Menopause
Menopause
Jane was fit, fine and 42 when she went to the gynecologist for her yearly checkup. It was a medical ritual that she''''d followed every year since her first pregnancy. She expected no news but the same news. All systems go.
This time, though, the gynecologist said lab tests showed that Jane was in something called perimenopause.
| Keep Control If you''''ve been using a birth control method, you need to continue to use it during perimenopause--since you''''re still producing some eggs and can still get pregnant. The hot flashes and funny periods of perimenopause aren''''t prophylactic. All it takes is one solitary egg for fertilization. That''''s why, to be safe, you need to practice birth control until at least a year after your very last period. At this stage there''''s an added bonus in choosing the Pill as your birth control method. Because it replaces your natural hormones, the Pill helps control irregular periods. For some women it might also help control any premenstrual syndromelike symptoms of menopause you''''re feeling, such as aches, irritability and food cravings. |
Jane''''s stomach dropped like a stone. Perimenopause--what was that? Premature menopause? She''''d planned on researching menopause before it happened. And here it had snuck up on her, taking her unprepared.
Her face must have reflected her feelings, because her doctor said, "It''''s not the end of the world, you know."
Maybe not. But it was the beginning of a new experience for Jane--an experience that every woman will have to face.
Life after Eggs
Menopause signals that you''''re done with the 900,000 or so eggs that you were born with. The supply source--your ovaries--shuts down hormone production.
It doesn''''t happen all at once. Before fertility is officially over, the ovaries make noises about retirement and get ready to hang out the sign, "Gone fishin''''." It''''s this stage of limbo that doctors call perimenopause.
During perimenopause a woman''''s supply of the hormone estrogen starts to waver. The hormone supply doesn''''t stop suddenly, but it declines enough to cause irregular periods. The hormone has an influence on so many of our body''''s functions that all sorts of changes occur when there''''s a shortage.
Perimenopause can last anywhere from two to ten years or so. For each woman the symptoms and signs of approaching menopause are different, and so is the time frame.
Falling levels of estrogen usually cause irregular periods, and often this is the first clue to menopause. Also, some women experience vaginal dryness and frequent urination.
About 85 percent of American women have hot flashes when they''''re in perimenopause. But hot flashes come in different forms. You might start sweating furiously even when the weather is cool. Or you might suddenly feel the merest flicker of heat at the back of your neck. Night sweats are another common form of hot flashes--which may in turn be responsible for some of the many other symptoms often blamed on menopause --insomnia, fatigue, irritability, mood swings, depression and forgetfulness, says Jennifer Prouty, R.N.C., clinical faculty at Northeastern University College of Nursing in Boston and a menopause consultant.
| The Symptoms of Menopause |
| In a Prevention magazine survey, some 15,000 readers shared their experiences of menopause. The following graph shows the percentage of women reporting each symptom. |
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Estrogen affects the body in other ways as well. "Everyplace you turn in a woman''''s body there are estrogen receptors. They''''re in her heart, her bones, her arteries and brain--not just in her reproductive organs and breasts," notes Bernadine Healy, M.D., a cardiologist at the Cleveland Clinic Foundation and former director of the National Institutes of Health.
But the connection to other signs generally attributed to menopause--weight gain, loss of sexual desire, joint pain, hair loss and dry skin--is much less clear. Is it menopause or just middle age or lifestyle? "We don''''t have enough hard data to really make those connections," says Prouty.
There''''s no doubt, however, that women''''s risk of osteoporosis and heart disease begin to soar when estrogen is depleted. Since estrogen protects your bones and is believed to also protect your heart, when it recedes, you have to consciously work to compensate for its loss--with diet, exercise and possibly hormone replacement therapy.
The Pause and After
As for menopause itself, that term just refers to the time of your final period. Of course, you don''''t know which is the last one. But if you go one year with no periods, you can say retrospectively that you''''ve been through menopause.
While there''''s no saying exactly when it will happen, the average age is about 51. Since there''''s nothing special to signal your last period, you may not even know that menopause has come and gone until your box of sanitary pads starts to gather dust. By then you''''re in postmenopause.
