).
3. In addressing the hormonal content of these substances, Dr. Taylor states:

"Wild yams produce no active hormones. Plants do produce sterols, called saponins, with structures similar to progesterone. Saponins first are hydrolized to sapogenins; the two principles being sarsasapogenin and diosgenin. These sterols can be used as precursors for the progesterone steroid skeleton, which in turn, can be used as the precursor for adrenal steroid synthesis. The sterols in wild yams cannot be converted in vivo to active compounds, and the amounts in yam creams are negligible." (42)

4. A commonly cited reference for "natural progesterone" is Dr. John R. Lee's book: Natural Progesterone: The Multiple Roles of a Remarkable Hormone. Dr. Taylor lists many of the claims made in this book, including beneficial effects on depression, blood sugar, blood clotting, thyroid function and libido!
5. Some women are choosing to use these "progesterone" creams in place of FDA approved progestins while they are using estrogens. This is essentially the same as taking unopposed estrogen - resulting in a risk for uterine cancer.

-Since there are so many different products on the market that claim to use wild yam, it's hard to generalize to any one in particular. Although I have clear reservations about this product, I have found that the older I get, the more education I have and the more experience I accumulate, the less sure I am of anything!! Without more research, it's hard for me to just write this off as quackery! Something obviously happened to the woman above who shared her experiences with this product - as has happened with other women who have had similar experiences. I believe that women know their bodies and know when something is clearly different. Women have a right to better information regarding these products and if I had more lives, I would love to take that product and evaluate it in a controlled double blind clinical trial. I can't find where that's been done. Anyone looking for a research project?

LIFESTYLE CHOICES

To reduce hot flashes

-Say no to late night heavy meals. - The process of digestion is heat producing and the objective is to decrease heat production especially during vulnerable evening hours.
-Use cotton sleepware, not nylon - nylon has a tendency to hold onto heat whereas cotton more easily breathes and heat escapes more easily.
-Reduce alcohol intake, especially at night - reducing alcohol helps you sleep better and avoids the increase in blood estrogen which may rebound to levels even lower than they were prior to drinking. (see ALLWISE topic for April)
-If you're especially thin, gain a few pounds (good formula: 5 feet =100lbs then add 5 lbs. for each inch after 5 feet) Women who are unusually thin have very low estrogen levels (increases risk of osteoporosis) while women who have a little extra fat on their bodies produce a little more estrogen in fat cells.
-Reduce stress (seems to work wonders for just about anything but since hot flashes seem to be associated with a heightened sympathetic nervous system, it makes sense that reduced stress will improve this experience)
-Get enough sleep-this may mean taking a nap in the afternoon if possible (works wonders even if only 20 minutes)
-Stop smoking - for any number of excellent reasons! But also, because nicotine decreases circulating estrogen levels.
-Turn down the thermostat! In a small ambient-temperature-controlled study, Kronenberg & Barnard found  that women's hot flashes were less frequent and less intense.
See: Kronenberg, F. & Barnard, RM. (1992). Modulation of menopausal hot flashes by ambient temperature. Journal of Thermal Biology, 17, 43-49.

Exercise

There is no question that exercise offers a number of health benefits including improving bone density and decreasing risks for heart disease

"I am 52 years old and started going through menopause several years ago. My mother had a fairly easy time with menopause and I seem to also. I have heard that this is hereditary. My first symptom was dizzy spells. These have long gone away. My doctor told me that this had nothing to do with menopause, but I really think it did."

Just a quick editorial comment - once again, a woman's instincts about her body were not validated and respected!

"I also started missing my period. Shortly after these first symptoms I started getting hot flashes and even though I am still interested in sex, it seemed to cut down the number of times I enjoy it. I don't feel like I have experienced much depression and still seem to have a lot of energy. I don't believe in taking anything unless it is absolutely necessary. I worry about my bone mass and of course my heart. What I have done and what seems to work well for me is exercise. I find when I stay on a fairly regular exercise routine (simple stuff...like walking up to four miles or doing step aerobics)I have very few hot flashes and feel great. When I don't exercise on a regular basis, I get tired, feel somewhat down and get hot flashes on a regular basis. I have also found out if I drink lots of water each day it helps a lot. While a proper diet certainly help me, I feel it's the exercise that really makes a difference."

In a wonderful review titled "Beyond Hormonal Therapies in Menopause", Shaver (1994) offers this summary of the research on exercise and menopause: (46)

"evidence exists that exercise (depending on intensity and duration) modulates the stress hormones and hormones of the hypothalmus-pituitary-ovary (HPO) axis in ways that could assist in modulating the trajectory of hormone shifts, and therefore, symptoms at menopause." The beneficial effects of exercise on cardiac and bone health are well documented.

Other lifestyle options:

The following health articles were written by Patricia Older who says, "I began writing them for several reasons, most notably, my own approaching transition to menopause. There is so much controversy over HRT, and so many negative connotations about menopause, I felt there had to be an easier way to get through what can be an enormous emotional and physical challenge."

Patricia Older is a writer and photographer who received a BA from Skidmore College in 1995 with a major in American Studies. She's very passionate about women's issues and presently is working on an exhibit involving domestic violence, made possible by a NYSCA grant . She began "working" on the project in the summer of '93, but the exhibit did not become a reality until this year with the award of the grant. She has also received numerous awards, scholarships, and grants for her writing and photography.

Other Practitioners Experiences

The following are excerpts from two individuals who wrote in to the ALLWISE pages under "Share Your Experiences". I thought it would be helpful for you to read what they shared, especially after considering the data presented in this review. Since this is anonymous, I have no idea who they are but they sound sincere. I think we need to have conversations with alternative providers and exchange our experiences and knowledge. Although I have many concerns about some of these alternative strategies, there may be some important knowledge that is being gained and we will never know unless we listen!

Additionally, I think it's also important to know what is being prescribed outside traditional biomedical and nursing practices. I have personally offered consultation to women who frequently visited with these practitioners, and it's been helpful to me, during these consultations, to have had prior knowledge regarding the kinds of assistance they are being offered.

"I have had some remarkable experiences with non-hormonal therapies with my patients, using alternatives such as Natural Progesterone (ProGest) cream, Herbal remedies and nutritional support. I would like to share some of them with the women here.

With mild cases of hot flashes and night sweats, it has been my experience that the daily use of ProGest cream (a Natural Progesterone body cream) has stopped symptoms in about 80% of my patients. I usually encourage them also to take a good STANDARDIZED extract of Black Cohosh herb (cimicifuga), and there are two brands that I like, one is a health food store item, Remiferin, and the other is a Menopausal Formula from IDN, which is not sold in stores. The latter has great advantages as it not only contains the Black Cohosh in correct form and dose, but also contains a large amount of Soy extract, the equivalent of 3oz of TOFU, as well as Kava Kava extract. The combination is awesome and the literature supports the value of each and every one of the ingredients for the purpose they are used in this formula.

Some very severe cases of hotflashes and night sweats that lingered on and on, and we ALMOST gave in and ALMOST decided on HRT, finally resolved through the addition to the above of 2000 mg of OIL OF EVENING PRIMROSE. This great oil has done a marvelous job of eliminating the hotflashes altogether, and restoring the women to equilibrium in about one week! The benefits of this oil are numerous, and include also the normalization of blood pressure and palpitations that are associated with menopause often times.

Some other options that worked well are:

1. Liquid extract of the herb SAGE. taking this 3-4 times a day, about 20 drops each time in a little bit of water, goes a long way to reducing sweating in general and the hotflashes in particular.
2. Liquid extract of Peppermint, added to the Sage at the same ratio (20 drops) is also a cooling, soothing effect.
3. Mixing about 1/3 box of Tofu with low fat yogurt in a blender with fruit creates a lovely smoothie, that will supply you with good phytoestrogens.
4. Adding 2 tablespoons of FRESHLY ground flaxseeds to your daily food intake also provide superior phytoestrogens.
5. Adding tablets of alfalfa extract is also phytoestrogenic.
6. Taking the liquid extract of Vitex (chase tree bark) is very normalizing to the female hormonal system.
7. Liquid extract of sarsaparilla is a precursor of Testosterone. Adding this may solve lowered or vanished LIBIDO (sex drive).
There are more suggestions, but I think this is already a handful!"

-I want to emphasize that I am not endorsing any of the strategies that are outlined above, however, neither medicine nor nursing has a handle on this topic and I think women benefit when we remain open and willing to dialogue with all practitioners.

This second practitioner is sharing her insight based on her own personal experiences:

"I am an herbalist from NE Florida - I have been taking premarin for 20 years as a result of a total hysterectomy. I am 54 years old. Six months ago I made the decision to abandon hormone therapy and so far so good. It is important that this is done gradually. So I started reducing one pill a week for a number of weeks, etc. I currently take 2 pills a week. However, as I started reducing the premarin I began taking tincture of orange peel, which contains a small amount of naturally occurring hormone (it is in the pith not the peel, so I tinctured the pith and the peel) and tincture of vitex. Commercially the tinctures are called extracts.

The process I used was reduce the premarin for 3 weeks, if no symptoms reduce again, when I begin experiencing symptoms I hold at that level of premarin and either do nothing or regulate the tincture dosage. At this point I may add some tincture of motherwort. It is important in making this decision that women are eating a healthy diet with adequate calcium intake and limit the mineral depleters in their diet such as ANY coffee, carbonated beverages, enriched flour, and white sugar (this is not as hard as it sounds).
MMP
Jacksonville, FL

I like this person's approach of "weaning off" estrogen supplements. I don't know of any studies supporting this approach, but it sounds reasonable to me and certainly something we could explore through nursing research.

SUMMARY

I'll start by repeating what I said in the introduction - there is so much we don't know! I think it is dangerous to consider that any one group - whether it represents a biomedical or alternative/complimentary approach - has the final answers on managing menopause. Sometimes it seems as though menopause is being addressed as if it were a new phenomenon! Women have been managing this transition since the beginning of time, and yes, women did live long enough to experience it, even if not in the record numbers that we have today!

"Where the patient is delicate and subject to female weakness, night sweats with flushing in the face and a hectic fever: For such; ass's milk, jellies and raw eggs, with cooling fruits will be proper. At meals she may be indulged with half a pint of old clear London porter, or a glass of Rhenish wine."
John Leake, 1777

Once again, I believe that women are our best sources of knowledge and information. Unfortunately, they have been subjected to enormous amounts of marketed propaganda, from both sides, which has resulted in a great deal of confusion. Sadly, many women no longer trust their own instincts and judgements and have unknowingly become part of enormous clinical trials simply by trying various products for which we know very little - whether it's a new pharmaceutical form of estrogen or an over the counter herbal tea. One woman shares her experience:

"I had been taking Premphase since early in 1994. Prior to this I had been taking Prozac. To this eventually was added Depacote. After about three years of this, I have developed type II Diabetes. Having read that hormones can affect blood sugar by increasing it, I have tried to wean myself off all my meds and onto an herbal based HRT: Remifemin, and St. John's Wort for my depression. It's been several weeks, 2 1/2, and I'm not having a wonderful time. I'm overly sensitive, teary at the drop of the wrong word, and generally on the doorstep of depression. There are about 1 1/2 weeks left of the herbal hormone and I'm wondering if I will see much good from my efforts."

This woman seems to be out there on her on - although she had health professionals who prescribed various treatments, she appears to be abandoning these treatments for what she perceives are safer and more effective alternatives. Since there is so much we don't know about her particular situation, I couldn't intelligently reflect on her dilemma except to say that she is loosing hope in becoming healthy. This is a sad example of how the health care system fails women. It seems we should be asking ourselves as health professionals, what we are doing (or not doing) that contributes to a culture which alienates women! And that's another topic for a future ALLWISE review! (I have to force myself to stop now!)

WAIT!!  Before you leave, you must complete the Post Test / Evaluation in order to obtain contact hours.

ADDITIONAL RESOURCES

Journals devoted to complimentary/alternative medicine:

Some journals related to alternative medicine that are indexed in MEDLINE are:

Acupuncture and Electro-Therapeutics Research
Alternative Therapies in Health and Medicine
American Journal of Chinese Medicine
Biofeedback and Self Regulation
Chen Tzu Yen Chui (Acupuncture Research)
Chinese Medical Journal
Chung-Hua I Hsueh Tsa Chih (Chinese Medical Journal)
Chung-Kuo Chung Hsi I Chieh Ho Tsa Chih
Chung-Kuo Chung Yao Tsa Chih (China Journal of Chinese Materia Medica)
Journal of Manipulative and Physiological Therapeutics
Journal of Natural Products
Journal of Traditional Chinese Medicine
Planta MedicaAlternative

Links to other web sites

This office, which is part of the National Institutes of Health, has a really neat slide presentation (52 slides) on complementary/alternative medicine.

A Modern Herbal Home Page
A hyper-text version of A Modern Herbal, 1931, by Mrs. M. Grieve. Over 800 varieties of medicinal, culinary, and cosmetic herbs, including economic properties, cultivation and folk-lore. Do a word search of all 860 pages.

ALTERNATIVE MEDICINE LINK
This site won a Tufts University award and is worth browsing through!

Ask a nurse who's into herbs
A nurse hosts one of the health forums for Sympatico and guides a dialogue that deals with herbal remedies - very interesting, though not specifically about menopause. It's wonderful to find a nurse taking an active role in moderating these discussions on the web.

Herb Research Foundation - Herbs and Herbal M...
The Herb Research Foundation (HRF) is a nonprofit research and educational organization focusing on herbs and medicinal plants

Mailing Lists and Newsgroups
This is an amazing list of alternative medicine mailing lists and newsgroups!

Interesting Books

BOOK REVIEW: Roots of Healing: A Woman's Book...

A book that I have recommended to women for years:
Menopause Without Medicine
by Linda Ojeda, Ph.D.
Another great publication from Hunter House, (Alameda, California) The original copyright is 1989. I have the second edition, 1992.

REFERENCES

1. Tansey, G. Hughes, CL. Cline, JM. Krummer, A. Walmer, DK & Schmoltzer, S.(1998)
Effects of dietary soybean estrogens on the reproductive tract in female rats. Proceedings of the Society for Experimental Biology and Medicine. 217(3): 340-344.

2. Zava, DT. Dollbaum, CM. Blen, M. (1998). Estrogen and progestin bioactivity of foods, herbs and spices. Proceedings of the Society for Experimental Biology and Medicine. 217(3):369-378.

3. Sheehan, DM. (1998). Herbal medicines, phytoestrogens and toxicity: risk-benefit considerations. Proceedings of the Society for Experimental Biology and Medicine. 217(3):379-385.

4. Olea, N. Pazos, P. Exposito, J. (1998). Inadvertent exposure to xenoestrogens. (1998) European Journal of Cancer Prevention. 7 (Suppl 1):S 17-S 23.

5. Murkies, AL. Wilcox, G. Davis, SR. (1998). Clinical Review 92 - Phytoestrogens. Journal of Clinical Endocrinology & Metabolism. 83(2): 297-303.

6. Lapcik, O. Hill, M. Hampl, R. Wahala, K. Adlercreutz, H. (1998). Identification of isoflavonoids in beer. Steroids 63(1): 14-20.

7. Safe, SH. & Gaido, K. (1998). Phytoestrogens and anthropogenic estrogenic compounds. Environmental toxicology and chemistry. 17(1): 119-126.

8. Stephens, FO. (1997). Breast cancer: aetiological factors and associations (A possible protective role of phytoestrogens). Australian and New Zealand Journal of Surgery. 67 (11): 755-760.

9. Divi, RL. Chang, HC. Doerge, DR. (1997) Anti-thyroid isoflavones from soybean: isolation, characterization and mechanism of action. Biochemical Pharmacology. 54(10):1087-1096.

10. Kardinaal, AFM. Waalkensberendsen, DH. Arts, CJM. (1997). Pseudo-oestrogens in the diet: health benefits and safety concerns. Trends in Food Science and Technology. 8(10): 327-333.

11. Wang, CF. & Kurzer, MS. (1997). Phytoestrogen concentration determines effects on DNA synthesis in human breast cancer cells. Nutrition and Cancer: An International Journal. 28(3): 236-247.

12. Ingram, D. Sanders, K. Kolybaba, M. & Lopez, D. (1997). Case control study of phytoestrogens and breast cancer. Lancet 350(9083): 990-994.

Women and Alzheimer's Disease

- By Gayatri Devi, M.D.

Menopause symptoms, due to estrogen deficits, include memory problems, trouble finding words, inability to pay attention, mood swings and irritability, in addition to the more well known symptoms. These symptoms are often overlooked or left untreated but should be addressed. Treatment will not only result in symptom remission but may also, in my opinion, have preventive value.Some common questions I have encountered in my practice about estrogen and memory loss include the following:

Q: Do I have Alzheimer's disease?

A: This unspoken fear is often the reason why women suffer in silence when they have cognitive symptoms of menopause. Scared about what they may find out, many women opt not to seek treatment. However, menopause related memory and cognitive disturbances are being increasingly described in scientific literature and are generally responsive to treatment. They should be addressed and treated, so that symptom resolution occurs.

Q: Does estrogen have an impact on functions of the mind?

