“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-life effect on human tissues (within a specific dosage range).
Herbs/botanicals/phytoestrogens relieve (peri-) menopausal symp-toms 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, chased berry, 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, 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.
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), 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.
*See the article “The Woman’s Health Initiative [WHI] Study and Estrogens: What Do the Results Really Mean” available elsewhere on this site.
*(Note to media source: Delete the above paragraph if full article is not available on your site).
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.
Oh my, there is lots! Books have been written to answer this. Here is an outline:
I. 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 symptoms.
II. Vitamins, supplements, and plant-sourced botanicals. Both those with “estrogen-like effects” (phytoestrogens) and those which are used for their helpful calming and psychological 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”.
1. 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”).
2. 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.
Headaches, especially migraine, are exquisitely sensitive in women to stress and hormonal changes. Midlife and peri-menopausal symptoms are stressful; hormonal levels rollercoaster. 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 +/- onehalf 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 perimenopause), 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 minuteby- 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. Goodman often receives questions from patients who are seeking answers in their quest for better health and well-being through menopausal medicine, vulvoaginal aesthetic surgeries, or general peri-menopausal and sexual medicine. He shares these questions and answers to help others who may have similar issues.
I’m 49 years old and had a total hysterectomy a little over a year ago, and I have horrible hot flashes and everything that goes with menopause. My hot flashes make me sick to my stomach and I get headaches with them. The problem is that I can’t take any hormones dues to blood clots.
Do you have any suggestions as to what I can do?
First, it is criminal that your physician removed your functioning ovaries without arranging for reasonable estrogen and testosterone replacement, as it is well-known that women whose ovaries are removed without proper hormonal replacement have a significantly increased long-term risk for cardiovascular disease, not to mention osteoporosis and cognitive decline. This is based on well-founded evidence. Additionally, removing your then-48-year-old ovaries deleted approximately 45% of your body’s testosterone, which is not a pleasant hit! I am continually dumbfounded that so many physicians forget that testosterone is a female hormone, too.
I’m not sure what you mean by “blood clots.” If these were clots you experienced with your former periods, there is absolutely no reason to withhold hormone therapy. But if, as I suspect, this refers to “clots” secondary to thrombophlebitis (in other words, clots in the veins of your legs), hormone therapy would be contraindicated only if you have a situation where you are genetically at risk for blood clots. Your primary care physician or a hematologist can test you for this. In the absence of a genetic rationale for withholding hormonal replacement, there is no reason why you cannot take transdermal (administered through the skin) hormone therapy. The old fear that estrogen replacement therapy increases the risk of blood clots is entirely based on research done on oral estrogens (specifically, Premarin™). These studies have since been repeated with transdermals (“TD”), and the findings show that low-dose TD estrogen administration has the same clot risk as a placebo; it is oral estrogen that has an increased risk.
My recommendation is that you seek a North American Menopause Society (“NAMS”) Certified Practitioner in your area to help you. A large portion of general OB-GYNs, and essentially all Family Practitioners and Internists, are woefully behind the times when it comes to hormone therapy and are doing their patients a disservice. Up-to-date data is clear about the fact that, if started within several years of menopause, estrogen therapy DOES NOT increase breast cancer risk, and in fact lowers the risk of cardiovascular death by up to 30%! To find a Certified Menopause Practitioner (“NCMP”) near you, visit www.menopause.org.
There is no reason for you to suffer! A low-dose Estradiol patch or daily gel (not a pill) plus transdermal testosterone may be just “what the doctor ordered.”
-Michael P Goodman MD, FACOG, NCMP, CCD
Caring For Women Wellness Center
Davis, CA 95616
Hi Dr. Goodman,
I am 52 years old, and I had a partial hysterectomy at 28 years old due to Fibroid. I am still experiencing breast tenderness along with pain and discomfort, although I am no longer seeing my period. Mammogram and ultrasound have shown no cancerous cells, and my hormone levels are o.k. Why is this happening at this age when I am in the transitional stage of menopause?
Ahh…Don’t we love our hormones? Removal of your uterus stopped your periods, but it did not change your ovarian function. The ovaries signal the uterus to go through its cyclic changes to either gestate a pregnancy or menstruate if you don’t conceive in a given cycle. The ovaries act independently; even though your uterus is long gone, your ovaries will still do what they’re supposed to do until you run out of eggs and go through menopause. (Which you will, uterus or no.)
The typical woman reaches menopause somewhere between the ages of 40-57. The average age in the U.S. is around 51 years. At 52 (a great age, by the way!), you are right in the zone. You are probably in pre- or peri-menopause, a time when hormone levels frequently “rock ‘n roll.” Unfortunately, “testing” hormone levels (which many faux “hormone specialists” offer) is generally worthless during this time period, as whatever your hormone levels were on the day of testing, I can guarantee they were different 3-5 weeks prior, and will be different 3-5 weeks in the future. It is a time of transition.
My recommendation is that you see a practitioner in your area (specifically, a gynecologist or nurse practitioner) who is skilled in menopause and in working with women who are “in transition” as you are. Breast tenderness can be a sign of temporarily high estrogen levels, as well as too much caffeine in your diet. Frequently, cycling you on long-cycle, low-dose oral contraceptive pills is the perfect ticket for the difficult peri-menopausal transition and leaves your body less susceptible to your present roller coasting hormone levels.
To read more on the menopause transition, you can see my latest book, “The Midlife Bible: A Woman’s Survival Guide,” visit the North American Menopause Society’s website, and also check out the Red Hot Mamas website!
-Michael P Goodman MD, FACOG, NCMP, CCD
Caring For Women Wellness Center
Davis, CA 95616
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Dear Dr. Goodman,
I have been menopausal for over a year now since my hysterectomy (uterus only) 5 years ago. I am 48 now. I have just started getting electric shock sensations when I get stressed or at all warm. These sensations are all over my body and very painful, and they last several minutes. They aren’t hot flashes; I don’t sweat or get flushed. (I have had those in the past.) I am on Estradiol pills and not feeling any better. I have also taken Estratest HS. I also take iCool. Have you heard of this before? I am at my wits’ end…
There are several possibilities that could explain what you’re experiencing, but remember that I’m limited as I don’t know your full medical history, nor am I able to ask you questions that would enable me to make a more focused diagnosis (without which, proper therapy is difficult).
Be that as it may, the following are things to consider:
1. These might be hot flashes (“HFs”) after all. HFs can take different forms; not all women experience sweating. How long have you been on Estradiol? It may take 1-2 months to control symptoms. What is your dose? It should be around 1 mg taken orally, although in my opinion transdermal (through-the-skin patches or gels) have considerable advantages over orals. A Vivelle Dot patch dose 0.05mg may be best the for you?
If the estrogen is still inadequate, you could work with your doctor to add in a medication called Gabepentin, beginning at a low dose 2 times a day and ending up at therapeutic doses 2-3 times a day within a month or so.
2. This could be a sign of a seizure disorder or neurological phenomena of some kind. A consultation with a neurologist would determine this.
3. Another strong possibility is that this could be a stress/anxiety reaction of some sort. If so, I would recommend mindfulness exercises (Google “mindfulness” along with the name your city to find classes near you) and possibly botanical relaxants such as l-theanine of phosphotidyl serine with a benzodiazepine medication (Alprazolam, Lorazepam, etc.) as a “backup” if needed.
I would recommend exploring possibility #1 first, while at the same time pursuing #3. If you see no significant improvement is 4-6 weeks, I would then pursue #2.
Good luck! Write back to let us know how things turn out.
-Michael P Goodman MD, FACOG, NCMP, CCD
Caring For Women Wellness Center
Davis, CA 95616