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HOW DO I KNOW IF I AM
(PERI-) MENOPAUSAL?
“Menopause” is the time of a
woman’s final menstrual
period. Of course, the only
way to know if it is your
“final” menses is to see if
any more follow. By
definition, 12 months
without menses, in the
presence of other
“menopausal symptoms” equals
menopause.
Perimenopause is that
(usually several year) time
around (just before) the
final menses. It is
frequently punctuated by the
classical symptoms of peri-menopausal/menopause
including but not
necessarily limited to: Hot
flashes/night sweats, poor
sleep quality, mood and
memory dysfunction, vaginal
dryness, heart palpitations,
joint stiffness, “crawly
skin”, depression, etc.
Menopause is a normal,
functional passage of life.
There are many life-style,
nutritional, botanical,
herbal and pharmaceutical
ways to ease the passage.
DO HERBS WORK?
For many women, yes. Whether
this is secondary to a
specific medicinal effect of
the compounds used, or
secondary to the known
30-50% placebo effect of
menopausal supplements taken
with the belief that they
will provide relief, is
unknown. It makes no
difference, however. If it
works, causes no harm and is
affordable, hurrah!!
A brief definition: “Herbs”
are the leaves of plants.
“Botanicals” can be from
leaf, stem, root or rhizome.
Phyto-estrogens are
botanicals that have
specific estrogen-life
effect on human tissues
(within a specific dosage
range).
Herbs/botanicals/phytoestrogens
relieve (peri-) menopausal
symptoms in many women;
however, their success rate
(approximately 50-60%) is
lower than that for
hormones/pharmaceuticals.
IS THERE SOMETHING “NATURAL”
THAT I CAN DO?
What do you mean by natural?
Nowadays, “natural” is
little more than advertising
gimmick, designed to “reel
you in” to buying some
probably untested
nutritional supplement of
uncertain medicinal or
therapeutic benefit.
By definition, “natural”
means “native to plant or
animal”. By this definition,
Premarin, derived from
pregnant mare’s urine, is
“... natural”.
Know what you are taking
(and whether it interacts
with other supplements and
pharmaceuticals you are
ingesting).
That said, there are several
things: Pick/choose/mix ‘n
match with the aid of your
healthcare practitioner:
Bioidentical hormones:
Estriol, estradiol, estrone,
progesterone, testosterone.
These are all synthesized
from a plant source (soy or
wild yam) to exactly mimic
the molecule found in the
body. 2. Lifestyle changes
(are certainly natural!).
Proper diet (increasing
fresh fruits/veggies;
decreasing meat, fats,
convenience foods) and
exercise! 3. Vitamins,
herbs, botanicals,
phytoestrogens (see above
F.A.Q. #2). Include but not
limited to soy isoflavones,
black cohosh, chased berry,
Vitamin E, calcium, etc.,
etc.
MY SEX DRIVE IS IN THE
TOILET. WHAT CAN I DO?
You are not the only one!
All sorts of things conspire
to diminish libido in (peri-)
menopausal women. It is hard
to feel sexy if you are
flash-flushing all over the
place. Or if your vagina is
dry and lovemaking feels
like sandpapering a sore.
Been married a long time? A
few teenagers always in and
out of the house? And what
about your testosterone?
Well before your estrogen
levels fluctuate and then
take a giant plunge,
testos-terone slowly but
steadily declines. The same
testosterone that is
responsible for energy, sex
drive, perseverance, etc.
So: What can you do? Get
your menopausal symptoms
under control. Get to
sleeping better. Work with
your mate and perhaps a
therapist on ways to
rekindle you and your mate’s
sexual connection, and
definitely work with your
healthcare practitioner to
check on and improve your
testosterone levels with
transdermal or oral therapy.
WHAT ABOUT THAT BIG STUDY
[THE WHI]? AREN’T ESTROGENS
DANGEROUS?
Much misinformation and
questionable interpretation
headline-highlighted by the
media has followed the
reports in the Journal of
the American Medical
Association of the findings
of the Womens Health
Initiative [WHI], a large
double-blind study of the
effects of “hormones”
(estrogen and artificial
progesterone or “progestin”)
on cardiovascular function
in postmenopausal women.