A: Yes. Estrogen influences language skills, mood, attention, and a number of other functions in addition to memory.

Q: How does estrogen affect the mind?

A: Estrogen receptors are present in several regions of the brain, including those involved in memory (such as the hippocampus). When activated by estrogen, these receptors, in turn, activate processes that are beneficial to the brain. In addition, estrogen may, in effect, raise levels of certain chemicals (neurotransmitters) within the brain. These include the neurotransmitters acetylcholine (implicated in memory), serotonin (implicated in mood), noradrenaline (implicated in mood and other autonomic functions), and dopamine (implicated in motor coordination). Thus, estrogen facilitates networking between nerve cells, promoting their ability to "talk to" one another.

Q: Does this mean that my recent irritability, apathy, 'foggy' state of mind, trouble finding words, constantly losing my keys, inability to function at my job, etc. may be related to estrogen deficit?

A: Given estrogen's myriad role in brain processes, it should come as no surprise that it can influence many of the mind's functions. However, a careful history and a thorough examination are needed to sort through symptoms. You should plan to spend about an hour to an hour and a half with your physician to discuss the issues related to menopause, symptoms and treatment options.

Q: If estrogen replacement corrects my memory and other cognitive symptoms, do I need to do anything more?

A: Generally, if hormone replacement treats one's difficulties, your physician may decide that further work-up is not necessary.

Q: I am on hormone replacement and my symptoms persist. What next?

A: If your symptoms do not resolve with hormone replacement, you may need to discuss the dosage and type of hormone replacement you are on with your doctor. Sometimes, changing to another preparation is helpful. If problems still persist, you might want to seek further help from a physician who specializes in this area.

Q: What are other treatment options for my problems?

Estrogen related cognitive deficits may be differentiated from those associated with other conditions through a careful history, examination and testing. During this time in a woman's life, many problems coexist, including treatable causes (e.g.: depression, hypothyroidism). Focused neuropsychological testing is useful in this regard to delineate the nature of the problem. Testing will also establish a cognitive baseline for future comparison. Thus, treatment options will depend on the cause(s) of the memory loss.

Q: Ideally, what areas should be covered in neuropsychological testing?

A: As estrogen affects various cognitive functions, comprehensive testing should assess all aspects of language (reading, naming, understanding, word fluency), memory (both short and long term memory, visual and verbal memory), and other cognitive functions (problem solving skills, visuospatial skills, etc). Simple screening tools, such as the mini mental status examination, will most often remain normal in peri- and post-menopausal cognitive loss. A good neuropsychological battery of tests should establish a cognitive baseline for future comparison, answer the questions asked and allow monitoring of treatment response.

Q: Will my depression get better if I go on estrogen?

A: If the mood changes are related to estrogen deficiency, they usually will respond to hormone or estrogen treatment. If the mood changes persist, you need to discuss this with your physician.

Q: Is estrogen useful for preventing memory loss?

A: Various naturalistic studies have suggested a preventive role for hormone replacement with estrogen for memory loss. However, more rigorous trials to investigate this are now under way and need to be concluded before consensus recommendations can be made.

Q: I have heard that estrogen prevents Alzheimer's disease. Is this true?

A: The results of several naturalistic studies suggest that estrogen may reduce risk for Alzheimer's by up to 50% although other studies did not find this benefit. The more significant of these studies involved looking at risk in large populations (epidemiological studies). However, controlled clinical trials are needed to confirm this observation before a decision of estrogen's benefit in this regard can be reached.

Q: My friend's mother has Alzheimer's disease. Will estrogen or hormone replacement help in this case?

A: There is a body of evidence to suggest that estrogen or hormone supplementation helps to slow progression of Alzheimer's. Further work still needs to be done in this area. As of the present time, the opinions of experts vary in this regard.

Q: What about the naturally occurring estrogens found in substances like soy milk?

A: There is not enough data on the use of these naturally occurring hormones for treatment of cognitive symptoms of menopause.

Q: Why do I need hormone replacement? Isn't it the natural order of life that women go into menopause?

A: The average age of menopause is 52.3 years and has not changed much over the years. However, a century ago, life expectancy was much less for a woman than it is today. Today, the average woman will spend from a fourth to up to half of her life without the protective and beneficial effects of estrogen.

Q: What is the difference between hormone replacement and estrogen replacement therapy (HRT vs. ERT)?

A: Hormone replacement therapy is a combination of estrogen and progestogen and is generally given to women who have not undergone hysterectomies.

Q: If there is a family history of breast cancer, should I not take estrogen?

A: A family history of breast cancer does not preclude treatment with estrogen. Every person needs to be evaluated on an individual basis. Risk in each person varies and you will need to discuss this with your doctor.

Q: Does my risk for breast cancer increase if I am on estrogen?

A: The data in this area is conflicting. Some studies have noted an increased risk, while others have found an increase in certain types of breast cancer. You need to discuss this issue with your physician. Additionally, every woman on estrogen or hormone replacement should undergo periodic breast self examinations and mammograms as determined by her physician.

Q: What is the difference between a patch and an oral preparation?

A: Skin patches are often used when oral estrogen is not tolerated. Skin absorption bypasses the liver circulation and is more easily titrated.

Q: If my hormone levels are normal on testing, but I am having all these symptoms of menopause, what next?

A: Hormone levels fluctuate and may need to be rechecked if your symptoms are attributable to menopause (or estrogen deficit). You would need to discuss this with your physician.

Q: How does estrogen affect other organ systems?

A: Estrogen keeps bones healthy and prevents osteoporosis. It may also be helpful with cardiovascular diseases, although studies in this area are less unanimous.

Q: What are the risks of taking estrogen or hormone replacement therapy?

A: The most common concern for women deciding on estrogen or hormone replacement therapy is fear of increased risk for breast cancer. Several large, prospective studies have yielded varying results, including increased risk for certain kinds of breast cancer, although some studies found that the total risk for breast cancer of all kinds may not be increased. This is an area that you would need to discuss carefully with your physician. Other more common side effects include spotting, some bloating, breast tenderness and mood changes.

Q: Should I take estrogen or hormone replacement?

A: This is a question that every peri- and post- menopausal woman needs to discuss with her physician. Pros and cons of estrogen use in an individual woman vary.

Women need to be well informed about all options available to them as they undergo menopause.

Many of these questions are answered in our new book, Estrogen, Memory and Menopause. If you have other questions that you would like answered, you may post it on our discussion board.

Contents

• Signs of Menopause
• Hot Flashes & Night Sweats
• Osteoporosis
• Sex and Mid-Life Change
• Therapies
• After Menopause

A Major Turning Point
Menopause is one of the major turning points in a woman's life.

Some women dread reaching menopause while others look forward to it.

Some feel it is an affliction that will make them unattractive, lonely, helpless, and useless. They mourn the loss of their fertility and youth.

Other women discover that it gives them a new lease on life�physically, emotionally, sexually, and spiritually. They are enthusiastic about becoming free of their concerns about pregnancy and premenstrual syndrome (PMS). Most experience a wide range of feelings, from anxiety and discomfort to release and relief.

If you are like most of today's women, you will live a third of your life after menopause. Planned Parenthood urges you to plan ahead for what could prove to be one of the most rewarding and enriching times of your life.

What Menopause Means

Menopause is the time at "mid-life" when a woman has her last period. It happens when the ovaries stop releasing eggs. Most often it is a gradual change. Sometimes it happens all at once.

Perimenopause is the gradual period of change leading into menopause. It affects a woman's hormones, body, and feelings. It can be a rocky, stop-start process that takes years. "Climacteric" is another word for the time when a woman passes from the reproductive to non-reproductive years of her life.

The ovaries' production of estrogen slows down during perimenopause. Hormone levels fluctuate, causing changes just as they did during adolescence. But for many women, the changes leading to menopause are much more intense than those of puberty.

These changes may also be affected by a woman's feelings about aging.

The time after menopause is called postmenopause.

Surgical menopause occurs if the ovaries are removed or damaged�as in a radical hysterectomy or chemotherapy. In this case, menopause begins immediately, with no perimenopause

Temporary "stress menopause" occurs when women in their late 30s or older have no periods for long stretches of time. It can be caused by stress, chemotherapy, grief, illness, bulimia, anemia, or excessive exercise.

As most women approach menopause, their menstrual periods become irregular � they happen closer together and/or further apart. Other common signs include:

A woman may have one, some, or none of these signs. But the ones she does have can be so unpredictable and disturbing that she can feel like she's "going crazy."

A woman's experiences during menopause may also be influenced by other life changes:

• children leaving home
• changes in domestic, social, and personalrelationships
• changes in identity and body image
• divorce or widowhood
• retirement
• increased anxiety about aging and death
• loss of friends, loved ones, and financial security
• increased responsibility for aging parents
• anxiety about loss of independence, disability, or loneliness

Increasing numbers of perimenopausal women also have young children to care for.

Whatever the cause or circumstance, the conditions women experience before and after menopause are very real and sometimes very serious. While 10-15 percent of American women experience no signs of menopause, another 10-15 percent become physically or emotionally disabled for various periods of time by these conditions.

Perimenopause may begin as early as 35. It starts about two years earlier for women who smoke than for women who don't.

Women reach menopause at different times. The timing is not related to race, class, pregnancy, breastfeeding, fertility patterns, the birth control pill, height, age of menarche (first period), or age at last pregnancy.

The average age for menopause is 51. If menopause is reached naturally or surgically before the age of 40, it is called early menopause.

Estrogen levels drop very abruptly during surgical menopause�especially when both ovaries are removed at the same time. This often intensifies the conditions associated with menopause and may lead to major physical and emotional changes, including depression.

It is somewhat reassuring to remember that perimenopause is just a phase�that all these symptoms are temporary. For most women it will last two or three years, though for some it lasts as long as 10 or 12 years.

It is important to remember that all women need regular checkups�whether or not they are menstruating.

Hot flashes are sudden explosions or mild waves of upper body heat that last from 30 seconds to five minutes. They are caused by sudden changes in hormonal levels in the blood. Hot flashes often start with a tingling sensation in the fingers. The tingling is followed by fast rises in skin temperature from the chest to the face and rapid heart palpitations.

Seventy-five percent of women have hot flashes during perimenopause. Fifty percent of women have one each day. Twenty percent have more than one a day. Ten percent have them up to five years after menopause. They are very uncommon after that.

Hot flashes often include drenching sweats that can soak the bedding when they happen at night.

Some Tips for Relieving Hot Flashes:

• Try regular exercise, biofeedback, cold showers, decreased stress, and cooler rooms.
• Reduce intake of tea, alcohol, hot beverages, and spicy foods.
• Wear thin layers of all-cotton clothes that can be removed.
• Keep a hot-flash diary to learn what triggers them.

Women who have hot flashes generally weigh less than women who don't.

Osteoporosis is the loss of bone mass. One of the causes is loss of estrogen after menopause. After menopause, women lose between 2-5 percent of bone mass per year for five years. This puts women with thin bones at high risk. Bones become more brittle and more likely to break as they become less dense. Complications can be fatal.

Osteoporosis has no symptoms in the early stages. It causes back and abdominal pain in the late stages. Bone density testing is recommended:

• following menopause or any other prolonged time without menstruation
• if a woman takes steroids, which can cause rapid bone loss
• if a woman has an overactive parathyroid gland, which can lead to rapid bone loss

Bone loss begins after age 35. That's why it is very important for women of all ages to build bone mass with weight-bearing exercise like walking, running, and weight lifting and with calcium- and vitamin D-rich diets�at least 1,000 mg of calcium before menopause and 1,200 mg after menopause.

Estrogen replacement can help stop osteoporosis, so can newer, non-hormonal medications.

Those at highest risk are women who:

• are white or Asian
• weigh less than average for their height
• have early menopause
• have a family history of osteoporosis
• have a diet low in calcium and vitamin D
• have a diet high in caffeine, alcohol, or protein
• have hormonal conditions like diabetes, hyperthyroid, Cushing's disease
• smoke
• don't get enough exercise
• take thyroid or cortisone medications.

After menopause, many women have increased sexual desire because they no longer worry about unintended pregnancy. On the other hand, about one-third lose some of their sex drive.

Sexual desire is often diminished during symptoms of perimenopause, but it is often restored when these conditions subside.

Vaginal dryness and the thinning of genital tissue can lead to discomfort during sexual intercourse and masturbation. Over-the-counter, water- soluble vaginal lubricants may be helpful. Estrogen replacement creams restore the tissues and are available by prescription.

Menopause is nature's original contraceptive. But wait a full year after what seems to be the last period before giving up contraceptives. Menstruation may be very sporadic for some time toward the end of perimenopause.

Using the Pill during perimenopause may mask menopause because periodic bleeding will continue. Women who use the Pill can have their hormone levels checked to find out if menopause has been reached.

Remember: Menopause is no protection against sexually transmitted infections. Male or female condoms are always necessary during sexual intercourse if you or your sex partner have more than one partner.

There are many therapies for the conditions associated with menopause. Hormone replacement therapy (HRT) works for millions of women. But the hormones used in HRT may pose risks as well as benefits. Many women avoid those risks by choosing alternatives, including: homeopathy, Chinese medicine, herbal treatments.

Alternative therapies may also have undesirable effects. It is best to consult a skilled, experienced practitioner to determine the remedy, dose, and treatment schedule for whatever therapy is chosen.

Hormone Replacement Therapy � HRT uses pills, patches, implants, and vaginal creams to restore estrogen and other hormones lost during perimenopause and menopause. Testosterone is sometimes used to increase sexual desire.

Non-Hormonal Treatment�Over-the-counter creams without estrogen are also available.

Homeopathy�Homeopaths use minute doses of medicines that in larger doses cause symptoms like those of the condition being treated. For example, a remedy made from onions is used to treat colds with symptoms like runny nose and teary eyes.

Herbal Treatments�Herbalists use herbal extracts, capsules, and infusions, especially those rich in phytosterols�plant estrogens and progesterones.

Chinese Medicine�Chinese medicine practitioners use acupuncture and herbal treatments to harmonize a person's life energy or Qi (chee).

Many women also benefit from counseling during mid-life changes.

Up to 20 percent of menopausal American women use HRT because they believe the benefits outweigh the risks. It is believed that prolonged use of estrogen replacement reduces the risk of heart attack by nearly 50 percent. Women base their decisions on their individual and family medical histories.

Some Treatment Resources

Planned Parenthood (mid-life services)
Many Planned Parenthood centers offer midlife services. For more information and an appointment with the center nearest you, call toll-free: 1-800-230-PLAN.
http://www.plannedparenthood.org

North American Menopause Society (to find physicians)
P.O. Box 94527
Cleveland, OH, 44101-4527
440-442-7550
800-774-5342 (for ordering materials)
http://www.menopause.org

The National Osteoporosis Foundation (bone-density testing and physician referrals)
Suite 500
1150 17th Street, NW
Washington, DC 20036
(202) 223-2226
http://www.nof.org

National Center for Homeopathy
801 N. Fairfax St., Ste. 306
Alexandria, VA 22314
(703)-548-7790
http://www.homeopathic.org

AAAOM Referrals
American Association of Acupuncture and Oriental Medicine
433 Front Street
Catasauqua, PA 18032
(610)-433-2448
aaaom1@aol.com
http://www.aaaom.org

Society offers few rites of passage for women�especially when it comes to biological changes. More and more women are forming self-help support groups to help navigate the changes that menopause brings�psychological, emotional, spiritual, social, as well as physical. Families and friends can provide important support, too.

Men also experience mid-life changes that may include decreased ability to become erect, depression, and the loss of muscle mass, sexual desire, and a sense of well-being. But the hormonal changes of "andropause" are more gradual. Women and men need to educate their partners about the changes they experience. They can try to build common ground for mutual support by keeping one another informed. Couples counseling is often very valuable for partners in mid-life

Be prepared!

Ensure continued good health for yourself: annual Pap tests, pelvic and breast exams, and mammograms can help prevent cervical and breast cancer. A good low-fat, high-calcium diet and plenty of weight-bearing exercise three or more times a week may help prevent osteoporosis and heart disease. Use condoms to protect against sexually transmitted infections. Start preparing for perimenopause and menopause as early as possible. Today is a good time�no matter how young you are.

Many women discover a sense of liberation after menopause. They are eager to say good-bye to premenstrual syndrome, cysts, fibroids, childrearing responsibilities, worries about unintended pregnancy, and the gender-role stereotypes associated with youth! They find they're tough enough to handle gender-role stereotypes associated with age, and they welcome a world in which 50 years of wisdom can guide their lives.

Many others face increased responsibilities and declining health. Instead of being freed of many responsibilities, they inherit the care of aging parents or other family members. Many suffer ill health and reduced financial status and are overwhelmed with the profound losses of those they love.

But on the whole, postmenopausal women are the least likely of all women to be depressed. They have a greater sense of well-being than at any other point in their lives.

Postmenopausal women often become leaders in their families and communities. They can enjoy the pleasures of introspection, rest, heightened career pursuits, or an intensified sense of their sexuality or femininity. They may retreat or they may take up new challenges with restored vigor. Whatever they choose, they are more likely to do what pleases themselves than they are at any other time in their lives.