But some women''''s bodies don''''t conform to general predictions. About 5 percent of all women are born with fewer eggs than the other 95 percent. These women inherit a tendency toward early menopause, shutting down egg production by age 41 or even younger.
Having your ovaries removed or destroyed by radiation or chemotherapy also produces premature menopause along with all the symptoms. Once your ovaries are gone, your estrogen drops sharply, just as if you''''d gone through menopause.
If you can''''t remember when you had your last period, and you''''re not sure what stage you are in, there''''s a way to find out. Your doctor can give you a follicle-stimulating hormone (FSH) test. It measures how hard your pituitary gland is working to get your ovaries to function. High numbers mean that you''''re menopausal.
Planning Ahead
Knowing that someday your body will stop producing estrogen, you can help reduce your risks of bone loss and heart disease if you prepare for that change. "We have to prepare for what''''s coming--protect our bodies, preserve our health. Menopause is sobering, but it''''s exhilarating, too, if we plan ahead and really take charge of our health," says Anita L. Nelson, M.D., associate professor of obstetrics and gynecology at the University of California, Los Angeles, UCLA School of Medicine and director of the women''''s medical clinic at Harbor-UCLA Medical Center in Torrance.
The two best ways to prepare for menopause sound awfully familiar. They''''re the one-two combo of diet and exercise. But even if you already pay attention to both, you may need to revise them a little to get ready for the changes that menopause brings.
Bear some weight. If your diet is low in calcium and your life is low in exercise, you may actually start losing bone in your thirties. That loss accelerates as you approach menopause. But you can slow the rate of bone loss with weight-bearing exercise. "Exercise that bears the full weight of the body is what''''s important," says Prouty. For many women the most convenient weight-bearing exercises are walking, running or low-impact aerobic dancing. Doctors recommend that you aim for at least 20 to 30 minutes of nonstop moderate aerobic exercise three times a week.
Be upwardly mobile. While walking and running will help build the bones below your waist, you need strength training to build bone in the upper part of your body. Experts recommend resistance exercise three times a week (preferably on nonconsecutive days) using dumbbells, weight machines or exercise bands to target specific muscles or muscle groups in your body.
Attack fat. Since your risk of heart disease shoots up when your body needs estrogen, the less artery-clogging fat in your diet, the better. A diet that''''s low in saturated animal fat and high in fiber, fruits and vegetables is your best heart-healthy bet.
Knowing Where You Stand
Once you''''ve started perimenopause, you need some basic information in order to plan how much or how little you need to do for a body on the brink of change. Since the risks of osteoporosis rise sharply after menopause, many doctors will recommend a test to determine the condition of your bones. A bone mineral density test will tell you if you need to take aggressive steps to ward off the bone-depleting effects of osteoporosis.
To get the test, you''''ll need a referral from your physician. Some doctors are reluctant to refer a woman for testing unless her family or medical history shows that she''''s at risk for osteoporosis. Also, insurance companies often don''''t cover its cost. But you really do need to know the condition of your bones as you get into perimenopause--so the cost is usually worth it.