To be specific and
explanatory would take many
paragraphs, so I shall
succinctly summarize what
WHI found:
Giving estrogens, especially
estrogen and the synthetic
progestin Provera, to older
women, possibly with
pre-existing cardiovascular
disease may increase risk
(especially in the short
term) of an “event”.
Therefore, it is
inappropriate to give
estrogens, especially
estrogen and synthetic
progestins to older women
for the singular purpose of
diminishing risk of
cardiovascular disease. 2.
Bathing one’s organs in
estrogen, especially
estrogen and progestin, for
years beyond what they
normally would get/encounter
increases the relative risk
of breast cancer (even
though the actual risk
remains extremely low). 3.
Adding a progestin
(synthetic progesterone),
specific- ally Provera to
estrogen may increase both
cardio- vascular and breast
cancer risk. 4. Starting
estrogens well after
menopause for the purpose of
decreasing risk of
Alzheimer’s Disease is
probably not appropriate.
SHOULD I BE ON ESTROGENS
FOREVER? HOW DO I STOP?
The most common usage of
estrogen supplementation is
to ease the passage through
menopause, taking control of
your shifting and suddenly
diminishing estrogen levels.
Understanding this, there
are not many reasons to be
on “estrogen forever”.
Taking control of the (peri-)
menopause rollercoaster,
after a modest amount of
time, most women can start a
slow, progressive tapering
off (after you have tapered
off, you and your
health-care practitioner may
wish to start you on another
medication to help with
other issues such as bone
loss, breast cancer
protec-tion and abnormal
lipids, which could lead to
a higher risk of
cardiovascular disease--by
far the largest killer of
women).
How do you taper off?
Slowly!! Don’t do this “cold
turkey” or in a week or
three. The easiest to taper
is the patch. You simply cut
off a bit, slowly, over
months, working down to the
next lowest dose (e.g.
one-eighth off for a month,
then one-quarter off for a
month, then down to the next
lower dose...and repeat
again), until you are either
off all together or on a
mini dose if you wish to
continue hormones or have
trouble tapering off all
together. With pills?
Combine the next lowest dose
with your present pill:
Substitute the lower dose
every third day for a few
weeks, going to every other
day, then two out of three
days at the lower dose and
on to the next lower dose.
Do the same thing to taper
off to zero from the lowest
dose.
You may, because of quality
of life issues, wish to
remain on estrogens. If so,
remember: Lowest possible
dose. There truly is very
little increased actual risk
for adverse events!
WHAT ABOUT PROGESTERONE
CREAM??
Progesterone has a definite
place in the therapy of peri-menopausal
travails. Bioidentical
progesterone (synthesized
usually from wild Mexican
yam to mimic the molecule
found in nature) is
different from and possibly
“safer” than the commonly
used (and stronger)
artificial progesterones,
called “progestins”.
Although bioidentical
progesterone is synthesized
from wild yam, wild yam
itself contains no
progesterone, nor is the
human body capable of
metabolizing it into
progesterone. There are a
plethora of over-the-counter
creams containing
progesterone in the market.
The problem is finding out
how much progesterone each
contains and how much to use
per dose.
Better is to have a
compounding pharmacy prepare
a preparation (cream or
lotion) to your and your
doctor’s specifications. The
usual therapeutic dose is
25-75 mg per day. If you buy
and over-the-counter cream,
ask the pharmacy personnel
if they can tell you how
much progesterone is
actually in each quarter or
one-half teaspoon full.
Since absorption is a
problem from different areas
of the skin, make sure you
use only the inner aspect of
your upper arms or inner
thighs, where the skin is
soft and thin. Since
bioidentical progesterone
can cause sleepiness in some
people, it may best be used
at night.
What can it be used for? May
women find it helpful in
miti-gating PMS symptoms as
well as hot flashes
(especially nighttime
flashes) in menopause. It is
cardiac and breast neutral;
there is no evidence that it
helps improve bone density.