Perimenopause can be a challenging time to reassess life's goals. Menopause can be a new beginning, a gateway to personal growth.

Books to Read

As you approach your mid-life changes, you may find these books useful:

Managing Your Menopause, Ruth S. Jacobowitz and Wulf H. Utian,
Prentice Hall, 1990

The Change, Germaine Greer, Alfred A. Knopf, 1991

The Complete Book of Menopause, Susan Perry and Katherine O'Hanlan, M.D., Addison-Wesley, 1992

The Silent Passage, Gail Sheehy, Random House, 1992

Menopause & Midlife Health, Morris Notelovitz, M.D., Ph.D., and Diana Tonnessen, St. Martins Press, 1993

Menopause: A Midlife Passage, Joan C. Callahan, Indiana University Press, 1993

The Pause, Lonnie Barbach, Dutton, 1993

Ourselves, Growing Older, Paula B. Doress-Worters and Diana Laskin Siegal, Simon and Schuster, 1994

Without Estrogen, Dee Ito, Random House, 1994

Estrogen � The Facts Can Change Your Life, Lila E. Nachtigall and Jan Rattner, HarperCollins, 1995

What Your Doctor May Not Tell You about Menopause�The Breakthrough Book on Natural Progesterone, John R. Lee, Warner Books, 1996

Wise Women Don�t Have Hot Flashes, They Have Power Surges!, D. Reid Wallace, St. Gerard,1996

Off the Rag�Lesbians Writing on Menopause, Lee Lynch and Akia Woods, New Victoria, 1996

What Every Women Needs to Know about Estrogen�Natural and Traditional Therapies for a Longer, Healthier Life, Karen Anne Hutchinson and Judith Sachs, Plume, 1997

Dr. Susan Love�s Hormone Book: Making Informed Choices about Menopause, Susan Love, Random House, 1997

Approaching Menopause

Glenn Brynes, M.D.
Carol Watkins, M.D.
Baltimore, Maryland

Hormone Changes During Perimenopause

Symptoms of Perimenopause

Dealing Actively With Your Midlife Changes 

• Healthy Lifestyle Changes

• Social Support

• Hormone Replacement Therapy

• Social Support

• Psychological Support

The term �menopause� comes from two Greek words that mean �month� and �to end.� It translates as �the end of the monthlies.�  The medical definition of menopause is the absence of menstruation for 12 months. In American women, the average age for menopause is 51. However, it can occur between a woman�s late thirties and her late 50s. Menopause also occurs when a woman�s uterus and ovaries are surgically removed.  

Perimenopause is the two to fifteen year span before menopause during which a woman experiences changes due to declining levels of estrogen and progesterone. For some women, the perimenopausal time can be more troubling than actual menopause.  

Hormone Changes During Perimenopause 

A woman�s menstrual cycle is governed by the endocrine system. The central glands, located deep in the brain are the hypothalamus and the pituitary. These structures regulate the sex hormones produced by the ovaries. Other glands and structures are also involved, but these are the main players. When a woman is having regular menstrual cycles, the hypothalamus releases Gonadotropin-Releasing Hormone (GnRH.) This induces the pituitary to release increased amounts of Follicular Stimulating Hormone (FSH) during the first two weeks of the menstrual cycle. The FSH stimulates growth in some of the eggs in the ovary. The ripening egg (follicle) produces estrogen, which causes the lining of the uterus to thicken. At about day 14 in the cycle, the pituitary produces an increased amount of  luteinizing hormone (LH.) This causes the release of the follicle from the ovary. The area around the released follicle becomes the corpus luteum. The corpus luteum secretes a lower amount of estrogen and an increasing amount of progesterone.  If the egg is not fertilized in the critical period after ovulation, the corpus luteum produces declining amounts of estrogen and progesterone. When the estrogen and progesterone reach a low point, the hypothalamus begins to start the next cycle, and menstruation begins.  

A woman may notice changes in her menstrual cycle several years before true menopause. The ovary has a finite number of eggs, and these begin to run out. The hypothalamus stimulates the pituitary to make more FSH in an attempt to cause the remaining eggs to mature. FSH and LH levels rise. Estrogen levels may vary. FSH levels can help determine whether a woman is entering menopause.  

During perimenopause, ovulation occurs intermittently. If there is no ovulation, the progesterone does not increase and the estrogen production may continue. This may cause the uterus to build up a thicker lining. The menstrual period may occur irregularly and may be quite heavy. Other cycles may produce a light menstrual period. As perimenopause moves into menopause, the ovaries produce much less estrogen and progesterone and the menses cease.  

Symptoms of Perimenopause 

During true menopause, estrogen and progesterone levels are low and fairly constant. However, during perimenopause, their levels may fluctuate in an irregular pattern. Some perimenopausal women have an exacerbation of their premenstrual symptoms. Fortunately, when menopause occurs, the PMS symptoms cease. 

Hot flashes are experienced by up to two-thirds of perimenopausal women. They usually occur one to five years before the end of menstruation. These symptoms are more severe in women who have had their ovaries surgically removed. It is thought that low levels of estrogen cause the brain to release a surge of Gonadotropin-releasing hormone. This may be the cause of the hot flash. A woman suddenly feels hot and may perspire profusely. She may then have a cold chill. They are more common at night but can occur at any time of day. They last from a few seconds up to an hour.  

Changes in menstrual cycles: Menses may be heavier, or lighter. There may be increased or decreased cramping. Eventually, menses lighten, become less frequent and then stop.   

Increased PMS symptoms

Mood changes and irritability: This may be more common in women who have had difficulty with PMS. There is some suggestion that estrogen levels influence the production of serotonin.  

Difficulty with memory and attention span: Some women report difficulty with concentrating or remembering specific words. A woman with attention deficit disorder may first come for treatment at this age because declining estrogen level has exacerbated her ability to concentrate. 

Insomnia is a common complaint of women in perimenopause or menopause itself. Night sweats may disrupt sleep. Irritability and depression can impair sleep. Reduced sleep can lead to tiredness and irritability during the day. 

Vaginal dryness: Before and after menopause, lowered estrogen levels cause the lining of the vagina to become drier and thinner. This may lead to painful intercourse and decreased interest in sexual relations.  

Urinary leakage: Some urinary symptoms may be related to pelvic floor changes that occurred years ago during labor and delivery.  As the estrogen level drops, further changes can occur. Low estrogen levels may weaken the urethral sphincter that helps hold in urine. If the woman has gained weight, it may put more strain on the bladder. 

Skin and hair changes 

Dealing Actively With Your Midlife Changes 

There are many choices in dealing with symptoms associated with approaching menopause. These include healthy lifestyle changes, hormone replacement therapy, other medications, social support and therapy. 

Healthy Lifestyle Changes: Regular exercise may decrease depression and irritability. Good muscle tone can also improve energy level and decrease aches and pains. Some forms of exercise may help decrease bone loss. Yoga or Tai Chi decrease stress and may reverse the decreased flexibility often associated with aging. Regular Tai Chi has been shown to decrease the incidence of hip fractures in older individuals. A diet high in complex carbohydrates, including multiple small meals may reduce irritability and improve one�s feeling of well-being.  

Social support: Many women experience menopause as a time of increased freedom and new possibilities. As their own children grow up, they may have more time and flexibility. However, some women experience the empty nest as the loss of their central role in life. Loss of a spouse through death or divorce can increase isolation. The physical changes associated with hormonal fluctuations can be confusing. Menopause may cause some women to start to think about the finite nature of life. Supportive friends and family can help a woman understand and cope with life changes. Reading about menopause or talking to one�s doctor can help make the changes less mystifying. A return to spirituality can spur growth at this phase of life.  

Hormone Replacement Therapy (HRT) Taking estrogen and progesterone can help some of the symptoms associated with approaching menopause. The decision to take hormones is an individual one. A woman considering HRT needs to consider the severity of her symptoms, her health history and her family history. She may also have personal preferences about taking medications. Estrogen is the hormone that seems to relieve many of the symptoms of approaching menopause. If a woman has already had her uterus removed, she may take estrogen by itself.  However, if a woman with an intact uterus takes estrogen without progesterone, the lining of the uterus may build up, and the woman may be at increased risk of uterine cancer. Thus HRT often requires a combination of estrogen and progesterone. The doses of estrogen and progesterone used for HRT are generally lower than the doses used for birth control pills. Often, women only need HRT for a limited number of years after menopause. There can be benefits and drawbacks to the use of HRT. Estrogen can relieve hot flashes, vaginal dryness, urinary problems, and sometimes insomnia. It can also promote a feeling of well-being. Some women feel that it improves memory and concentration. HRT can reduce the chance of osteoporosis. Estrogen may help prevent heart disease, but recent data has suggested that this effect may not be as dramatic as previously thought. For some women there may be drawbacks to HRT. Some studies have suggested a link between HRT and an increased incidence of breast cancer. Estrogen may elevate blood sugar, cause headaches, weight gain, or other side effects.  

Psychological support: For some women, social support, healthy lifestyle changes and hormone replacement therapy are not enough. The death of loss of a spouse, heath changes and other stresses may cause stress. Depression and mood swings are more common during perimenopause than after menopause is well established. However, a woman with a history of anxiety or major depression may have a reoccurrence during either of these periods.  Counseling may help some women deal with losses. Counseling may also help a woman review her life and make decisions about new directions and interests. If a woman has a persistent depression or experiences sleep, appetite and energy changes, or has suicidal thoughts, she may want to consider a psychiatric consultation and antidepressant medication.  

Passage through this life transition may leave one with a larger view of the rhythm and flow of life.

 

Northern County Psychiatric Associates 

Our practice has experience in the treatment of Attention Deficit disorder (ADD or ADHD), Depression, Separation Anxiety Disorder, Obsessive-Compulsive Disorder, and other psychiatric conditions. We are located in Northern Baltimore County and serve the Baltimore County, Carroll County and Harford County areas in Maryland. Since we are near the Pennsylvania border, we also serve the York County area.   Our services include psychotherapy, psychiatric evaluations, medication management, and family therapy. We treat children, adults, and the elderly.

Carol Watkins, MD
Northern County Psychiatric Associates
Lutherville and Monkton
Baltimore County, Maryland
Phone: 410-329-2028
Web Site http://www.baltimorepsych.com
Copyright 2000

What is Menopause?

Menopause (also called the change of life) is the transition period in a woman's life when the ovaries stop producing eggs. When the ovaries stop producing eggs, menstrual activity decreases and eventually ceases, and the body decreases the production of the female hormones, estrogen and progesterone.

Menopause affects individual women differently. In some women, menstral activity stops suddenly. In other women, menstral activity tapers off until it completely stops. It may take up to 3 years for the menstral cycle to completely stop. Menopause is a natural event.

When does Menopause occur?

The occurence of menopause is different for each woman. It usually occurs between the ages of 40 and 55

What are the Symptoms of Menopause?

The major symptoms of menopause are: missed periods, hot flashes, vaginal dryness, changes in mood and lack of sex drive.

Each of these symptoms are a result of hormonal changes. Hot flashes are caused by an increase of blood flow in the blood vessels of the face, neck, chest and back. Vaginal dryness is caused by thinning of the tissues of the vaginal wall, are the two side effects most frequently complained about. The mood changes and lack of sex drive may result partially from the hormone decrease, but may also result from having to deal with hot flashes and vaginal dryness.

Can Menopause be prevented?

No. Menopause is a natural event that will occur to all women.

Hot Flashes

Hot flashes are caused by rapid decreases in estrogen levels. Unfortunately hot flashes cannot be prevented. However, here are some techniques that can help you deal with them.

1. Wear loose clothing and dress in layers so you can peel off the top layers during a hot flash.
2. Wear fabrics that absorb moisture and dry quickly.
3. Avoid foods that may trigger hot flashes (hot drinks and spicy foods are common triggers)
4. Splash your face with cool water at the start of a flash.
5. Avoid Stress. It may contribute to the occurence of hot flashes.

Menopause Statistics 

All women will experience menopause. 
About 75% of women experiencing menopause will have hot flashes. 
After menopause, as a womans body�s supply of the hormone estrogen declines the likelihood of developing heart disease increases.

Menopause

Definition:

Menopause is the point in a woman's life when menstruation stops permanently, signifying the end of her ability to have children. Known as the "change of life," menopause is the last stage of a gradual biological process in which the ovaries reduce their production of female sex hormones--a process which begins about 3 to 5 years before the final menstrual period.

Suggested Treatment:

 

The following is the daily suggested adult (150lb.) use.
Royal Jelly	3 tablets daily. 1 20 minutes before each meal.
Gin-Chia	4 to 6 tablets daily. 2 20 minutes before each meal.
Nature-Min	6 tablets daily. 2 each meal.
Supplementary Help
A-Beta-CarE	2 capsules daily. 1 before each meal.
Fields of Greens	3 tablets daily.  1 each meal.
Bee Pollen	1 tablet per meal
Aloe Vera Nectar	4 to 6 ounces daily.  2 ounces before each meal.

Causes, incidence, and risk factors:

Menopause is an individualized experience. Some women notice little difference in their bodies or moods, while others find the change extremely bothersome and disruptive. Estrogen and progesterone affect virtually all tissues in the body, but everyone is influenced by them differently.

The National Institute on Aging has a great site full of information about menopause.

What are the symptoms of menopause?

Menopause, which is a natural part of aging, is the time in a woman's life when she stops getting her period. I will brief you on the changes and symptoms on approaching menopause and the health conditions you are at risk for after menopause.

The average age of women who go through menopause is around 50 years old, but it can also start near or about the age of 42. The natural events that each woman experiences differently are, perimenopause and menopause. The closer you get to menopause; the ovaries produce less estrogen, which has effects on your health.

Some of the immediate changes are usually the difference in your period schedule or flow. Some of the symptoms include quick mood swings, urinary changes like going more often, hot & cold flashes, excessive sweating, vaginal dryness, problems with sleeping at night & changes in sexual habits because of hormone changes.

You are more at risk for some health conditions once you have reached menopause. One of these conditions is called osteoporosis, which is the thinning of your bones, which makes them more easily breakable. The spine, wrists and hips are the joints more often affected by this. Another condition that you are at risk for is heart disease and a stroke, because your body doesn�t produce estrogen, which in turn makes women more susceptible to these health conditions.

In order to help reduce these symptoms and risks, women should go on hormone replacement therapy. This therapy supplies your body with estrogen and progestin to aid in the reduction of the uncomfortable symptoms. It also helps protect against any other health conditions associated with menopause. As with any other medication warnings, and with all the benefits and risks, it is extremely important that you learn as much as you can about hormone replacement therapy, to be sure you are a good candidate for this medication. If you feel that you are possibly going through change of life, then by all means, set up an appointment to visit with your doctor to discuss your options. There is a blood test that can show whether or not you are starting menopause, which would be considered perimenopause.

Your diet and exercise are very important things to do to keep yourself healthy. You will need to eat a balanced diet enriched with calcium foods to protect you bones, consuming approximately 1400-1500 mg of calcium per day. You should reduce your fat and cholesterol intake also. Exercising helps to slow down the bone loss and it�s good for your overall health. Some exercises should include, walking, swimming, biking, and taking possibly aerobic exercise classes. Do anything that you like to do to keep yourself in good condition during these times. Smoking and drinking alcohol if you must do it, should only be done in moderation.

It is absolutely necessary for women to visit with their doctor for regular checkups and a visit with your Gynecologist for routine screenings which include yearly Pap tests, breast exams and the wonderful mammograms.

Never be afraid to talk with your doctor about what you are experiencing, and by all means ask questions no matter how ridiculous they may seem. Because by knowing what to expect you will be able to take steps to ease your menopausal symptoms and alleviate health problems in the future.

Author's name omitted by request

Title: What are the symptoms of menopause?
Description: Menopause,which is a natural part of aging, is the time in a woman's life when she stops getting her period.

Menopause and hormone replacement therapy

Hormone Replacement Therapy has become a standard procedure for women approaching, or going through that time of life know as menopause. During menopause a woman�s body does not produce as much estrogen or progesterone -- the female hormones. Her periods slow down and eventually stop and her ability to bear more children ceases. To some women this is a great relief, to others it is a cause for depression. Whatever the case may be, learning about hormone replacement therapy as a way to ease the symptoms that are part and parcel of menopause is a wise choice.

What Are The Symptoms of Menopause? Between the ages of 35 and 55 a woman�s periods will begin to slow down and become irregular. Some of the physical changes that MAY accompany this change in periods are hotflashes (described as intense body heat,) a change in sleep patterns, vaginal dryness, urinary problems, weight gain, lowered ability to handle caffeine and alcohol, mild memory loss, mood swings, weakened bones, and lowered heart health.

It is helpful if a woman keeps a diary of her periods when she is approaching the age of menopause. This will enable her to be more aware of what is going on with her body at this time of change. If the symptoms become too uncomfortable it may be time to look into hormone replacement therapy(HRT). Many women begin therapy before they experience any menopausal symptoms.