| Bracing for Bone Loss A tiny old woman with a bent-over back: That''''s the common image of osteoporosis. But the bone-thinning disease begins much earlier, when a woman is still young and standing tall. If she''''s done little exercising and a lot of dieting, if she doesn''''t eat dairy products or calcium-rich food, if she''''s a small woman with northern European ancestry or if she smokes, then her bones may be too thin before she''''s 40. What is it with bones and calcium? Well, bones are as busy as bees. Cells called osteoclasts dissolve old bone and carry it to the bloodstream, while cells called osteoblasts spin soft protein fibers--collagen--into honeycombs of new bone. Calcium and phosphorus crystals make those soft fibers hard--and the end product is solid bone. Up until ages 30 to 35, osteoblasts and osteoclasts move in lockstep, so you''''re making new bone about as fast as the old dissolves. As the years go by, though, the destroyers gain the upper hand, with estrogen playing a role in the coup. And when estrogen plummets after menopause, the osteoclasts get the advantage. The aftermath? They can carry away up to 7 percent of our bone mass during early postmenopausal years. Working Out Your Risk
Those most at risk of severe osteoporosis--which follows a worst-case script--are small-framed Caucasian or Asian women smokers. If you fit this description, it''''s especially important to take it seriously. "Osteoporosis is not only deadly, it''''s crippling," says Anita L. Nelson, M.D., associate professor of obstetrics and gynecology at the University of California, Los Angeles, UCLA School of Medicine and director of the women''''s medical clinic at Harbor-UCLA Medical Center in Torrance. Not only will half of the women over age 50 fracture a bone because of the "silent crippler," but "by the age of 65, a woman who fractures her hip has a less than 50 percent chance of full recovery," Dr. Nelson says. You can fight those statistics, though, and win. If you use hormone replacement therapy (HRT) during the first five postmenopausal years, you can reduce the likelihood of osteoporosis-related bone fractures by more than 50 percent. But HRT isn''''t the only answer. One of the studies coming out of the National Institutes of Health''''s breakthrough Postmenopausal Estrogen/Progestin Interventions Trial looked at the effects of lifestyle on bone mineral density. Investigators who studied 875 women at seven clinical centers around the country found three bone-protective factors. Women with the strongest bones were those who got the most exercise, got plenty of dietary calcium and consumed small amounts of alcohol. Specifically: * Women in the "best" group had strenuous activity at least three times a week--though mild to moderate exercise produced bone-strengthening benefits, too. * Women in the "best" group also got at least 800 milligrams of calcium daily and drank about two glasses of wine (or the equivalent) a week. In the same study researchers also concluded that--other factors being equal--using estrogen produced about a 2 percent increase in bone density. (In the group they studied, the average time of estrogen use was about 3.2 years.) Despite the lessons to be learned from this study, however, researchers caution about overindulging in wine. Two glasses is acceptable, but when people increase their consumption, the excessive alcohol begins to have a negative effect on the bone density. Holding On to Calcium
Researchers also warn that certain kinds of foods can rob the good calcium that we eat. A diet that''''s heavy in animal protein and salt, for instance, will flush calcium out of your body and into your urine. The phosphorus in soda pop may do the same thing--so limit your drinking of cola, which is high in phosphorus, to one can a day. Caffeine can interfere with calcium absorption, too, says Stephanie Beling, M.D., medical director of Canyon Ranch in the Berkshires, a health spa in Lenox, Massachusetts. But, she adds, it''''s okay to have one or two cups of tea or coffee every day. Another nutrient necessary for calcium absorption is vitamin D, Dr. Beling notes. Some women get enough from the sun, but if you are unable to go outdoors, you can have vitamin Dfortified milk or cereal. And if you''''re taking supplements, check the label to make sure they also have vitamin D in them. |
The best kind of test is with a dual energy x-ray absorptiometer--better known as DEXA. To avoid the expense of a DEXA test, though, your doctor might use a cheap, new, easy urine test that measures the rate of bone loss.
Since your risks of heart disease also shoot up after menopause, it''''s advisable to have a lipid analysis to get the numbers on your total cholesterol--both the "good" high-density lipoproteins (HDLs) and the "bad" low-density lipoproteins (LDLs). Another number you''''ll need is the triglyceride figure. Triglycerides are a fat in the bloodstream that plays a part in women''''s heart disease.
The HDL number is an important predictor of heart disease risk in women. You want a number over 50 milligrams per deciliter (mg/dl). (Women average higher HDLs than men.) As for your LDLs, you want them below 130 mg/dl. Your triglyceride number should be below 150 mg/dl. If any of these numbers is in the danger area, or if the ratio of HDLs to LDLs isn''''t high enough, your doctor is likely to recommend a cholesterol-lowering diet and exercise program or even medication.