It is very safe.
"I AM MISERABLE WITH HOT
FLASHES AND MOODINESS AND
VERY POOR SLEEP. WHAT CAN I
DO?"
Oh my, there is lots! Books
have been written to answer
this. Here is an outline:
Hormonal: a. Estrogens,
either synthesized (ethinyl
estradiol; conjugated
estrogens; etc.) or a
bioidentical (estriol;
estradiol; estrone) can be
delivered either orally or
transdermally via patches,
creams and lotions or (more
rarely) via injection. b.
Progesterone: Bioidentical
progesterone, delivered via
cream, lotion or capsules,
can help with these
symptoms. c. Bioidentical
testosterone, usually given
either as a transdermal gel,
lotion or capsule, or
synthesized testosterone
supplied in pill form works
wonderfully synergistically
along with estrogen to
mitigate symp- toms.
II. Vitamins, supplements,
and plant-sourced
botanicals. Both those with
“estrogen-like effects” (phytoestrogens)
and those which are used for
their helpful calming and
psycho- logical effects: a.
Soy and other legume-derived
isoflavones help some
women’s hot flashes,
especially when combined
with other measures listed
below. b. Black cohosh,
chased berry (Vitex) and
evening prim- rose oil
(singly or in combination)
have all been of help to
some women. c. Mega-dose B
Vitamins and high-dose
(800-1200 mg) Vitamin E can
help with hot flashes.
III. Non-hormonal
pharmaceuticals. a. Hot
flashes: The anti-depressant
Effexor and the
anti-seizure/anti-depressant
medication Neurontin, used
in low-ish doses are quite
effective in relieving
nighttime flashes (daytime
too to some extent). The old
standby Bellergal is less
helpful. The anti-
hypertensive Clonidine, in
patch form, helps some. b.
Moodiness/Depression/Anxiety:
Xanax and Ativan, in low
doses, is great for
anxiety/”panic”. (Both can
aid in sleep also). Mood
stabilizers/anti-depressants
such as Prozac, Paxil,
Zoloft, Celexa, Lexapro,
Effexor, Wellbutrin, etc.
may be quite helpful.
Insomnia. Sonata lasts +/-
four hours and is good for
women with difficulty
getting to sleep or
middle-night awakening.
Ambien lasts 6-7 hours.
Restoril and Halcion last a
bit longer. These
medications are best used
short-term until the
problems causing the
insomnia are brought under
control.
IV. Lifestyle Changes: a.
Avoid “triggers”. Most women
suffering from hot flashes
are aware of situations such
as heat, caff- eine, spicy
foods, stress, etc. that
trigger their “flash”.
Exercise! Probably the
single most important thing
increasing quality of life
in midlife women is exer-
cise. A total of 30-40
minutes of strenuous
“sweaty” exercise will go a
long way towards clearing
your mind, uplifting your
mood and chasing away
“flashes”. (As it releases
endorphins, which increase
the sero- tonin in your
brain, exercise has
appropriately been called
“nature’s Prozac”).
Stress reduction: Peri-menopausal
symptoms themselves are
stressful. Stress reduction
help such as medita- tion,
paced respiration and muscle
group tension/- relaxation
techniques are imperative,
especially at bedtime.
WHY ARE MY HEADACHES WORSE?
Headaches, especially
migraine, are exquisitely
sensitive in women to stress
and hormonal changes.
Midlife and peri-menopausal
symptoms are stressful;
hormonal levels
roller-coaster. Both hot
flashes and many headaches
are centrally mediated by
areas in the brain that are
exquisitely sensitive to
hormonal fluctuations.
More often, headaches are
secondary to the “valleys”
after hormonal peaks, but in
many women the generally
elevated levels of estrogens
during the peri-menopause
exacerbate their head-aches.
WHAT WILL HAPPEN TO MY BONES
IF I QUIT ESTROGEN?
By far the greatest amount
of bone loss in women occurs
in the 1-2 years following
menopause. For women taking
hormone therapy to ease the
menopausal transition, the
same situation obtains after
discontinuing their estrogen
therapy.