What is HRT? Hormone replacement is just that. It replaces the female hormones that a woman�s body is making less of during menopause. HRT can lessen the side-effects of menopause and also help keep bones and heart strong. HRT can be administered in a pill, a patch, an injection or a cream. If one product doesn�t work talk to your doctor and move on to the next product type. HRT is a totally personal treatment and needs to be adjusted and sometimes readjusted for each woman. Following is a list of the types of replacement hormones:

ERT(estrogen replacement therapy), this is usually given to women who have had their uterus removed. Progesterone Replacement Therapy - replaces progesterone. Also used in some women to regulate their periods. This hormone gives relief for hot flashes and aids in keeping the bones healthy.

Combined Hormone Therapy, (or, Opposed Estrogen Therapy) � This is the treatment usually given to women who still have their uterus. It replaces estrogen and progesterone and can be administered in various forms, as natural or as synthetic.

"Natural" hormones are medications that are chemically identical to what the body produces, while "synthetic" hormones are medications that are similar but not identical to the hormones naturally produced in the body. The combined hormone therapy is the most beneficial. Estrogen and progesterone work in many parts of the body. While estrogen's main benefit is easing the discomfort of menopausal symptoms, it causes a thickening of the uterine lining which can lead to cancer. The progesterone protects the uterine wall from tissue build-up thus reducing that risk.

Testosterone Replacement Therapy Some women do not respond well to estrogen replacement therapy. This seems to hold true in women that have had their ovaries removed. In this case testosterone replacement therapy can offer relief and also has some additional benefits such as increased energy level, a higher sex drive, and an improved sense of well-being.

Another increasingly popular way to treat menopause is with a transdermal progesterone cream. These creams (some available without a prescription in low doses) may offer help to a woman, before she notices any of the symptoms of menopause. They deliver a small amount of progesterone through the skin. They are natural products, not synthetics and they can also help with premenopausal(PMS) as well as menopausal and post-menopausal symptoms. Your local health-food store, or Internet sites that reference alternative health products, can offer you more advice on these topical applications.

Title: Menopause and hormone replacement therapy
Description: Can hormone replacement threatment start before the onset of menopause?

The safest ways to stop hot flashes

You�re sitting in a climate-controlled room. You begin to feel strange. Suddenly it seems as though someone has just raised the thermostat to 100 degrees. You look around and notice you�re perhaps the only one who feels like stripping off your clothes and diving into the water cooler. Ten minutes later, you�re shivering like you�ve just come in from a blizzard.

You�ve had that feeling before, remember? It came in the form of a blaring alarm clock the night before when you did more weeping than sleeping. Your mate�s suggestion? See a psychiatrist. Good advice, wrong medical field; gynecologist, internist or general practitioner is more like it.

Menopause affects women in many different ways. Some feel they�re about to faint or experience a heart attack, while others will become overly sensitive, highly depressed and cry for no reason. You no longer feel desirable. And any compliment from your mate could send you right over the edge. All in all, the tremendous hormonal fluctuations during this confusing time are uncomfortable and disturbing sensations.

If you�re over age 40, you�ve just entered the Outer Limits. It�s not your fault your dysfunctional ovaries are now controlling the horizontal and vertical lines of your normal behavior pattern. About 80% of all menopausal women suffer, some more than others. This imbalance is more severe in women who do not sweat, whose menopause was surgically induced, and who are also enduring external stress.

Your gynecologist or internist can prescribe estrogen and progesterone to help you endure this change of life. However, there are quite a few natural remedies that can help you get through this difficult time.

If you are not diabetic, high doses of Vitamin E can be effective. Diet supplements containing black cohosh, unicorn root and ginseng have helped some women. Licorice root works to balance hormone levels. Japanese women report that a daily menu of rice and soy helps them control their hot flashes. There are numerous herbal and homeopathic remedies on the market aimed at balancing hormone levels.

Keep in mind the store attendant is not a medical expert and is not interested in whether you are diabetic or asthmatic; some of these remedies, like ginseng, could do you more harm than good. Be sure to ask your doctor about the supplements before you purchase them.

Some women report that moderate exercise and an active sex life help them because both activities raise important endorphin levels. Others may turn to meditation and visualization to promote a more positive mood.

Recent studies show that hormone levels do, in fact, affect sleep. Doctors have been looking closely at melatonin, a hormone secreted by the pineal gland. If you are disturbed by night sweats, melatonin has been proven successful in treating insomnia and jet lag. However, this supplement can cause depression in some women, which may defeat the purpose.

Chamomile tea and St. John�s wort with Kava Kava also help menopause-related insomnia. Sage, which contains plant estrogens, reduces excessive sweating and also helps reduce the frequency of night sweats.

Another safe way to get a good night�s rest is pamper yourself with a soothing, hot bath before bedtime. Take calcium in your preferred form and listen to soft music or a mood enhancement audio tape.

Yes, the new millennium has given the �M� word a name. So it�s okay to talk about your symptoms with mature family members and compassionate friends. Your mate, in particular, needs to understand this menopausal passage in order to help you get through it.

After talking with your doctor, visit Hot Flash!, a web site which sponsors an excellent support group with emphasis on perimenopause, menopause and other women�s health problems.

Written by Sharon Raiford Bush

Title: The safest ways to stop hot flashes
Description: Hot flashes are a reaction of menopause. The pulse races, skin reddens and then drenching sweats occur. That's what 80% of menopausal women experience. There are alternatives to hormone replacement therapy.

Menstrual Cycles:
What Really Happens in those 28 Days?!

Have you ever wondered about the connection between your body's 28 day cycle and the cycle of the moon? Here's the theory. In the days before electricity, women's bodies were influenced by the amount of moonlight we saw. Just as sunlight and moonlight affect plants and animals, our hormones were triggered by levels of moonlight. And, all women cycled together. Today, with artificial light everywhere, day and night, our cycles no longer correspond to the moon. This article is dedicated to exploring menses: fact and fiction, then and now.

The philosophic foundation of the Feminist Women's Health Center is "Knowledge is Power." We believe when women have complete, unbiased information, they are empowered to make their own decisions leading to healthy whole lives. An important role of the FWHC is to provide information, resources for additional information, and give an analysis of the information we present. Here we describe a typical 28 day menstrual cycle and we begin to challenge the dominant American cultural assumptions about menses.

Consider for a moment all you've heard about menstruation. Who first told you? What did they call it? How is menstruation viewed by your culture? What taboos have influenced you? How does your partner feel about your period? What impact has advertising had on your knowledge and attitude? What is the motivation of the advertiser? Is your experience different now compared to earlier in your life?

First we'll discuss the basic biology of menstruation, then we'll look at ancient traditions.

Basic Biology: the cycle begins

Did you know that when a baby girl is born, she has all the eggs her body will ever use, and many more, perhaps as many as 450,000? They are stored in her ovaries, each inside its own sac called a follicle. As she matures into puberty, her body begins producing various hormones that cause the eggs to mature. This is the beginning of her first cycle; it's a cycle that will repeat throughout her life until the end of menopause.

Let's start with the hypothalamus. The hypothalamus is a gland in the brain responsible for regulating the body's thirst, hunger, sleep patterns, libido and endocrine functions. It releases the chemical messenger Follicle Stimulating Hormone Releasing Factor (FSH-RF) to tell the pituitary, another gland in the brain, to do its job. The pituitary then secretes Follicle Stimulating Hormone (FSH) and a little Leutenizing Hormone (LH) into the bloodstream which cause the follicles to begin to mature.

The maturing follicles then release another hormone, estrogen. As the follicles ripen over a period of about seven days, they secrete more and more estrogen into the bloodstream. Estrogen causes the lining of the uterus to thicken. It causes the cervical mucous to change. When the estrogen level reaches a certain point it causes the hypothalmus to release Leutenizing Hormone Releasing Factor (LH-RF) causing the pituitary to release a large amount of Leutenizing Hormone (LH). This surge of LH triggers the one most mature follicle to burst open and release an egg. This is called ovulation. [Many birth control pills work by blocking this LH surge, thus inhibiting the release of an egg.]

Ovulation

As ovulation approaches, the blood supply to the ovary increases and the ligaments contract, pulling the ovary closer to the Fallopian tube, allowing the egg, once released, to find its way into the tube. Just before ovulation, a woman's cervix secretes an abundance of clear "fertile mucous" which is characteristically stretchy. Fertile mucous helps facilitate the sperm's movement toward the egg. Some women use daily mucous monitoring to determine when they are most likely to become pregnant. Mid cycle, some women also experience cramping or other sensations. Basal body temperature rises right after ovulation and stays higher by about .4 degrees F until a few days before the next period.

Inside the Fallopian tube, the egg is carried along by tiny, hairlike projections, called "cilia" toward the uterus. Fertilization occurs if sperm are present as the live egg reaches the uterus. [A tubal pregnancy (ectopic pregnancy) is the rare situation where the egg is fertilized inside the tube. It is a dangerous life-threatening situation. If an fertilized egg begins to develop into an embryo inside the tube it will rupture the tube causing internal bleeding. Surgery is required if the tube ruptures. If the pregnancy is discovered before the tube ruptures, medication (Methotrexate) can be used to stop the development of the embryo.]

A woman can use a speculum to monitor her own ovulation and use this information to avoid or encourage a pregnancy. This is the all-natural fertility awareness method (FAM) of family planning.

Uterine Changes

Between midcycle and menstruation, the follicle from which the egg burst becomes the corpus luteum (yellow body). As it heals, it produces the hormones estrogen and, in larger amounts, progesterone which is necessary for the maintenance of a pregnancy. [RU-486 works by blocking proges-terone production.] In the later stages of healing, if the uterus is not pregnant, the follicle turns white and is called the corpus albicans.

Estrogen and progesterone are sometimes called "female" hormones, but both men and women have them, just in different concentrations.

Progesterone causes the surface of the uterine lining, the endometrium, to become covered with mucous, secreted from glands within the lining itself. If fertilization and implantation do not occur, the spiral arteries of the lining close off, stopping blood flow to the surface of the lining. The blood pools into "venous lakes" which, once full, burst and, with the endometrial lining, form the menstrual flow. Most periods last 4 to 8 days but this length varies over the course of a lifetime.

Bleeding - A New Theory

Some researchers view menses as the natural monthly cleansing of the uterus and vagina of sperm and bacteria they carried.

Cramps and Other Sensations

Women can experience a variety of sensations before, during or after their menses. Common complaints include backache, pain in the inner thighs, bloating, nausea, diarrhea, constipation, headaches, breast tenderness, irritability, and other mood changes. Women also experience positive sensations such as relief, release, euphoria, new beginning, invigoration, connection with nature, creative energy, exhilaration, increased sex drive and more intense orgasms.

Uterine cramping is one of the most common uncomfortable sensations women may have during menstruation. There are two kinds of cramping. Spasmodic cramping is probably caused by prostaglandins, chemicals that affect muscle tension. Some prostaglandins cause relaxation, and some cause constriction. A diet high in linoleic and liblenic acids, found in vegetables and fish, increases the prostaglandins for aiding muscle relaxation.

Congestive cramping causes the body to retain fluids and salt. To counter congestive cramping, avoid wheat and dairy products, alcohol, caffeine, and refined sugar.

Natural options to alleviate cramping:

• Increase exercise. This will improve blood and oxygen circulation throughout the body, including the pelvis.
• Try not using tampons. Many women find tampons increase cramping. Don't select an IUD (intra-uterine device) as your birth control method.
• Avoid red meat, refined sugars, milk, and fatty foods.
• Eat lots of fresh vegetables, whole grains (especially if you experience constipation or indigestion), nuts, seeds and fruit.
• Avoid caffeine. It constricts blood vessels and increases tension.
• Meditate, get a massage.
• Have an orgasm (alone or with a partner).
• Drink ginger root tea (especially if you experience fatigue).
• Put cayenne pepper on food. It is a vasodilator and improves circulation.
• Breathe deeply, relax, notice where you hold tension in your body and let it go.
• Ovarian Kung Fu alleviates or even eliminates menstrual cramps and PMS, it also ensures smooth transition thrrough menopause
• Take time for yourself!

Anecdotal information suggests eliminating Nutra-Sweet from the diet will signifcantly relieve menstrual cramps. If you drink sugar-free sodas or other forms of Nutra-Sweet, try eliminating them completely for two months and see what happens.

Lifestyle

The hormones in our bodies are especially sensitive to diet and nutrition. PMS and menstrual cramping are not diseases, but rather, symptoms of poor nutrition.

Premenstrual Syndrome or PMS

PMS has been known by women for many many years. However, within the past 30 or so years, pharmaceutical companies have targeted and created a market to treat this normal part of a woman's cycle as a disease. These companies then benefit from the sale of drugs and treatments.

Premenstrual syndrome refers to the collection of symptoms or sensations women experience as a result of high hormone levels before, and sometimes during, their periods.

One type of PMS is characterized by anxiety, irritability and mood swings. These feelings are usually relieved with the onset of bleeding. Most likely, this type relates to the balance between estrogen and progesterone. If estrogen predominates, anxiety occurs. If there's more progesterone, depression may be a complaint.

Sugar craving, fatigue and headaches signify a different type of PMS. In addition to sugar, women may crave chocolate, white bread, white rice, pastries, and noodles. These food cravings may be caused by the increased responsiveness to insulin related to increased hormone levels before menstruation. In this circumstance, women may experience symptoms of low blood sugar; their brains are signaling a need for fuel. A consistent diet that includes complex carbohydrates will provide a steady flow of energy to the brain and counter the ups and downs of blood sugar variations.

Menstrual Myths

• Every woman's cycle is or should be 28 days long.
• Every woman will or should bleed every month.
• Every woman will or should ovulate every cycle.
• If a woman bleeds, she is not pregnant.
• A woman cannot ovulate or get pregnant while she is menstruating.

The above statements are myths. Every woman is different.

It's true that most women will have cycles that are around 28 days. But, a woman can be healthy and normal and have just 3 or 4 cycles a year.

Ovulation occurs about 14-16 days before women have their period (not 14 days after the start of their period). The second half of the cycle, ovulation to menstruation, is fairly consistently the same length, but the first part changes from person to person and from cycle to cycle. In rare cases, a women may ovulate twice in a month, once from each ovary.

A woman can become pregnant only after ovulation. The egg stays alive for about 24 hours once released from the ovary. Sperm can stay alive inside a woman's body for 3-4 days, but possibly as long as 6-7 days. That's why a woman can get pregnant for about one week in her cycle.

Fertility awareness is a birth control method where women monitor their cycles daily to identify ovulation. They are learning to predict ovulation to prevent or encourage pregnancy. It requires training and diligent record keeping.

From our work providing abortion services, we know that some women can be pregnant and continue to have periods at the same time. We also know of cases where women have gotten pregnant during their menstrual period.

Menopause

Technically menopause is the last menstrual flow of a woman's life and the climateric is period of time preceeding and following this event. In general usage, menopause refers to the whole process. For most women, menopause occurs between the ages of forty and sixty and takes place over a period from 6 months to three years.

The menstrual cycle usually goes through many changes, some slow and some sudden, before stopping altogether. A woman's periods may become erratic, closer together, or further apart. She may skip a period or two, or have spotting at other times in her cycle.

A common experience is loss of large amounts of blood with a period and passage of large clots. When a woman nears the cessation of her periods, she may not ovulate for one cycle or several cycles. In this case, the endometrium doesn't receive the chemical message to stop thickening. It grows and grows until its heavy bulk causes a heavy flow.

Signals of menopause include hot flashes or flushes, changes in sleep patterns, headaches or migraines, high energy, high creativity, and/or mood changes. As with PMS, some of these symptoms are hormone imbalances caused by poor nutrition.

Did You Know?

• Women lose between 20 and 80 cc's (1-2 ounces) of blood during a normal period.
• One in six fertilized eggs naturally results in miscarriage, some of which are re-absorbed by the body and the woman is not aware she's been pregnant.
• The length of a woman's menstrual cycle (the number of days from the first day of one period to the first day of the next) is determined by the number of days it takes her ovary to release an egg. Once an egg is released, it is about 14 days until menstruation, for nearly all women.

Alternatives for Handling Menstrual Flow

1. Chlorine-free biodegradable 100% cotton tampons recently hit the market in response to environmentally conscious feminists. Studies have shown that organochlorines can be linked to cancer. Women using chlorine-free tampons are not putting chlorine into their bodies, nor are they supporting an industry which produces enormous volumes of industrial waste containing chlorine. If your regular pad or tampon isn't chlorine-free, write and urge them to make 100% cotton pads and tampons without chlorine.
2. Natural sponges from the ocean (not cellulose) are used by some women. They are dampened then inserted directly into the vagina. When full, they are removed, washed with water, and reused. Washable reusable cloth pads are also available.
3. The menstrual cap is another reusable alternative. It is similar to the cervical cap, but worn near the vaginal opening in the same place as a tampon. When full, it is simply removed, washed and reinserted. A cervical cap has also been used successfully in this manner.
4. The Keeper - a specially made reusable device for catching monthly flow.

To learn more about your own cycle, you may wish to keep a journal or calendar and make note of how you feel, emotionally and physically.