The Big Decision
If you''''re in your forties or even late thirties, your eye has probably been caught by the latest article on menopause and hormone replacement therapy (HRT). Every day, it seems, new research on HRT''''s risks and benefits hits the journals and papers.
Women on HRT take pills or use patches to replace the estrogen that''''s missing from their bodies. Many women don''''t take estrogen by itself, though, because without other hormones in the mix, it increases the risk of uterine cancer. A typical HRT regimen combines estrogen with the synthetic hormone progestin.
There''''s a good amount of evidence indicating that HRT stops bone loss, and it may lower the risk of heart disease by as much as 50 percent. But some other evidence shows that HRT may be associated with increased risk of breast cancer--so doctors are still weighing the risks.
As soon as you approach your perimenopause, your gynecologist will most likely raise the issue of HRT for you to consider. She may believe deeply in its benefits, because it does chill out hot flashes and may relieve other symptoms such as irritability and sleep disturbances. HRT will also improve the ratio of "good" HDL cholesterol to "bad" LDL cholesterol in your blood, and it helps put the brakes on bone loss. There are even some studies linking HRT to a lower incidence of Alzheimer''''s disease.
One factor to consider is how long you might be on HRT. Originally, the hormones were prescribed to quell hot flashes and other menopause symptoms. "But that''''s a relatively short-term consideration--five years or so," says Irma L. Mebane-Sims, Ph.D., epidemiologist and program administrator of the National Institutes of Health''''s ground-breaking Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial.
A woman who is taking HRT for its two greatest benefits--to reduce heart disease risk and osteoporosis risk--is using it as a preventive medication for the long term. "Osteoporosis specialists give a woman at least 10 to 15 years on HRT, and then they reevaluate her. A cardiologist knows that only current users of HRT enjoy the reduction from heart attack risks," says Dr. Nelson. In other words, to get continued protection from heart disease, you need to continue HRT. As soon as you stop HRT, you can start losing bone at a faster rate.
Despite the benefits of HRT, some doctors are reluctant to prescribe it, relying instead on exercise and diet to treat symptoms and lessen risk.
The decision to go ahead with HRT should really be based upon the profile of each individual, according to Stephanie Beling, M.D., medical director of Canyon Ranch in the Berkshires, a health spa in Lenox, Massachusetts. "If your symptoms aren''''t severe and you aren''''t at risk for osteoporosis or heart disease, then hormone replacement therapy might not be prescribed."
Other experts have come up with guidelines to help decide when they''''ll prescribe HRT. "If you face more than one risk for a disease that estrogen deficiency definitely causes, like heart disease and osteoporosis, then HRT unifies their treatment, so you don''''t have to take many different drugs," says Rena Vassilopoulou-Sellin, M.D., associate professor of endocrinology at the University of Texas M. D. Anderson Cancer Center in Houston.
| Hormones, the Heart and Breast Cancer A woman at risk for both heart disease and breast cancer is caught on the horns of a tricky dilemma. Hormone replacement therapy (HRT) would protect her heart, but at the same time it might increase her chances of breast cancer. Heart disease claims many more women than breast cancer. It is the number one cause of death for women over age 65 and claims the lives of a quarter of a million women each year. Forty-six thousand women die of breast cancer each year. But many women fear breast cancer more than heart disease. There''''s little evidence to support the view that HRT significantly increases the risk of breast cancer. "Most everybody in the medical community says that if there is a risk, it''''s so small that we''''re hard-pressed to find it," says Rena Vassilopoulou-Sellin, M.D., associate professor of endocrinology at the University of Texas M. D. Anderson Cancer Center in Houston. "There is a lot of compelling evidence that HRT cuts heart disease risk." Other evidence of oral estrogen''''s heart benefits also keeps mounting. Estrogen lowers "bad" LDL cholesterol and raises "good" HDL cholesterol. It lowers a clotting factor in the blood that can cause strokes. It relaxes the blood vessels and keeps them flexible. |
A number of doctors, such as JoAnn E. Manson, M.D., associate professor of medicine at Harvard Medical School and co-director of women''''s health at Brigham and Women''''s Hospital in Boston, agree with the conclusion of a mega-study that reviewed all the data on hormone therapy since 1970: "Hormone therapy should probably be recommended for women who have had a hysterectomy and for those with coronary heart disease or at high risk for coronary heart disease. For other women the best course of action is unclear."