The unknown is: How much do
you have to lose? A woman’s
peak bone mass is obtained
in her 20s and is dependent
on genetics, general health
and nutrition, calcium
consumption, physical
activity and estrogen
levels. If you are
genetically challenged in
the bone density department,
if you didn’t drink your
milk (see, your mother was
right!), if your estrogen
levels were chronically low
secondary to a very lean
body mass...well, you may
have less leeway after
menopause.
Estrogen protects women
against excessive bone loss,
just as testosterone
protects men. The fact that
males have a far lower
incidence of osteoporosis is
a testament to their
testosterone not abandoning
them (as estrogen abandons a
woman) at midlife. Of
course, calcium, protein and
exercise are necessary to
build bone; hormones simply
inhibit excess resorption or
bone loss.
Woman at perimenopause and
women stopping hormone
therapy are well advised to
get at least a peripheral
(wrist or heel) scan; better
is a “central” hip and spine
(or DXA) exam to assess
their risk.
Estrogens inhibit excess
bone resorption. Other
non-estrogen substances that
protect bone to a similar
degree include alen-dronate
(Fosamax), risedronate (Actonel),
raloxifene (Evista),
testosterone and possibly
DHEA at a dose of 50 mg per
day.
MY DOCTOR PUT ME ON
PREMARIN, BUT I STILL WAS
HAVING HOT FLASHES. SHE
INCREASED IT, BUT I AM STILL
NOT BETTER. WHAT SHALL I DO?
Don’t increase the Premarin!
There are many alternatives.
Since oral estrogens are
metabolized differently by
different individuals, many
women have “break through
hot flashes” at night after
a morning dose. You can
experiment with supper-time
dosing, or splitting dosage
half in the morning, half at
night.
Transdermal patches give a
more reliable and constant
level of hormones. You might
switch “laterally” to patch
at equivalent doses.
In all cases, you might want
to eventually slowly wean
your dose down. If you do it
slowly-slowly-slowly, you
usually can accomplish this
without return of flashes.
Progesterone cream is also
quite helpful, especially
for “night sweats”. A dose
of 50-100 mg of cream at
bedtime is the usual dose
(made by a compounding
pharmacist), or +/- one-half
teaspoon of over-the-counter
cream.
Also good for resistant hot
flashes can be Vitamin E
400-800 mg in the morning
and at bedtime.
“Psychoactive” medications
usually utilized for
depression, but at lower
doses, can also help with
both daytime and evening hot
flashes. The most commonly
used are Effexor, Neurontin
and one of the SSRI meds
(Prozac, Celexa, Zoloft,
etc.).
I CAN’T SEEM TO LOSE WEIGHT!
You and everyone else!! It
is “the way of life” that
humans (especially women)
gain weight around midlife.
There is a physiological
reason:
As both men and women
(especially women) pass
through midlife (especially
at peri-menopause), the ACTH
(“growth hormone”) level
from their pituitary glands
slow down, stimulating less
cortisol output from the
adrenal glands. This leads,
basically, to a “slowing
down” of the “idle” of the
body’s engine. Less
energy/less calories being
utilized minute-by-minute.
Therefore, many midlife
women can eat the same and
exercise the same and expect
to gain 3-5 or more pounds
per year through the (peri-)
menopause.
Bummer!!
Of course, this is not the
same for all women. (There
are the lucky ones).
What to do?
Tough love here (sorry!).
There is no “magic bullet”.
Unfortunately, the only way
to deal with this is to
consciously cut down your
calorie intake by 5-10% (eat
a bit less) and at the same
time increase your calorie
output by the same. You can
do this by increasing
exercise plus eating more
but smaller meals (e.g.
stretch out the food you
normally eat in a day to 4-5
smaller meals instead of
2-3). This gets your
“digestive motor” working
more times, burning a bit
more calories.
You can also get used to a
bit rounder figure...you’ll
still look good!
Article courtesy of Dr.
Michael Goodman
http://www.caringforwomyn.com
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