Moon Time

Throughout all cultures, the magic of creation resides in the blood women gave forth in apparent harmony with the moon, and which sometimes stayed inside to create a baby. This blood was regarded with reverence: it had mysterious magical powers, was inexplicably shed without pain, and was wholly foreign to male experience. Early menstrual rites were perhaps the first expression of human culture.

Native American (Lakota):

"Follow your Grandmother Moon. Her illuminating cycles will transform your spirit." Begin with the Grandmother Moon at her brightest and most open. This is a time of outward activity and high energy. Sleep where the moonlight touches you. Walk outside where there are no artificial lights. Feel joy and creativity. As the Grandmother begins to cover her face, begin to withdraw into a quieter, less social place. Move to that inward place that is more about "being" than "doing." In the dark of the moon, when bleeding, the veil between you and the Great Mystery is the thinnest. Be receptive to visions, insights, intuitions. Go to a quiet separate place such as a Moon Lodge. Later, come out of the dark, a woman with a cleansed body. As the moon returns, come back out into the world, carrying your vision.

Customs and Traditions

• Indians of South American said all humans were made of "moon blood" in the beginning.
• In Mesopotamia, the Great Goddess created people out of clay and infused them with her blood of life. She taught women to form clay dolls and smear them with menstrual blood. Adam translates as bloody clay.
• In Hindu theory, as the Great Mother created the earth, solid matter coalesced into a clot with a crust. Women use this same method to produce new life.
• The Greeks believed the wisdom of man or god was centered in his blood which came from his mother.
• Egyptian pharoahs became divine by ingesting the blood of Isis called sa. Its hieroglyphic sign was the same as the sign of the vulva, a yonic loop like the one on the ankh.
• From the 8th to the 11th centuries, Christian churches refused communion to menstruating women.
• In ancient societies, menstrual blood carried authority, transmitting lineage of the clan or tribe.
• Among the Ashanti, girl children are more prized than boys because a girl is the carrier of the blood.
• Chinese sages called menstrual blood the essence of Mother Earth, the yin principle giving life to all things.
• Some African tribes believed that mensrual blood kept in a covered pot for nine months had the power to turn itself into a baby.
• Easter eggs, classic womb-symbols, were dyed red and laid on graves to strengthen the dead.
• A born-again ceremony from Australia showed the Aborigines linked rebirth with blood of the womb.
• Post-menopausal women were often the wisest because they retained their "wise blood." In the 17th century these old women were constantly persecuted for witch craft because their menstrual blood remained in their veins.

Calendars:

The Roman Goddess of measurement, numbers, calendars, and record-keeping; derived from the Moon-goddess as the inventor of numerical systems; measurer of time.

It has been shown that calendar consciousness developed first in women because their natural body rhythms corresponded to observations of the moon. Chinese women established a lunar calendar 3000 years ago. Mayan women understood the great Maya calendar was based on menstrual cycles. Romans called the calculation of time mensuration, meaning knowledge of the menses. In Gaelic, menstruation and calendar are the same word.

The lunar calendar's thirteen 28-day months had four 7-day weeks, marking the new, waxing, full, and waning moons. Thirteen months is 364 days. Pagan traditions describe an annual cycle as a 13 months and a day. Even today, Easter is the first Sunday after the first full moon after the spring equinox. The 13 month calendar also led to pagan reverence for the number 13 and the Christian attempts to demolish it. Generally, the ancient symbols of matriarchy were the night, moon and 13. Patriarchy (under Christianity) honored the day, the sun and 12.

Resources

Menopausal Years: The Wise Woman Way by Susan S. Weed
PMS Self-Help Book and Menstrual Cramps by Susan M. Lark, MD
A New View of a Woman's Body by the Federation of FWHCs
Our Bodies Ourselves by the Boston Women's Health Book Collective
Buffalo Woman Comes Singing by Brooke Medicine Eagle
The Woman's Encyclopedia of Myths and Secrets by Roberta G. Walker
Blood, Bread and Roses by Judy Grahn

Links

Birth Control Handbook - offers an excellent and thorough explanation of the menstrual cycle and how each birth control method works to prevent pregnancy.
Menstruation - connecting heart, mind, body and spirit - Menstruation is an Art because if we are living our cycles and tapping into the gifts, power and responsibilities of being authentically Feminine, then we are tapping into an everchanging, never-ending source of creativity.
Museum of Menstruation - Herstory of menstruation, menstrual pad alternatives, and selected women's health topics.
Lunar Calendars from Snake and Snake
1995 Village Voice article "Pulling The Plug on the Tampon Industry"
Fertility Awareness Method of Birth Control (FAM).
Tools for Self Exam - use your own speculum, mirror and flashlight.
Organic Tampons

Sexual Desire in Menopause

by Patricia Rackowski & Kathleen Gill, Ph.D.

Objectives

• Describe changes in androgens in aging, menopause, and following oophorectomy.
• Define patients who might be appropriate for testosterone therapy.
• Discuss alternative medical therapy versus prescription medical therapy.

WOMEN AND LIBIDO-IS THERE A ROLE FOR TESTOSTERONE?
Testosterone is an important metabolic and sex hormone produced by the ovary throughout a woman's lifetime, with levels changing at different times of life and under certain medical conditions. The variable reduction in testosterone production during the perimenopause is sometimes associated with a syndrome of specific changes in sexual desire and sexual response.¹ Estrogen deficiency also impairs sexual response, but its replacement will not improve and might exacerbate sexual symptoms from androgen loss.²

Decreasing testosterone may be one of many possible causes of decreasing sexual desire; however, disorders of desire are complex and require careful, non-judgmental history taking. Testosterone replacement/supplementation may be appropriate in a small percentage of women who complain of decreased desire.³ Many women experiencing the clinical symptoms of androgen deficiency and low free testosterone levels respond well to testosterone replacement therapy.

Androgen Production
There is very little androgen action in the female fetus-the placenta has absorbed all the mother's androgens and although fetal adrenal glands produce a high level of weak androgens, the female usually is not virilized in humans. Androgens remain relatively low until adrenarche, when dehydroepiandrosterone sulfate (DHEAS) develops. During puberty, the adrenal gland makes higher levels of weak androgens-DHEAS is very high during puberty into the early twenties. The adrenal and ovarian androgen production from puberty to menopause is relatively high, although there is a decline of adrenal production after the early twenties while ovarian production continues until well after menopause. The predominant symptom of women with androgen deficiency is loss of sexual desire.⁴ This is not limited to women experiencing a surgical menopause but may also be a feature of women who have either undergone premature or natural menopause.

Menopause and Disorders of Desire
Sexuality and sexual function involve more than just physical ability; psychological factors are just as important. The aging process involves many normal physical changes, some of which naturally affect sexuality. There is a gradual slowing of response, but women do not ordinarily lose their capacity for orgasm.^5,6 During menopause, women may experience a variety of conditions that cause changes in sexual function. These changes include diminished sexual responsiveness, dyspareunia (painful intercourse related to estrogen deficiency), decreased sexual activity, decreased desire, a dysfunctional male partner, or lack of a partner.⁷ When assessing disorders of desire, answers to the following questions will provide important clues:

• What is the nature of the patient's current sexual activity?
• Is there an identifiable event associated with loss of desire?
• How much disparity is there between the patient's desire and her partner's?

It is the issues surrounding a woman's autoerotic behavior, her own sexual thoughts, dreams and fantasies, and masturbation, which define a woman's libido that need to be examined. Is the problem really lack of interest or is it anger, fear of rejection, or negative messages partners give to one another? Is the lack of desire selective? Is the underlying effort to remain sexually aloof a way to punish or control the partner? Have there been attempts to solve the problem?

It is important to determine if there is a surgical event connected to loss of desire. Women who can clearly define their sexual drive through issues of fantasy and desire, and who can say there was a specific drop associated with a specific medical event, are very likely to respond to androgen therapy.⁸

There are a number of medical causes of decreased libido. These include acute and chronic illness, fatigue, malnutrition, alcohol, drugs, stroke, pituitary disease, renal disease, depression, and testosterone and estrogen deficiency. Traumatic deliveries can also result in chronic dyspareunia and incontinence, both affecting sexual relations and satisfaction.

Possible Medical Causes of Decreased Libido Illnesses Virtually any illness (genital or general; physical, emotional, or both): liver, renal, cardiac or hormonal disease, cystitis, anemia, hypertension, stroke, cancer, neurologic disease, colostomy, neostomy, bladder surgery, incontinence, herpes virus or HIV infection, gonorrhea, venereal warts. Medications Antihypertensives, antineoplastic drugs, some antidepressants, (including selective serotonin reuptake inhibitors), major or minor tranquilizers (depending on dose), diuretics, antihistamines. Treatments Major surgery (hysterectomy, mastectomy, cardiac bypass, organ transplant), dialysis, radiotherapy, chemotherapy.

There are also interpersonal causes of disorders of desire. These include reduced sexual attractiveness of patient or partner, boring sexual routines, situational disturbances, and marital adjustment problems. Contrary to popular belief, marriages do not increase in emotional intimacy with time.⁹ It is not uncommon for a couple who were very sexually active in their twenties to lack emotional intimacy in their forties. The kind of emotional intimacy that leads to desire is often lacking in long-term married relationships.

In disorders of desire, 90 percent of it has to do with the relationship. However, 10 percent of it may be related to decreasing levels of testosterone. The biggest question to ask in evaluating disorder is whether the patient has had desire in the past, including autoerotic behavior and fantasies.

Androgen Therapy
Changes in the circulating levels of androgens play an important role in psychologic and sexual changes that occur after menopause. The effects of short-term estrogen therapy in improving psychologic symptoms, maintaining vaginal lubrication, decreasing vaginal atrophy, and increasing pelvic blood flow in postmenopausal women are well documented; however, some patients require more than estrogen alone to improve psychologic dysfunction, decreased sexual desire, or other sexual problems associated with menopause. Results from clinical studies show that hormone replacement therapy with estrogen plus androgens provides greater improvement in psychologic (e.g., lack of concentration, depression, and fatigue) and sexual (e.g., decreased libido and inability to have an orgasm) symptoms than does estrogen alone in naturally and surgically menopausal women.¹⁰

For menopausal women who have never had much sexual desire, or who experience no change in libido, testosterone would probably not be the right therapy. But for those women who have felt sexual desire and wonder where it went, testosterone may be helpful.

During menopause, low estrogen levels lead to vulvar and vaginal atrophy,¹¹ which can cause discomfort. This can have a dampening effect on libido, although lubricants can help. Estrogen replacement therapy can increase vulvar sensation and decrease dyspareunia, but it does not do anything for desire.¹²

Non-androgenic progestins in oral contraceptives, with the addition of ethinyl estradiol, can drive free testosterone to very low levels. This will eliminate the mid-cycle surge of androgens and accompanying surge of autoerotic and sex-seeking behavior in humans related to ovulation.

There is no convincing evidence that adding physiologic doses of androgens consistently enhances libido in menstruating women. Naturally menopausal women over 50 still produce a fair amount of androgens, for at least five to 10 years. For 35- to 60-year-old women who have had oophorectomies, there may be an increase in libido with the addition of androgens.¹³ Evidence that this is the case comes from a study, comparing estrogen-only, estrogen-testosterone, and placebo therapy in women who have had oopherectomies.¹⁴ The levels of testosterone used in the study were, however, superphysiologic, sometimes four to five times the average in males.

Testosterone and estrogen combined may increase bone density more than estrogen alone.¹⁵ Recent studies have also shown estrogen-androgen therapy to contribute to the prevention of osteoporosis and reduce serum levels of total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.^16,17 Finally, there appears to be some connection between testosterone and an elevated sense of well being in some patients, although this is difficult to assess given the powerful placebo effect.¹⁸

For women who might be candidates, there are a number of androgen therapies available: combined oral conjugated estrogens, injectables, subcutaneous testosterone pellets, transdermal patches (in development), and creams and gels.

Oral preparations are difficult to evaluate because their androgen delivery cannot be measured; only secondary effects can be measured. So it is hard to tell whether patients are receiving a lot or not enough testosterone. Transdermal preparations can vary in application effectiveness and dosing, but can achieve very high testosterone levels.

Androgen therapy does have side effects. These include hirsutism, increased facial oiliness, acne, deepening voice, hostility, weight gain, alopecia,¹⁹ elevated liver functions, lower HDL levels, and (rarely) epedicellular carcinoma.²⁰ Finding the right balance that will help women with their libido without causing adverse side effects is very difficult. How much is too much or too little testosterone has yet to be determined.

Other potential indications for androgen therapy in women are currently being evaluated. These include use in women with premature ovarian failure, premenopausal androgen deficiency symptoms, postmenopausal and glucocorticosteroid-related bone loss, alleviation of wasting syndrome secondary to human immunodeficiency virus infection, and management of premenstrual syndrome.²¹

REFERENCES
¹ Davis SR. Androgen replacement in women: a commentary. J Clin Endocrinol Metab. 1999 Jun;84(6):1886-91.

² DeCherney AH. Hormone receptors and sexuality in the human female. J Womens Health Gend Based Med. 2000;9 Suppl 1:S9-13.

³ Sarrel PM. Effects of hormone replacement therapy on sexual psychophysiology and behavior in postmenopause. J Womens Health Gend Based Med. 2000;9 Suppl 1:S25-32.

⁴ Davis SR. The therapeutic use of androgens in women. J Steroid Biochem Mol Biol. 1999 Apr-Jun;69(1-6):177-84.

⁵ Masters WH. Sex and aging - expectations and reality. Hospital Practice. August 15, 1986. 175-198.

⁶ Meston CM. Aging and sexuality. West J Med. 1997 Oct;167(4):285-90.

⁷ Kingsberg SA. Postmenopausal sexual functioning: a case study. Int J Fertil Womens Med. 1998 Mar-Apr;43(2):122-8

⁸ Myers CS, et al. Effect of estrogen, androgen, and progestin on sexual psychophysiology and behavior in post-menopausal women. J Endocrinol Metab 1990;70(4): 1124-1131.

⁹ Greer R. et al. Aspects of geriatric sexuality. Family Practice Recertification. Vol 13:No 6: 57-73.

¹⁰ Sarrel PM. Psychosexual effects of menopause: role of androgens. Am J Obstet Gynecol. 1999 Mar;180(3 Pt 2):319-14.

¹¹ Cutson TM, Meuleman E. Managing menopause. Am Fam Physician. 2000 Mar 1;61(5):1391-400, 1405-6.

¹² Naftolin F, et al. The cellular effects of estrogens on neuroendocrine tissues. J Steroids Biochem 1988;Vol 30:195-107.

¹³ Myers CS, et al. Effect of estrogen, androgen, and progestin on sexual psychophysiology and behavior in post-menopausal women. J Endocrinol Metab 1990;70(4): 1124-1131.

¹⁴ Sherwin BB, Gelfand MM. Differential symptom response to parenteral estrogen and/or androgen administration in the surgical menopause. Am J Obstet Gynecol 1995;151: 153-160.

¹⁵ Shoupe D. Androgens and bone: clinical implications for menopausal women. Am J Obstet Gynecol 1999 Mar;80 (3 pt 2):329-333.

¹⁶ Bachmann GA. Androgen cotherapy in menopause: evolving benefits and challenges. Am J Obstet Gynecol. 1999 Mar;180(3 Pt 2):308-11. ¹⁷ Hoeger KM, Guzick DA. The use of androgens in menopause. Clin Obstet Gynecol. 1999 Dec;42(4):883-94.

¹⁸ Sherwin BB, Gelfand MM. Differential symptom response to parenteral estrogen and/or androgen administration in the surgical menopause. Am J Obstet Gynecol 1995;151: 153-160.

¹⁹ Redmond GP. Hormones and sexual function. Int J Fertil Womens Med. 1999 Jun-Aug;44(4):193-7.

²⁰ Hoeger KM, Guzick DS. The use of androgens in menopause. Clin Obstet Gynecol. 1999 Dec;42(4):883-94.

²¹ Davis S. Androgen replacement in women: a commentary. J Clin Endocrinol Metab. 1999 Jun;84(6):1886-91.

An Active Menopause: Using Exercise to Combat Symptoms

Mona M. Shangold, MD

In Brief: There's no better time than the years surrounding menopause for a woman to start or renew an exercise program. Exercise may reduce the immediate symptoms of menopause, and it decreases the long-term risk of cardiovascular disease, osteoporosis, and obesity. The exercise prescription includes aerobic exercise, resistance training, and stretching components, and should be individualized according to the woman's exercise history.

Menopause, which occurs at an average age of 52 years, is defined as a woman's final menstrual period. This event results from lack of endometrial stimulation by estrogen as the ovarian follicles become depleted. For 5 to 10 years preceding menopause and for 5 to 10 years following it, a woman is hormonally different from the way she was before and the way she will be after this climacteric interval.

Premenopausal women (prior to the climacteric or perimenopausal years) usually experience cyclic production of estrogen and progesterone, with high concentrations of estrogen prior to each ovulation and high concentrations of estrogen and progesterone during the luteal phase, after ovulation. Postmenopausal women (following the climacteric or perimenopausal years) usually have low levels of estrogen and progesterone, with little fluctuation and no cyclicity. Perimenopausal women commonly have fluctuating levels of estrogen that lack cyclicity and predictability.