"A woman needs to look at her own profile of risk to make an informed decision," says Dr. Mebane-Sims. "There isn''''t an easy answer."
Looking at Lifestyle
Whether you choose HRT or not, doctors agree that you shouldn''''t neglect diet and exercise. "You shouldn''''t rely on pills to do things that a good lifestyle should be doing," says Dr. Vassilopoulou-Sellin. The American Medical Women''''s Association has declared that "for a woman entering or past the age of menopause, exercise may be the single best thing she can do for her emotional and physical health."
When Prevention magazine and the Center for Women''''s Health at Columbia Presbyterian Medical Center in New York City surveyed 15,000 Prevention readers, they discovered that women who exercised three times or more a week had a better experience with menopause than women who worked out less than that. They also found that eating a low-fat diet was even a bigger factor than exercise in helping women have a positive experience with menopause.
In addition to eating a low-fat diet, you can select specific foods to help compensate for an estrogen shortage. Plants have estrogens, too, called phytoestrogens, which can be quite powerful, observes Wulf Utian, M.D., Ph.D., director of the Department of Reproductive Biology at Case Western Reserve University in Cleveland.
Phytoestrogens are converted in the gut
| Fine-Tuning Your HRT Let''''s suppose that you have done a personal risk assessment and concluded that, yes, you want hormone replacement therapy (HRT). That''''s just the beginning. Finding the right dosage, the right form of hormones and the right schedule could take as long as menopause itself. Oral hormones have their own side effects--and, actually, they''''re often similar to menopause symptoms. If you''''ve had a hysterectomy, adjustment to HRT will be easier, because you can just take estrogen rather than estrogen plus progestin. (Since you don''''t have a uterus to protect from cancer, you don''''t need the protective effect of the progestin hormone.) Increased estrogen can cause headaches, especially if you get migraines. Also, if you have a uterus, estrogen can activate fibroids again--benign tumors that grow on the uterine wall and sometimes cause heavy bleeding. Estrogen can also aggravate fibrocystic breast disease. Progestin, a synthetic form of the hormone progesterone, is more problematic. While estrogen thickens the uterine wall, progestin tells it to slough off. While that protects the uterus, it also produces a period--and if you''''re done with menopause, that''''s surely unwelcome news. If the bleeding is heavy, your doctor will probably put you on a lighter dose or a different schedule. Eventually, you will probably stop bleeding. There is no guarantee, however. Some women continue to have bleeding to the age of 60 and beyond. Some of progestin''''s other side effects include bloating, food cravings, breast pain or tenderness, headaches and depression or anxiety. But sometimes these side effects go away when progestin is taken continuously in a smaller daily dose. |
to hormonelike substances that the body can mistake for estrogen. They come in two forms--isoflavones and lignins. Isoflavones are found in soy foods, such as tofu and soy milk. Lignins show up in whole grains and flaxseed. Fruits and vegetables contain smaller amounts of lignins.
Soy is an excellent source of phytoestrogen. When researchers in Australia gave 58 women soy flour mixed into a drink, mixed into cereal or baked into a muffin, the average number of hot flashes fell by 40 percent.
Since soybeans are such a good source, you''''ll probably get enough from just three to four ounces a day of tofu--which is made from soybean curd. (For some tasty ideas on how to include more soy foods in your diet, see "So Many Soy Sources" on page 281.)
Cooling the Hot Flashes
One of the benefits of HRT is that it eliminates hot flashes. But even if you''''re not on HRT, there are a number of specific techniques you can use to help control the hot flashes that are so uncomfortable for women in perimenopause. Here''''s what Diana Dell, M.D., assistant professor of obstetrics and gynecology at Duke University Medical Center in Durham, North Carolina, recommends.
