1. How do I know if I am menopausal or perimenopausal?
2. Do herbs work?
3. Is there something “natural” I can take?
4. My sex drive is in the toilet. What can I do?
5. What about that big study [The WHI]. Aren’t estrogens dangerous?
6. Should I be on estrogens “forever”? How do I stop?
7. What about progesterone cream?
8. I am miserable with hot flashes and moodiness and very poor sleep. What can I do?
9. Why are my headaches worse?
10. What will happen to my bones if I quit my estrogen?
11. My doctor put me on Premarin, but I still was having hot flashes, so she increased it, but I am still not better. What should I do?
12. I can’t seem to lose weight.
“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.
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-like 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.
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:
1. 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, chasteberry, Vitamin E, calcium, etc., etc.
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, testosterone 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.
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:
1. 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), specifically 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.
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!
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.
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 symptoms.
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 primrose 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.
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.
c. 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, caffeine, spicy foods, stress, etc. that trigger their “flash”.
b. Exercise! Probably the single most important thing increasing quality of life in midlife women is exercise. 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 serotonin in your brain, exercise has appropriately been called “nature’s Prozac”).
c. Stress reduction: Peri-menopausal symptoms themselves are stressful. Stress reduction help such as meditation, paced respiration and muscle group tension/ relaxation techniques are imperative, especially at bedtime.
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.
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.
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.).
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!
Dr. Michael Goodman
Caring for Women
A Specialty Women's Healthcare Practice
635 Anderson Road, Suite 12B
Davis, California 95616
Michael Goodman, M.D., a gynecologist, is a Certified Menopause Clinician, Certified Menopause Practitioner and a Certified Clinical Bone Densiometrist. His medical practice specializes in peri-menopausal medicine, midlife sexuality, osteoporosis prevention, gynecological ultrasound, compounding and alternative therapies and difficult-to-manage women’s health issues.
Dr. Goodman received his training from Stanford University and has over 33 years’ experience in the field. An early pioneer in Family Centered Maternity Care, he was the first doctor in California to include children at in-hospital birth and one of the first in the nation to work with midwives, and to allow fathers into the OR for C-sections. An accredited Laparoscopic Surgeon, he authored the first published U.S. series on Advanced Operative Laparoscopy and has taught and proctored many courses and seminars on these procedures.
Dr. Goodman is a medical communicator practicing patient-oriented health care and specializes in listening to women. His empowering book, "The Midlife Bible: A Woman's Survival Guide," published by Robert D. Reed Publishers, San Francisco, is available above.