Symptoms are common among perimenopausal and postmenopausal women. Some symptoms and problems are due to hormonal changes of the menopausal transition, while others result from the aging process and adverse lifestyle factors (eg, sedentary behavior, cigarette smoking, poor diet). It is often impossible to isolate these etiologic factors in evaluating and counseling individual women.

Benefits of Exercise

Specific types of exercise can be used to treat many problems experienced by menopausal women, and those who exercise regularly tend to report fewer menopausal symptoms and problems than sedentary women.

Vasomotor symptoms. The cause of vasomotor symptoms (hot flushes) is not yet known. However, these symptoms can be very uncomfortable and can lead to chronic sleep deprivation, as well as mood and behavior changes. Vasomotor symptoms are less common among physically active postmenopausal women than among sedentary controls (1), but exercise has not been shown to relieve such symptoms. Estrogen remains the most effective treatment for vasomotor symptoms.

Bone loss. Bone loss results from deficiencies of estrogen, exercise, and dietary calcium. The rate of bone loss in women accelerates at menopause because of the marked reduction in serum estrogen concentrations. (See "Guidelines for Diagnosing Osteoporosis" by Gail P. Dalsky, PhD)

It is preferable to prevent bone loss before it occurs, rather than to treat osteopenia or osteoporosis. Strategies for prevention of bone loss include hormone replacement therapy, calcium supplementation (unless dietary sources are adequate), and exercise. Both weight training and aerobic exercise enhance and maintain bone density. Postmenopausal women require 1,500 mg of calcium daily if they are not taking exogenous estrogen therapy and 1,000 mg of calcium daily if they are. Estrogen therapy prevents bone loss better than calcium supplementation or resistance exercise does; however, the combination of hormone replacement therapy and resistance exercise leads to a greater increase in bone density than does hormone replacement therapy alone (2), and it is likely that the combination of estrogen, calcium, and exercise is even more beneficial.

Cardiovascular disease. Cardiovascular disease risks rise with age among both sexes as a result of aging, other risk factors, and the cumulative effects of an adverse lifestyle. In women, cardiovascular disease risks rise sharply after menopause because estrogen deficiency induces lipid and vascular changes. Many of the adverse effects of aging and menopause on lipids (3) are reversed by aerobic exercise. Aerobic exercise promotes cardiovascular fitness and reduces risks of cardiovascular disease and cardiovascular mortality. Estrogen replacement therapy leads to a reduction in mortality from coronary heart disease and other causes (4).

Urogenital atrophy. Urogenital atrophy results from estrogen deficiency and is best treated with estrogen therapy, administered by any route. Exercise does not affect urogenital atrophy.

Depression and sleep disturbances. Some mood and sleep disturbances are related to estrogen deficiency; vasomotor symptoms can impair sleep and induce chronic sleep deprivation, which can cause mood disorders. Estrogen therapy improves sleep quality and enhances mood for many women with these symptoms. Regular aerobic exercise improves cognitive function, enhances mood, and promotes daytime alertness and nocturnal sleepiness. If mood and sleep disturbances are not relieved by estrogen therapy and/or exercise, antidepressant or other psychotropic medication should be prescribed, depending on the specific diagnosis.

Weight gain. Weight gain and accumulation of fat from aging and inactivity are common among perimenopausal and postmenopausal women. Aerobic and resistance exercise, which increase energy expenditure and lean-body mass, are the most effective ways to treat this problem.

Muscle weakness. Another common accompaniment of the aging process is loss of muscle tissue and strength. Many older women lack sufficient strength to remain functional and independent. Resistance exercise is the most effective way to increase and maintain muscle strength.

Hormone Replacement Therapy

Hormone replacement therapy includes both estrogen and progestogen. Nearly all of the benefits result from estrogen alone. Progestational therapy should be added for endometrial protection in any woman who has a uterus but should not be prescribed for any woman who has had a hysterectomy.

Benefits. As described, estrogen therapy relieves vasomotor symptoms, prevents bone loss, reduces cardiovascular disease risk, relieves urogenital atrophy, and improves mood and sleep quality.

Contraindications and risks. In general, estrogen should not be prescribed for women who have breast or endometrial cancer, a history of thromboembolic disease, active hepatic dysfunction, or undiagnosed vaginal bleeding. Rare exceptions to these contraindications should be considered and managed on an individual basis. Relative contraindications include hormonally induced headaches and myomata uteri.

Hormone replacement therapy has not been associated with weight gain (5), despite nonscientific beliefs to the contrary. The major risk of hormone replacement therapy is the inconvenience of vaginal bleeding, which can often be minimized, eliminated, or regulated. If progestational therapy is adequate, the risk of endometrial cancer is less than in untreated women.

A Commitment to Exercise

All women should be encouraged to exercise regularly, and older women often need instruction in specific, individualized programs. A plan that includes both aerobic and resistance training can help to prevent or relieve problems that are common among menopausal women, such as cardiovascular disease, obesity, muscle weakness, osteoporosis, depression, and sleep disturbances. It is the responsibility of physicians caring for these women to educate them appropriately and monitor their compliance (see "The Menopause Exercise Prescription," below).

Emphasizing the exercise component for women who are undergoing menopause can dramatically improve their quality of life. The short-term goal of exercise therapy is minimizing menopause symptoms, and the long-term goal is enabling women to remain independent and self-sufficient.

References

1. Hammar M, Berg G, Lindgren R: Does physical exercise influence the frequency of postmenopausal hot flushes? Acta Obstet Gynecol Scand 1990;69(5):409-412
2. Notelovitz M, Martin D, Tesar R, et al: Estrogen therapy and variable-resistance weight training increase bone mineral in surgically menopausal women. J Bone Miner Res 1991;6(6):583-590
3. Taylor PA, Ward A: Women, high-density lipoprotein cholesterol, and exercise. Arch Intern Med 1993;153 (10):1178-1184
4. Ettinger B, Friedman GD, Bush T, et al: Reduced mortality associated with long-term postmenopausal estrogen therapy. Obstet Gynecol 1996;87(1):6-12
5. Kritz-Silverstein D, Barrett-Connor E: Long-term postmenopausal hormone use, obesity, and fat distribution in older women. JAMA 1996;275(1):46-49

Suggested Reading

Shangold M, Mirkin G: Women and Exercise: Physiology and Sports Medicine, ed 2. Philadelphia, FA Davis, 1994

Dr Shangold is director of the Center for Sports Gynecology and Women's Health in Philadelphia. She is a fellow of the American College of Sports Medicine and the American College of Obstetricians and Gynecologists. Address correspondence to Mona M. Shangold, MD, The Center for Sports Gynecology and Women's Health, 2 Franklin Town Blvd, Philadelphia, PA 19103.

An Introduction to Menopause

By Dr. Deborah Moskowitz

What is Menopause?

Menopause is defined as the cessation of menstruation as a result of the normal decline in ovarian function. Technically, you enter menopause following 12 consecutive months without a period. Menopause has become increasingly medicalized, which means it is viewed as something that requires intervention and treatment rather than as a natural life transition that may benefit from support. Menopause signals the end of fertility and the beginning of a new and potentially rewarding time in a woman's life. Part of the stigma of menopause is its association with aging, but we age no more rapidly in our 50s than in any other decade of life.

When Does Menopause Happen?

For most women, natural menopause occurs between the ages of 45 and 55, with the average age of onset being 51. In rare instances menopause can occur as early as the 30s or as late as the 60s. Menopause is considered premature if it occurs before the age of 40 or artificial if radiation exposure, chemotherapeutic drugs, or surgery induces it. Other factors that may contribute to the early onset of menopause include a history of smoking, poor nutrition, or a coexisting medical condition.

The Physiology of Menopause

To best understand what occurs at menopause, it is helpful to know about the physiology of menstruation and the hormones that are involved in our monthly cycle. Hormones are substances in our bodies that act like messengers. They travel throughout the body and can bind to specialized areas of cells known as receptor sites, where they then initiate a specific chain of events. The first half of the menstrual cycle is dominated by estrogen, whose role is to build the lining of the uterus in preparation for a potential pregnancy. At approximately day 14 of the cycle, or two weeks prior to menstruation, an egg is released from the ovaries. This is referred to as ovulation.

As a result of ovulation the ovary begins producing progesterone. It is during this second half of the cycle that progesterone is dominant. Progesterone's role is to change the character of the uterine lining to prepare for pregnancy, and to prevent further buildup of the lining by estrogen. At the end of the cycle, if the egg is not fertilized, estrogen and progesterone levels drop, causing a sloughing of the uterine lining, or menstruation. The body goes through this cycle every month to ensure a fresh uterine lining in preparation for a potential pregnancy.

If a woman fails to ovulate, however, she does not produce progesterone, and this may result in the experience of symptoms of hormonal imbalance. Women are born with a finite number of eggs that eventually runs out. At birth, a woman has close to a million eggs, by puberty a mere 300,000. In the 10 to 15 years prior to menopause, this loss begins to accelerate. Perimenopause is the term used to describe the time of transition between a woman's reproductive years and when menstruation ceases completely. Typically perimenopause occurs between the ages of 40 and 51 and may last anywhere from six months to ten years. During this time, hormone levels naturally fluctuate and decline, but they do not necessarily do so in an orderly manner. Shifts in hormones are a major contributor to that sense of physical, mental, and emotional imbalance that may characterize a woman's experience of menopause.

Eventually estrogen levels decrease to the point that the lining of the uterus no longer builds up and menstruation ceases. This is menopause. After menopause, estrogen levels off at approximately 40 to 60% of its premenopausal levels and progesterone falls close to zero. Although there are similarities in what happens hormonally, each woman's experience can be very different. Genetics may play a role in the timing, but lifestyle can certainly influence a woman's experience of menopause. Many women find that the right combination of herbs, exercise, nutritional support, and natural hormones helps them to manage most of their symptoms. Others find they may need some medical intervention and pharmaceutical agents. This site will help guide you in making the decisions that best support your individual needs.

Menopause

NATIONAL INSTITUTES OF HEALTH
National Institute on Aging

Prepared by the
National Institute on Aging
December 1992

CONTENTS

What is Menopause?

How Does it Happen?
Surgical Menopause

What to Expect

Hot Flashes
Vaginal/Urinary Tract Changes
Menopause and Mental Health
What About Sex?
Is My Partner Still Interested?

Long-Term Effects of Estrogen Deficiency

Osteoporosis
Cardiovascular Disease

Treatment

Hormone Replacement Therapy
Estrogen and Your Bones
Estrogen's Effect on Your Heart
Drawbacks of HRT: The Cancer Risk
Other Risks

Keeping Healthy

Nutrition
Exercise

Ongoing/Future Research

Glossary

Organizations

Resources

WHAT IS MENOPAUSE?

I wasn't sure what to expect with menopause, although I
certainly looked forward to not having my period anymore. I
have to admit, I'm concerned about how my body will change. My
mother never talked about menopause. She says her mother never
did either, probably because then it was linked to old age and
poor health. Now, you hear about it all the time. The "baby
boom "generation is making menopause a big issue because of
their sheer numbers, and because they'll live with it much
longer than their grandmothers did. Back then, menopause did
come near the end of life. Now I'm going through it, but I feel
like I still have my whole life ahead of me.

More than one third of the women in the United States,
about 36 million, have been through menopause. With a life
expectancy of about 81 years, a 50 year old woman can expect to
live more than one-third of her life after menopause.
Scientific research is just beginning to address some of the
unanswered questions about these years and about the poorly
understood biology of menopause.

Menopause is the point in a woman's life when menstruation
stops permanently, signifying the end of her ability to have
children. Known as the "change of life," menopause is the last
stage of a gradual biological process in which the ovaries
reduce their production of female sex hormones--a process which
begins about 3 to 5 years before the final menstrual period.
This transitional phase is called the climacteric, or
perimenopause. Menopause is considered complete when a woman
has been without periods for 1 year. On average, this occurs at
about age 50. But like the beginning of menstruation in
adolescence, timing varies from person to person. Cigarette
smokers tend to reach menopause earlier than nonsmokers.

How Does It Happen?

The ovaries contain structures called follicles that hold
the egg cells. You are born with about 500,000 egg cells and by
puberty there are about 75,000 left. Only about 400 to 500 ever
mature fully to be released during the menstrual cycle. The
rest degenerate over the years. During the reproductive years,
a gland in the brain generates hormones that cause a new egg to
be released from its follicle each month. The follicle then
produces the sex hormones estrogen and progesterone, which
thicken the lining of the uterus. This enriched lining is
prepared to receive and nourish a fertilized egg which could
develop into a baby. If fertilization does not occur, estrogen
and progesterone levels drop, the lining of the uterus breaks
down, and menstruation occurs.

For unknown reasons, the ovaries begin to decline in
hormone production during the mid-thirties. In the late
forties, the process accelerates and hormones fluctuate more,
causing irregular menstrual cycles and unpredictable episodes
of heavy bleeding. By the early to mid-fifties, periods finally
end altogether. However, estrogen production does not
completely stop. The ovaries decrease their output
significantly, but still may produce a small amount. Also, some
estrogen is produced in fat cells with help from the adrenal
glands (near the kidney).

Progesterone, the other female hormone, works during the
second half of the menstrual cycle to create a lining in the
uterus as a viable home for an egg, and to shed the lining if
the egg is not fertilized. If you skip a period, your body may
not be making enough progesterone to break down the uterine
lining. However, your estrogen levels may remain high even
though you are not menstruating.

At menopause, hormone levels don't always decline
uniformly. They alternately rise and fall again. Changing
ovarian hormone levels affect the other glands in the body,
which together make up the endocrine system. The endocrine
system controls growth, metabolism and reproduction. This
system must constantly readjust itself to work effectively.
Ovarian hormones also affect all other tissues, including the
breasts, vagina, bones, blood vessels, gastrointestinal tract,
urinary tract, and skin.

Surgical Menopause

Premenopausal women who have both their ovaries removed
surgically experience an abrupt menopause. They may be hit
harder by menopausal symptoms than are those who experience it
naturally. Their hot flashes may be more severe, more frequent,
and last longer. They may have a greater risk of heart disease
and osteoporosis, and may be more likely to become depressed.
The reasons for this are unknown. When only one ovary is
removed, menopause usually occurs naturally. When the uterus is
removed (hysterectomy) and the ovaries remain, menstrual
periods stop but other menopausal symptoms (if any) usually
occur at the same age that they would naturally. However, some
women who have a hysterectomy may experience menopausal
symptoms at a younger age, possibly due to a decreased blood
supply to the ovaries as a result of surgery.

I had hot flashes, but they were fairly mild. Sometimes at
night I'd suddenly start to sweat and have to throw all my
covers off. But they never lasted long and I could usually get
right back to sleep. During the day I noticed they tended to
come whenever I had a big derision to make or when I felt a
little tense. But they only lasted about 2 years. I feel
blessed. I've had no other problems.

WHAT TO EXPECT

Menopause is an individualized experience. Some women
notice little difference in their bodies or moods, while others
find the change extremely bothersome and disruptive. Estrogen
and progesterone affect virtually all tissues in the body, but
everyone is influenced by them differently.

Hot Flashes

Hot flashes, or flushes, are the most common symptom of
menopause, affecting more than 60 percent of menopausal women
in the U.S. A hot flash is a sudden sensation of intense heat
in the upper part or all of the body. The face and neck may
become flushed, with red blotches appearing on the chest, back,
and arms. This is often followed by profuse sweating and then
cold shivering as body temperature readjusts. A hot flash can
last a few moments or 30 minutes or longer.

Hot flashes occur sporadically and often start several
years before other signs of menopause. They gradually decline
in frequency and intensity as you age. Eighty percent of all
women with hot flashes have them for 2 years or less, while a
small percentage have them for more than 5 years. Hot flashes
can happen at any time. They can be as mild as a light blush,
or severe enough to wake you from a deep sleep. Some women even
develop insomnia. Others have experienced that caffeine,
alcohol, hot drinks, spicy foods, and stressful or frightening
events can sometimes trigger a hot flash. However, avoiding
these triggers will not necessarily prevent all episodes.

Hot flashes appear to be a direct result of decreasing
estrogen levels. If there is no estrogen, your glands release
other hormones that dilate blood vessels and destabilize body
temperature. Hormone therapy relieves the discomfort of hot
flashes in most cases. Some women claim that vitamin E offers
minor relief, although there has never been a study to confirm
it. Aside from hormone therapy, which is not for everyone, here
are some suggestions for coping with hot flashes:

* Dress in layers so you can remove them at the first sign
of a flash.

* Drink a glass of cold water or juice at the onset of a
flash.

* At night keep a thermos of ice water or an ice pack by
your bed.

* Use cotton sheets, lingerie and clothing to let your skin
"breathe."

Vaginal/Urinary Tract Changes

With advancing age, the walls of the vagina become
thinner, dryer, less elastic and more vulnerable to infection.
These changes can make sexual intercourse uncomfortable or
painful. Most women find it helpful to lubricate the vagina.
Water-soluble lubricants are preferable, as they help reduce
the chance of infection. Try to avoid petroleum jelly; many
women are allergic, and it damages condoms. Be sure to see your
gynecologist if problems persist.