Breathe deeply. Hot flashes can hit unexpectedly whether you''''re lying in bed about to doze off or on the brink of a very important meeting with a very big client. What to do? When that telltale flush starts to prickle your skin and heat up your neck, deep breathing just might do the trick.
Expel as much breath as you can, then fill your lungs again by expanding your diaphragm--the area between your rib cage and abdomen. Release that breath fully. Repeat with a steady rhythm, and you may be able to squelch a hot flash before the sweating begins.
Douse that sizzle. Avoid sizzling foods--whether their heat comes from high temperature or red-hot chili peppers. These foods are notorious hot-flash provocateurs. They can jack up your body temperature and send a rush of heat through your face and chest.
Check your drinks. Alcohol and caffeine can make you flush. Watch your reaction to coffee, tea and colas--and give them up if they lead to hot flashes. Remember: Chocolate also has caffeine, so you may want to forfeit that, too.
Hydro Power
Some women report a lack of sexual desire that comes with menopause--which may be partly caused by vaginal discomfort. Loss of
| Using Exercise and Diet |
| By controlling your exercise habits and your diet, you may set the stage for an easier "change of life" during menopause. The graph below shows the percentage of women who reported a relatively "positive experience" during menopause. |
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estrogen has a general drying effect on tissues and organs in the body, particularly in the pelvic region. If your vagina is dry, sexual activity may be uncomfortable. Bummer, you say? Not for long. Simple solutions exist. Here''''s what experts recommend.
Make it moister. "There are a variety of lubricants and moisturizers on the market now," says Prouty. K-Y jelly is the classic. It has been joined by moisturizers such as Replens and Astroglide. "They have chemicals in them that create a little bit of penetration into the vaginal walls, so they''''re longer lasting."
Some women like evening primrose or vitamin E oils--and saliva works, too, adds Prouty. But avoid perfumed oils and petroleum jelly that may contain irritating substances.
Do a dab of estrogen. A topical estrogen cream, available by prescription, thickens the tissues around the vagina. But talk to your doctor in detail before using it long term: Since estrogen is very efficiently absorbed by the body, using it for a long time can have side effects, according to Dr. Dell.
Go orgasmic. Regular orgasms--either with a partner or through masturbation--help maintain healthy tissues, according to Prouty.
Controlling Factors
After menopause, tissues in the pelvic area get thinner and weaker, which can cause an increase of urinary tract and vaginal infections in some women. Lacking estrogen, muscles in the pelvis also start to slacken. When the bladder loses the support of surrounding tissues, you''''ll probably find that you need to urinate more often. And a sudden laugh or cough may produce the unsettling sensation that you''''re wetting yourself.
| The Menopause Diet With just a little tweaking, a good diet can easily turn into a menopause menu that counters some of the effects of falling estrogen. For starters, you''''ll need more calcium--1,500 milligrams daily (or 1,000 milligrams if you''''re on hormone replacement therapy). Ideally, you should get all this calcium from food, because the mineral is best absorbed when it comes from food sources. Calcium isn''''t the only nutrient that you need at menopause. Here are some other foods that Diana Dell, M.D., assistant professor of obstetrics and gynecology at Duke University Medical Center in Durham, North Carolina, recommends to help you through this time. * Eight glasses of water a day can help keep that pelvic area moist. * Foods with fatty acids, such as sunflower seeds, salmon, soybeans and leafy green vegetables moisturize the body, too. * Potassium salt (such as Morton salt substitute) instead of table salt can reduce menopausal bloating and water retention. * Foods with beta-carotene and vitamins C and E--the antioxidants--have been found to help reduce the risk of heart disease. * Onions and garlic lower cholesterol. * Foods with fiber, such as whole-wheat breads and fruits and vegetables, also help lower cholesterol and may be useful in colon cancer prevention. * Chamomile and ginger are herbs that soothe symptoms. Both make good tea. |
To help prevent urinary tract and vaginal infections, Dr. Dell advises wea