Tissues in the urinary tract also change with age,
sometimes leaving women more susceptible to involuntary loss of
urine (incontinence), particularly if certain chronic illnesses
or urinary infections are also present. Exercise, coughing,
laughing, lifting heavy objects or similar movements that put
pressure on the bladder may cause small amounts of urine to
leak. Lack of regular physical exercise may contribute to this
condition. It's important to know, however, that incontinence
is not a normal part of aging, to be masked by using adult
diapers. Rather, it is usually a treatable condition that
warrants medical evaluation. Recent research has shown that
bladder training is a simple and effective treatment for most
cases of incontinence and is less expensive and safer than
medication or surgery.

Within 4 or 5 years after the final menstrual period,
there is an increased chance of vaginal and urinary tract
infections. If symptoms such as painful or overly frequent
urination occur, consult your doctor. Infections are easily
treated with antibiotics, but often tend to recur. To help
prevent these infections, urinate before and after intercourse,
be sure your bladder is not full for long periods, drink plenty
of fluids, and keep your genital area clean. Douching is not
thought to be effective in preventing infection.

Menopause and Mental Health

A popular myth pictures the menopausal woman shifting from
raging, angry moods into depressive, doleful slumps with no
apparent reason or warning. However, a study by psychologists
at the University of Pittsburgh suggests that menopause does
not cause unpredictable mood swings, depression, or even stress
in most women.

In fact, it may even improve mental health for some. This
gives further support to the idea that menopause is not
necessarily a negative experience. The Pittsburgh study looked
at three different groups of women: menstruating, menopausal
with no treatment, and menopausal on hormone therapy. The study
showed that the menopausal women suffered no more anxiety,
depression, anger, nervousness or feelings of stress than the
group of menstruating women in the same age range. In addition,
although more hot flashes were reported by the menopausal women
not taking hormones, surprisingly they had better overall
mental health than the other two groups. The women taking
hormones worried more about their bodies and were somewhat more
depressed.

However, this could be caused by the hormones themselves.
It's also possible that women who voluntarily take hormones
tend to be more conscious of their bodies in the first place.
The researchers caution that their study includes only healthy
women, so results may apply only to them. Other studies show
that women already taking hormones who are experiencing mood or
behavioral problems sometimes respond well to a change in
dosage or type of estrogen.

Studies indicate that women of childbearing age,
particularly those with young children at home, tend to report
more emotional problems than women of other ages.

The Pittsburgh findings are supported by a New England
Research Institute study which found that menopausal women were
no more depressed than the general population: about 10 percent
are occasionally depressed and 5 percent are persistently
depressed. The exception is women who undergo surgical
menopause. Their depression rate is reportedly double that of
women who have a natural menopause.

Studies also have indicated that many cases of depression
relate more to life stresses or "mid-life crises" than to
menopause. Such stresses include: an alteration in family
roles, as when your children are grown and move out of the
house, no longer "needing" mom; a changing social support
network, which may happen after a divorce if you no longer
socialize with friends you met through your husband;
interpersonal losses, as when a parent, spouse or other close
relative dies; and your own aging and the beginning of physical
illness. People have very different responses to stress and
crisis. Your best friend's response may be negative, leaving
her open to emotional distress and depression, while yours is
positive, resulting in achievement of your goals. For many
women, this stage of life can actually be a period of enormous
freedom.

What About Sex?

For some women, but by no means all, menopause brings a
decrease in sexual activity. Reduced hormone levels cause
subtle changes in the genital tissues and are thought to be
linked also to a decline in sexual interest. Lower estrogen
levels decrease the blood supply to the vagina and the nerves
and glands surrounding it. This makes delicate tissues thinner,
drier, and less able to produce secretions to comfortably
lubricate before and during intercourse. Avoiding sex is not
necessary, however. Estrogen creams and oral estrogen can
restore secretions and tissue elasticity. Water-soluble
lubricants can also help.

While changes in hormone production are cited as the major
reason for changes in sexual behavior, many other
interpersonal, psychological, and cultural factors can come
into play. For instance, a Swedish study found that many women
use menopause as an excuse to stop sex completely after years
of disinterest. Many physicians, however, question if declining
interest is the cause or the result of less frequent
intercourse.

Some women actually feel liberated after menopause and
report an increased interest in sex. They feel relieved that
the children are out of the house and pregnancy is no longer a
worry.

For women in perimenopause, birth control is a confusing
issue. Doctors advise all women who have menstruated, even if
irregularly, within the past year to continue using birth
control. Unfortunately, contraceptive options are limited.
Hormone-based oral and implantable contraceptives are risky in
older women who smoke. Only a few brands of IUD are on the
market. The other options are barrier methods -- diaphragms,
condoms, and sponges -- or methods requiring surgery such as
tubal ligation for women, and vasectomy for the male partner.

Is My Partner Still Interested?

Some men go through their own set of doubts in middle age.
They too, often report a decline in sexual activity after age
50. It may take more time to reach ejaculation, or they may not
be able to reach it at all. Many fear they will fail sexually
as they get older. Remember, at any age sexual problems can
arise if there are doubts about performance. If both partners
are well informed about normal genital changes, each can be
more understanding and make allowances rather than unmeetable
demands. Open, candid communication between partners is
important to ensure a successful sex life well into your
seventies and eighties.

For most women, natural menopause is not a major crisis
and does not influence their opinion of their general health.

In a society that places so much value on youth and
beauty, it's not much fun to think about menopause. But when
you get there, you find it doesn't really make that much
difference; you concentrate on how you feel about yourself, not
on how you think others see you. I continue trying to improve
myself, to keep learning and keep active. It's not your age
that counts, it's how you handle it.

LONG-TERM EFFECTS OF ESTROGEN DEFICIENCY

Osteoporosis

One of the most important health issues for middle-aged
women is the threat of osteoporosis. It is a condition in which
bones become thin, fragile, and highly prone to fracture.
Numerous studies over the past 10 years have linked estrogen
insufficiency to this gradual, yet debilitating disease. In
fact, osteoporosis is more closely related to menopause than to
a woman's chronological age.

Bones are not inert. They are made up of healthy, living
tissue which continuously performs two processes: breakdown and
formation of new bone tissue. The two are closely linked. If
breakdown exceeds formation, bone tissue is lost and bones
become thin and brittle. Gradually and without discomfort, bone
loss leads to a weakened skeleton incapable of supporting
normal daily activities.

Each year about 500,000 American women will fracture a
vertebrae, the bones that make up the spine, and about 300,000
will fracture a hip. Nationwide, treatment for osteoporotic
fractures costs up to $10 billion per year, with hip fractures
the most expensive. Vertebral fractures lead to curvature of
the spine, loss of height, and pain. A severe hip fracture is
painful and recovery may involve a long period of bed rest.
Between 12 and 20 percent of those who suffer a hip fracture do
not survive the 6 months after the fracture. At least half of
those who do survive require help in performing daily living
activities, and 15 to 25 percent will need to enter a long-term
care facility. Older patients are rarely given the chance for
full rehabilitation after a fall. However, with adequate time
and care provided in rehabilitation, many people can regain
their independence and return to their previous activities.

For osteoporosis, researchers believe that an ounce of
prevention is worth a pound of cure. The condition of an older
woman's skeleton depends on two things: the peak amount of bone
attained before menopause and the rate of the bone loss
thereafter. Hereditary factors are important in determining
peak bone mass. For instance, studies show that black women
attain a greater spinal mass and therefore have fewer
osteoporotic fractures than white women. Other factors that
help increase bone mass include adequate intake of dietary
calcium and vitamin D, exposure to sunlight, and physical
exercise. These elements also help slow the rate of bone loss.
Certain other physiological stresses can quicken bone loss,
such as pregnancy, nursing, and immobility. The biggest culprit
in the process of bone loss is estrogen deficiency. Bone loss
quickens during perimenopause, the transitional phase when
estrogen levels drop significantly.

Doctors believe the best strategy for osteoporosis is
prevention because currently available treatments only halt
bone loss -- they don't rebuild the bone. However, researchers
are hopeful that in the future, bone loss will be reversible.
Building up your reserves of bone before you start to lose it
during perimenopause helps bank against future losses. The most
effective therapy against osteoporosis available today for
postmenopausal women is estrogen (see p. 19). Remarkably,
estrogen saves more bone tissue than even very large daily
doses of calcium. Estrogen is not a panacea, however. While it
is a boon for the bones, it also affects all other tissues and
organs in the body, and not always positively. Its impact on
the other areas of the body must be considered.

Cardiovascular Disease

Most people picture an older, overweight man when they
think of a likely candidate for cardiovascular disease (CVD).
But men are only half the story. Heart disease is the number
one killer of American women and is responsible for half of all
the deaths of women over age 50. Ironically, in past years
women were rarely included in clinical heart studies, but
finally physicians have realized that it is as much a woman's
disease as a man's.

Influences on Bone Development

Increases bone formation Speeds bone loss

Dietary calcium Estrogen deficiency

Vitamin D Pregnancy

Exposure to sunlight Nursing

Exercise Lack of exercise

CVDs are disorders of the heart and circulatory system.
They include thickening of the arteries (atherosclerosis) that
serve the heart and limbs, high blood pressure, angina, and
stroke. For reasons unknown, estrogen helps protect women
against CVD during the childbearing years. This is true even
when they have the same risk factors as men, including smoking,
high blood cholesterol levels, and a family history of heart
disease. But the protection is temporary. After menopause, the
incidence of CVD increases, with each passing year posing a
greater risk. The good news, though, is that CVD can be
prevented or at least reduced by early recognition, lifestyle
changes and, many physicians believe, hormone replacement
therapy.

Menopause brings changes in the level of fats in a woman's
blood. These fats, called lipids, are used as a source of fuel
for all cells. The amount of lipids per unit of blood
determines a person's cholesterol count. There are two
components of cholesterol: high density lipoprotein (HDL)
cholesterol, which is associated with a beneficial, cleansing
effect in the bloodstream, and low density lipoprotein (LDL)
cholesterol, which encourages fat to accumulate on the walls of
arteries and eventually clog them. To remember the difference,
think of the H in HDL as the healthy cholesterol, and the L in
LDL as lethal. LDL cholesterol appears to increase while HDL
decreases in postmenopausal women as a direct result of
estrogen deficiency. Elevated LDL and total cholesterol can
lead to stroke, heart attack, and death.

I started taking estrogen for my hot flashes. They went
away immediately. I've felt no side effects, which I'm thankful
for. I don't think I'll stay on it forever, though -- no one
seems to know how long it's safe! My mother has never taken
hormones and she's in great shape at 87. I hope I'm as lucky!

TREATMENT

Hormone Replacement Therapy

To combat the symptoms associated with falling estrogen
levels, doctors have turned to hormone replacement therapy
(HRT). HRT is the administration of the female hormones
estrogen and progesterone. Estrogen replacement therapy (ERT)
refers to administration of estrogen alone. The hormones are
usually given in pill form, though sometimes skin patches and
vaginal creams (just estrogen) are used. ERT is thought to help
prevent the devastating effects of heart disease and
osteoporosis, conditions that are often difficult and expensive
to treat once they appear. The cardiovascular effects of
progesterone, however, are yet unknown. Hormone treatment for
menopause is still quite controversial. Its long-term safety
and efficacy remain matters of great concern. There is not
enough existing data for physicians to suggest that HRT is the
right choice for all women. Several large studies are currently
attempting to resolve the questions, though it will take
several more years to reach any definitive answers.

In the 1940's when estrogen was first offered to
menopausal women, it was given alone and in high doses. Today,
after 50 years of trial and error, it is well known that
estrogen stimulates growth of the inner lining of the uterus
(endometrium) that sheds during menstruation. This growth may
continue uncontrollably, resulting in cancer. Today, doctors
typically prescribe a lower dose of estrogen. However, few
doctors still prescribe estrogen alone to women who have a
uterus. Most now prefer to add a synthetic form of progesterone
called progestin to counteract estrogen's dangerous effect on
the uterus. Progestin reduces the risk of cancer by causing
monthly shedding of the endometrium. The obvious drawback to
this approach is that menopausal women resume monthly bleeding.
Once menopause arrives, most women enjoy the freedom of life
without a period. Many are reluctant to begin their cycles
again. In addition, there are other unpleasant side effects of
progestin which often discourage women from continuing HRT.
These include breast tenderness, bloating, abdominal cramping,
anxiety, irritability, and depression.

Only about 15 percent of women who are eligible for
hormone replacement therapy are now receiving it. This leaves
85 percent who either do not want or need it, or do not know
about it.

The good news is that researchers are evaluating different
schedules of low-dose estrogen and progestin to completely
eliminate monthly bleeding. Currently most women receive what
is called cyclic HRT. They may take estrogen continually and
progestin for the first 12 days of each month. The use of a
continuous combined dose, where estrogen and smaller amounts of
progestin are taken every day is also being studied. In theory,
this use of progestin stems endometrial growth so no bleeding
will occur. Unfortunately, it may take 6 months or more until
bleeding finally stops. In many cases, monthly bleeding has
been replaced by more bothersome irregular bleeding patterns.
Obviously, further research is needed to evaluate and perfect
this treatment. Various types of progestins in different
dosages, preparations, and schedules are being studied in hopes
of reducing its other unpleasant side effects while retaining
the known advantages of estrogen.

Estrogen and Your Bones

Estrogen therapy is the most successful method of
combatting osteoporosis. As previously discussed, estrogen
halts bone loss but cannot necessarily rebuild bone. Long-term
estrogen use (10 or more years) may be required to prevent
postmenopausal bone loss. Why estrogen helps protect the
skeleton is still unclear. We do know that estrogen helps bones
absorb the calcium they need to stay strong. It also helps
conserve the calcium stored in the bones by encouraging other
cells to use dietary calcium more efficiently. For instance,
muscles require calcium to contract. If there is not enough
calcium circulating in the blood for muscles to use, calcium is
"borrowed" from the bone. Calcium is also needed for blood
clotting, sending nerve impulses, and secreting various
hormones. Prolonged borrowing from bone calcium for these
processes speeds bone loss. That's why it's important to
consume adequate amounts of calcium in your diet
(see p. 27).

Estrogen's Effect on Your Heart

The majority of past clinical studies have shown that
women who take estrogen substantially reduce their risk of
developing and dying from heart disease. One or two studies
demonstrate conflicting evidence, but they are far outnumbered
by the positive reports. Results from a 1001 study showed that
after 15 years of estrogen replacement, risk of death by CVD
was reduced by almost 50 percent and overall deaths were
reduced by 40 percent. Some researchers credit this reduction
to oral estrogen's ability to maintain HDL and LDL at their
healthier, premenopausal levels, through its interaction with
proteins in the liver. Others believe it is estrogen's direct
effect on the blood vessels themselves (through receptors on
the vessel walls) which creates this benefit. In the latter
case, both oral estrogen and the skin patch would be effective.
Studies are underway to determine which mechanism contributes
most to a healthy heart.

Clearly, estrogen appears to benefit women at high risk
for heart disease. The high risk group includes women with a
strong family history of CVD, those with high blood pressure,
smokers, and obese women. One study observed fewer
cardiovascular deaths among estrogen users compared to
nonusers. Women whose ovaries had been surgically removed had
the greatest reduction of risk. The same study also confirmed,
as expected, the link between smoking, obesity and
cardiovascular disease.

At any time of life, women who smoke are much more likely
to develop heart disease or have a stroke than women who do not
smoke. But after menopause, a smoker's risk climbs
dramatically. Low estrogen levels and smoking are separate risk
factors for CVD. When the two are combined, the risk is much
higher than either one alone. Smoking also raises your risks
for some types of cancer and for chronic lung disease, such as
emphysema. Fortunately, quitting smoking--at any age--can cut
the risk of disease almost immediately. Studies have shown that
when older people quit, they increase their life expectancy.
Their risk of heart disease goes down, their lungs function
better, and blood circulation improves. So quitting smoking,
whether before, during or after menopause, can have a definite
impact on both the length and quality of your life.

Should women be treated with a drug to prevent a disease
they might never get (osteoporosis, heart disease)? Some people
will be placed at higher risk, while others will benefit. Each
woman should make a decision about HRT based on her own family
history and life experiences.

To me, exercise is the key to staying healthy. Some of
these ladies have been coming to this class for 10 years. I
think that really says a lot. Do you think they'd get up at
7:00 a.m. to jump around if it didn't make them feel better?

Many women who have quit smoking say they found support in
group counseling sessions. Local chapters of the American
Cancer Society and the American Heart Association are good
places to start looking for a smoking cessation group. Nicotine
gum and nicotine patches prescribed by a doctor may also help.

While we know that HRT users have a decreased risk of CVD,
it is not clear how or if women with preexisting heart disease
can benefit. Because uncertainty exists, some of these women
may be advised by their doctors not to take estrogen.
Researchers hope to further investigate nonhormonal methods of
preventing heart disease such as weight reduction or control,
exercise, smoking cessation, and dietary modification.
According to a 5-year study reported in 1988, weight gain (a
common occurrence among many menopausal women) significantly
raises blood pressure, total and LDL cholesterol, and fat
levels. Together, these make up a dangerous recipe for heart
disease. Several other studies also noted that moderate alcohol
consumption, about one drink per day, had a protective effect
on the heart. Physicians advise caution in this area, however,
as excess alcohol can increase risks for other serious problems
such as brain hemorrhaging, liver disease, and certain types of
cancer.

While cardiovascular benefits associated with oral
estrogen are fairly well-known, there is surprisingly little
information on the cardiovascular effects of progestin combined
with estrogen. Some studies suggest that progestins counteract
the favorable HDL and LDL effects achieved by estrogen alone,
while other studies show no such effect. This remains just one
more gray area where questions outnumber reliable answers.

Cautions to Estrogen Use

Serious risk

Stroke
Recent heart attack
Breast cancer (current or family history)
Uterine cancer
Acute liver disease
Gall bladder disease
Pancreatic disease
Recent blood clot
Undiagnosed vaginal bleeding

Relative risk

Cigarette smoking
Hypertension
Benign breast disease
Benign uterine disease
Endometriosis Pancreatitis
Epilepsy
Migraine headaches

Subjective Complaints

Nausea
Headaches
Breakthrough bleeding
Depression
Fluid retention

Source: R.L. Young, N.S. Kumar, and J.W. Goldzieher, Management
of Menopause When Estrogen Cannot Be Used, Drugs,
40(2):220-230,1990

Drawbacks of HRT: The Cancer Risk

As discussed previously, there is evidence that in women
with an intact uterus, estrogen may provoke growth of the
tissues lining the uterus and increase the risk of uterine
cancer. Also of great concern is the influence of estrogen on
breast cancer. Researchers believe that the longer your
lifetime exposure to naturally occurring estrogen, the greater
your risk of breast cancer. It has not been proven, however,
that estrogen administered at menopause has the same effect.
There is disagreement on the many trials conducted to date
because of wide variations in the populations studied and the
doses, timing, and types of estrogen used. A recent analysis of
previous studies suggests that low-dose estrogen token on a
short-term basis (10 years or less) does not pose an increased
risk of breast cancer. Long-term use (more than 10 years) at a
high dose may significantly increase the risk. By how much is
still a matter of heated debate. At the very most, researchers
think long-term use could possibly increase the risk of getting
breast cancer by 30 percent. This means that incidence would
rise from 10 women per 10,000 each year to 13 women per 10,000
each year. To reach any consensus, however, more women need to
be monitored for an extended period of time. The fear of cancer
is one of the most common reasons that women are unwilling to
use HRT. Interestingly, actual death rates for breast cancer
have not risen at all. This is probably because estrogen users
have more frequent medical visits and obtain more preventive
care including yearly mammograms.

While no one can determine who will eventually develop
breast cancer, there are certain risk factors you should be
aware of when considering HRT. A family history of breast
cancer (sister or mother) is probably the most important risk
factor of all. You may also be at an increased risk if: you
menstruated before age 12; delayed motherhood until later in
life; have a late menopause (after age 50). Also, the older you
are, the higher the risk. Most doctors believe that if you are
not in a high risk category for breast or endometrial cancer,
the benefits of HRT far outweigh the risks. However, for some
women, the side effects of therapy make it impossible to use.
This is a personal decision to be made by each woman with help
from her doctor.

Research shows that most women are concerned more with
quality of life than quantity of life. They give higher
priority to the short-term effects of hormone therapy (relief
from hot flashes and vaginal dryness) than to long-term
concerns (preventing osteoporosis).

Other Risks

Physicians usually caution women not to use HRT if they
are already at high risk for developing blood clots. Obesity,
severe vericose veins, smoking, and a history of blood clots
put you in this category. A history of gall bladder disease
could also be cause to avoid HRT, as women taking estrogen may
have a greater chance of developing gallstones.

Happiness is when the last tuition is paid for, the
youngest moves out and the dog dies. Now I can concentrate on
what I want to do. My doctor puts everyone on estrogen, so I
tried it for a while -- but it brought my menstrual flow back
just as heavy as before. Who needs that mess again? So now I
just exercise, try to eat well, and generally, I feel pretty
good.

KEEPING HEALTHY

Good nutrition and regular physical exercise are thought
to improve overall health. Some doctors feel these factors can
also affect menopause. Although these areas have not been well
studied in women, anecdotal evidence is strongly in favor of
eating well and exercising to help lower risks for CVD and
osteoporosis.

There is no consensus within the medical community about
the risks and benefits associated with hormone therapy. There
is no agreement on normal hormonal changes associated with
aging.

Nutrition

While everyone agrees that a well-balanced diet is
important for good health, there is still much to be learned
about what constitutes "well-balanced." We do know that
variety in the diet helps ensure a better mix of essential
nutrients.

Nutritional requirements vary from person to person and
change with age. For instance, the Recommended Dietary
Allowance (RDA) for calcium as determined by the National
Research Council is 800 mgs per day for a healthy man. A
healthy premenopausal woman should have more, about 1,000 to
1,200 mgs per day. The Council suggests that a postmenopausal
woman consume 1,200 to 1,500 mgs per day to help avoid bone
loss. Foods high in calcium include milk, yogurt, cheese and
other dairy products; oysters, sardines and canned salmon with
bones; and dark-green leafy vegetables like spinach and
broccoli. If you are lactose intolerant, acidophilus milk is
more digestible. Vitamin D is also very important for calcium
absorption and bone formation. A 1992 study showed that women
with postmenopausal osteoporosis who took vitamin D for 3 years
significantly reduced the occurrence of new spinal fractures.
However, the issue is still controversial. High doses of
vitamin D can cause kidney stones, constipation, or abdominal
pain, particularly in women with existing kidney problems.
Other nutritional guidelines by the National Research Council
include:

* Choose foods low in fat, saturated fat, and cholesterol.
Fats contain more calories (9 calories per gram) than
either carbohydrates or protein (each have only 4 calories
per gram). Fat intake should be less than 30 percent of
daily calories.

* Eat fruits, vegetables, and whole grain cereal products,
especially those high in vitamin C and carotene. These
include oranges, grapefruit, carrots, winter squash,
tomatoes, broccoli, cauliflower, and green leafy
vegetables. These foods are good sources of vitamins and
minerals and the major sources of dietary fiber. Fiber
helps maintain bowel mobility and may reduce the risk of
colon cancer. Young and older people alike are encouraged
to consume 20 to 30 grams of fiber per day.

* Eat very little salt-cured and smoked foods such as
sausages, smoked fish and ham, bacon, bologna, and hot
dogs. High blood pressure, which may become more serious
with heavy salt intake, is more of a risk as you age.

* Avoid food and drinks containing processed sugar. Sugar
contains empty calories which may substitute for
nutritious food and can add excess body weight.

For people who can't eat an adequate diet, supplements may
be necessary. A dietician should tailor these to meet your
individual nutritional needs. Using supplements without
supervision can be risky because large doses of some vitamins
may have serious side effects. Vitamins A and D in large doses
can be particularly dangerous.

As you age, your body requires less energy because of a
decline in physical activity and a loss of lean body mass.
Raising your activity level will increase your need for energy
and help you avoid gaining weight. Weight gain often occurs in
menopausal women, possibly due in part to declining estrogen.
In animal studies, scientists found that estrogen is important
in regulating weight gain. Animals with their ovaries
surgically removed gained weight, even if they were fed the
same diet as the animals with intact ovaries. They also found
that progesterone counteracts the effect of estrogen. The
higher their progesterone levels, the more the animals ate.

Exercise

Exercise is extremely important throughout a woman's
lifetime and particularly as she gets older. Regular exercise
benefits the heart and bones, helps regulate weight, and
contributes to a sense of overall well-being and improvement in
mood. If you are physically inactive you are far more prone to
coronary heart disease, obesity, high blood pressure, diabetes,
and osteoporosis. Sedentary women may also suffer more from
chronic back pain, stiffness, insomnia, and irregularity. They
often have poor circulation, weak muscles, shortness of breath,
and loss of bone mass. Depression can also be a problem. Women
who regularly walk, jog, swim, bike, dance, or perform some
other aerobic activity can more easily circumvent these
problems and also achieve higher HDL cholesterol levels.
Studies show that women performing aerobic activity or
muscle-strength training reduced mortality from CVD and cancer.

Just like muscles, bones adhere to the "use it or lose it"
rule; they diminish in size and strength with disuse. It has
been known for more than 100 years that weight-bearing exercise
(walking, running) will help increase bone mass. Exercise
stimulates the cells responsible for generating new bone to
work overtime. In the past 20 years, studies have shown that
bone tissue lost from lack of use can be rebuilt with
weight-bearing activity. Studies of athletes show they have
greater bone mass compared to nonathletes at the sites related
to their sport. In postmenopausal women, moderate exercise
preserves bone mass in the spine helping reduce the risk of
fractures.

Exercise is also thought to have a positive effect on
mood. During exercise, hormones called endorphins are released
in the brain. They are 'feel good' hormones involved in the
body's positive response to stress. The mood-heightening effect
can last for several hours, according to some endocrinologists.
Consult your doctor before starting a rigorous exercise
program. He or she will help you decide which types of
exercises are best for you. An exercise program should start
slowly and build up to more strenuous activities. Women who
already have osteoporosis of the spine should be careful about
exercise that jolts or puts weight on the back, as it could
cause a fracture.

ONGOING/FUTURE RESEARCH

To gather more data to help women make a well-informed
decision regarding hormone therapy, researchers at the National
Institutes of Health (NIH) launched the Postmenopausal
Estrogen/Progestin Interventions Trial (PEPI) in 1989. With 127
women enrolled at each of seven medical centers, PEPI will
address the short-term safety and efficacy of various methods
of HRT. The study will compare women who take estrogen by
itself to those who take it with different types of progestin.
It will also examine the effects of both cyclical and
continuous progestin on cardiovascular risk factors, blood
clotting factors, metabolism, uterine changes, bone mass, and
general quality of life.

To date most large-scale studies have not fully reported
on normal body changes as women move from pre- to
post-menopause. This lack of data has been one problem in
assessing the value of HRT. Without knowing what "normal" is,
scientists have difficulty judging the effect of a particular
treatment. Another problem with past studies is the "healthy
user effect." In many trials preceding PEPI, the HRT users
studied had freely chosen to begin treatment, with advice from
their doctors. In general, most physicians discourage women
with a preexisting illness or long family history of breast
cancer from taking HRT. This factor could skew study results to
appear that nonusers became ill or died more frequently simply
because they failed to take estrogen. Only by randomly
assigning study participants to the treatment can this bias be
overcome. Until more random trials are completed, the jury is
still out on HRT.

Many women feel that their physicians do not listen to
their concerns. Nor do they give them enough information to
make an educated decision about hormone therapy. Women's Health
Initiative include:

Another NIH study, begun in 1992 is the Women's Health
Initiative, a multicenter trial involving 70,000 postmenopausal
women ages 50 to 79. The study will assess the long-term
benefits and risk of hormone therapy as it relates to
cardiovascular disease, osteoporosis, and breast and uterine
cancer. It will also help determine the effects of calcium
supplementation, dietary changes, and exercise on women in this
age group. Some of the specific questions to be addressed by
the Women's Health Initiative include:

* How long is estrogen effective for each system of the body
(skeletal, cardiovascular, nervous, endocrine)?

* What is the best dose and route of administration of
estrogen and progestin to prevent side effects yet
maintain efficacy?

* How long is estrogen safe to take?

* Does estrogen act the same way in older women as in
younger women?

* Are there effective alternatives to HRT?

Clearly, no one has all the answers about menopause.
Medical research is beginning to give us more accurate
information, but some myths and negative attitudes persist.
Women are challenging old stereotypes, learning about what's
happening in their bodies, and taking responsibility for their
health. The important thing to remember as you go through
menopause is to be good to yourself. Take time to pursue your
hobbies, be they gardening, painting or socializing with
friends. Have a positive attitude toward life. Sharing concerns
with friends, a spouse, relatives or a support group can help.
Don't fight your body -- allow the changes that are happening
to become a part of you, a part that is natural and that you
accept.

GLOSSARY

angina -- a disease marked by brief attacks of chest pain

biopsy -- removal and examination of living cells from the body

cardiovascular disease -- disorders of the heart and
circulatory system

endometrium -- the tissues lining the uterus

estrogen -- one of the female sex hormones produced by the
ovaries

HDL -- high density lipoprotein cholesterol, the "good"
cholesterol thought to have a cleansing effect in the
bloodstream hysterectomy- surgical removal of the uterus

IUD -- Intrauterine birth control device, which prevents
implantation of an embryo into the uterus should
fertilization occur

LDL -- low density lipoprotein cholesterol, the "bad"
cholesterol believed to be linked to fat accumulation in
the arteries

menopause -- the point when menstruation stops permanently

oral contraceptives -- pills which usually consist of synthetic
estrogen and progesterone that are taken for three weeks
after the last day of a menstrual period. They inhibit
ovulation, thereby preventing pregnancy

osteoporosis -- a disease in which bones become thin, weak and
are easily fractured

perimenopause -- the time around menopause, usually beginning 3
to 5 years before the final period

progesterone -- one of the female sex hormones produced by the
ovaries

progestin -- the synthetic form of progesterone

tubal ligation -- a surgical procedure in which the uterine
tubes are cut and tied to prevent pregnancy

urinary incontinence -- loss of bladder control

vasectomy -- in males, the surgical removal of part of the
sperm duct (vas deferens) to induce infertility

ORGANIZATIONS

National Institute on Aging (NIA)
9000 Rockville Pike
Bethesda, MD 20892
800-222-2225

North American Menopause Society (NAMS)
University Hospitals
Department of OB/GYN
2074 Abington Road
Cleveland, OH 44106
fax: 216-844-3348
(written requests)

National Women's Health Network
1325 G Street, NW
Washington, DC 20005
202-347-1140

American College of Obstetrics and Gynecologists (ACOG)
409 12th Street, SW
Washington, DC 20024
202-638-5577

Alliance for Aging Research
2021 K Street, NW, Suite 305
Washington, DC 20006
202-293-2856

Older Women's League (OWL)
666 11th Street, NW
Suite 700
Washington, DC 20001
202-783-6686

National Women's Health Resource Center (NWHRC)
2440 M Street, NW
Suite 201
Washington, DC 20037
202-293-6045

Wider Opportunities for Women (WOW)
National Commission on Working Women
1325 G Street, NW
Lower Level
Washington, DC 20005
202-638-3143

American Dietetic Association (ADA)
216 West Jackson Boulevard
Suite 800
Chicago, IL 60606
312-899-0040

American Heart Association (AHA)
7320 Greenville Avenue
Dallas, TX 75231
214-373-6300

National Heart, Lung, and Blood Institute (NHLBI)
9000 Rockville Pike
Bethesda, MD 20892
3014964236

National Arthritis and Musculoskeletal and Skin Diseases
Information Clearinghouse
Box AMS
9000 Rockville Pike
Bethesda, MD 20892
301-495-4484

National Osteoporosis Foundation (NOF)
2100 M Street, NW
Suite 602
Washington, DC 20037
202-223-2226

Sex Information and Education Council of the U.S. (SIECUS)
130 West 42nd Street
Suite 2500
New York, NY 10036
212-819-9770

DEPRESSION Awareness, Recognition, and Treatment Program
National Institute of Mental Health
D/ART Public Inquiries
5600 Fishers Lane
Room 15C-05
Rockville, MD 20857
301-443-4513

National Mental Health Association (NMHA)
Information Center
1021 Prince Street
Alexandria, VA 22314-2971
703-684-7722/800-969-6642

National Cancer Institute
Cancer Information Service
9000 Rockville Pike
Bethesda, MD 20892
800-4-CANCER
(800-422-6237)

American Cancer Society
National Headquarters
1599 Clifton Road, NE
Atlanta, GA 30329
800-ACS-2345
(800-227-2345)

RESOURCES

Managing Your Menopause, Wulf H. Utian, M.D., Ph.D., and Ruth
S. Jacobowitz. New York: Prentice Hall/Simon & Schuster, 1990.

The Menopause Self-Help Book, Susan M. Lark, M.D. Berkeley:
Celestial Arts, 1990.

Ourselves Growing Older, Paula Brown Doress and Diane Laskin
Siegal. New York: Simon and Schuster, 1987 (in cooperation with
the Boston Women's Health Book Collective).

Estrogens: The Facts Can Save Your Life, Lila Nachtigall,
M.D., and Joan Rattner Heilman. New York: Harper & Row, 1986.

Choice Years, Judith Paige and Pamela Gordon. New York: Villard
Books, 1991.

Change of Life: The Menopause Handbook, by Susan Flamholtz
Trien. New York: Fawcett, 1986.

Menopause: A Positive Approach, Rosetta Reitz. Penguin Books,
1977.

The Menopause, Hormone Therapy, and Women's Health-Background
Paper. 'Congress of the United States, Office of Technology
Assessment, May 1992.

Who, What, Where? Resources for Women's Health & Aging,
National Institute on Aging, March 1992.