Medical Mondays 2

 

Dr. Patricia Yarberry Allen, publisher and co-founder of Women’s Voices for Change, is a board certified fellow of the American College of Obstetrics and Gynecology. She is the director of the New York Menopause Center.  Here, she takes on the troubling question “If everything is normal on my exams, doc, why do I feel so bad?”

 

 

Dear Dr. Pat,

I am 52 years old and have not had a period for a year. Actually, I’m  relieved at not having my period. But there are other problems I really need to fix.

I am the office manager for a trucking firm. There’s  lots of deadlines and stress. I come in early and stay late. But there’s a psychic reward to all this: I’m proud that I’m so very good at this job; it takes skill to keep this place running. There’s a social reward, too: I like hanging around after work and having a few drinks (and cigarettes and fast food) with the guys. In fact, I’m having a relationship with one of them—a long-haul driver. (I divorced my husband 10 years ago.) I see this guy whenever he’s in town, which is most weekends. The sex has been great, and he treats me really well.

BUT . . . ever since my divorce I’ve felt anxious—mostly about being alone in my old age. The fact is, I seem to be anxious all the time lately. And I’m overweight: 5-feet-5 and 170 pounds; I never lost the 40 pounds I gained in my third and last pregnancy.

Worse, my sleep is terrible. I wake up just as tired as when I went to bed. I know I snore and gasp and sometimes stop breathing when I sleep, because I’ve been told so by my kids and the men I have slept with.

And here’s the worst thing: Sex hurts! Is this the end for me? I’ve read in the women’s magazines about how much better women feel if they are taking hormones. Is there some reason I shouldn’t take those hormone pills?

I just got a thorough workup from my medical group here in town—stress test, colonoscopy, lots of blood work. My GP told me that all my tests were normal, including my thyroid tests, and that I had no anemia or diabetes, but that I would feel a lot better if I lost 20 pounds. He didn’t find a cause for, or give me any treatment for, my fatigue. He said it was just menopause.

Could all my symptoms be “just menopause?” I don’t even get hot flashes! And if it is all about menopause, what would hormones do for me?

Sarah in Maine

 

Dear Sarah,

Good news: You have had all the age-appropriate health screenings you should have, and everything is normal. This indicates that you are ready to look for answers to that troubling question, “If everything is normal on my exam, doc, why do I still feel so bad?”

In my opinion, it isn’t all “just menopause.”  However, some of the symptoms you describe could be caused by a lack of estrogen.  Some women with sleep disruption caused by frequent, drenching hot flashes and anxiety at the same time, who are then exhausted in the daytime, may choose to try short-term low-dose hormone therapy. That is a low dose estradiol in a transdermal or oral form and an appropriate dose of progesterone to prevent the estrogen from causing endometrial cancer.  And, short term is usually two years with a slow withdrawal from the hormonal treatment.  If the symptoms are just due to the decrease in estrogen levels, then the patient should feel really quite her old self again.  But the decision to treat all women with fatigue, poor sleep, anxiety, and weight gain alike, without probing into the back story, is a mistake.

Vaginal dryness and painful intercourse are menopausal symptoms. This is often easily managed with local estrogen and lubrication. Systemic hormone therapy is not the treatment for this.

However, we know that it’s convenient for some women who are in the menopausal transition to blame the decline of ovarian hormones for everything that is not right in their lives.  This is often not the case. It  just might be coincidence that the loss of menstruation occurs along with other difficult life experiences that are layered on top of a woman’s own brain biochemistry, temperament, and life choices.

Fatigue, weight gain, anxiety, and poor sleep have many causes. Some of your symptoms do work together to make the sleep bad, the energy poor, the anxiety worse, and weight loss more difficult. And menopause may not be to blame.

 • At the core of some of your symptoms is “just”— bad habits. You eat fast food and drink alcohol most nights, and you don’t exercise. These habits must be changed if you want a healthier life with energy and fewer symptoms. And you’d need to make these changes even if you took hormones.

 • Poor sleep can have so many causes. Alcohol disrupts the brain’s sleep cycle. Drinking may make it easier to fall asleep, but the sleep is fitful, due to the change in the normal sleep cycle. And you may suffer from sleep apnea—a cause of daytime fatigue, poor sleep, and difficulty in losing weight. People with sleep apnea are often overweight and have been told that they snore, then gasp and almost stop breathing, then start to snore again. And anxiety—ruminating about all the things that weren’t done in the day now gone and about all the terrible things that may happen tomorrow and tomorrow and tomorrow—is a sleep-stealer.

• Fatigue is, of course, partially the result of poor sleep, but it can be increased throughout the day by “food coma” from your diet of too much sugar, too many bad carbs, and foods high in fat. The body has to redirect the blood to the gut to manage all of these toxic foods, leaving the brain with less energy to work with.

Do check again with your doctor to get blood tests for Vit B12 and Vit D 25 OH. B12 is often low in those who drink too much and have bad diets. Vitamin D comes from lots of sunlight, and since you live in Maine, you don’t have lots of sunshine. If Vitamin B12 and D  are low, then the fatigue could be worsened by these deficiencies. If your levels are low, ask your doctor for recommendations for over-the-counter vitamins. Check the levels again in six months to make sure that you are absorbing them.

So, Sarah, are you ready for your prescriptions for a happier, healthier life? Are you ready to become the competent CEO of your menopausal transition?

1. Give up the booze (10 pounds can easily go in a month by doing just this alone). Bring food to work that is lower in calories and smaller in portion than the fast food you have been eating. Try to think of alcohol and these poor food choices as poison.   It is always said, “If you don’t want to drink, stay out of bars,” so ask your drinking buddies to put your health before their fun times with you.

 2. Join a gym that has classes for newbie exercisers and go there every day—7 days a week, at least for the first 28 days. You are working to avoid diabetes, high blood pressure, heart disease, and arthritis. Exercise improves sleep, decreases fatigue and anxiety, and helps with weight loss. Make this your new “bar.”  Find friends here who will be supportive of your new life choices.

 3. You really should be evaluated for sleep apnea.  Insist that you get a referral, since you have all the signs and symptoms of this condition. If you do have sleep apnea,  a device called a CPAP can be fitted for your mouth, improving the flow of oxygen to your blood—and then, of course, to your brain. In patients with sleep apnea, the quality of sleep is reported to improve significantly with CPAP treatment—and so is an increase in daytime energy and a better response to a weight loss program.

 4. Vaginal dryness and painful intercourse require a visit to your doctor. Ask for a vaginal estrogen preparation, use it for a month without intercourse, then add lubrication to the mix and you are very likely to have comfortable intercourse once again, since you never had any problem with this part of your life until the estrogen dropped.

 5. Ah, anxiety, the curse of modern life. But often, anxiety is about matters  over which we have no control anyway. Here’s a home remedy: Every night, write a note to yourself listing three things that you have to be thankful for. Take time with these choices, because this is what you are giving your brain to work with each night. (The brain does work all night long. Why not have it be a happy brain instead of one floating in a vat of acid with those ruminations of anxiety and doom?) If these simple ideas do not diminish the anxiety, take meditation classes and add meditative breathing to your nighttime and daytime routines: Breathe, breathe, breathe. 

A cautionary note: Anxiety may be the result of brain biochemistry that’s just a bit off and that might require a dusting of some medication. If simple remedies don’t help with your anxiety and it is impairing your ability to function, find a therapist and discuss your symptoms. And if your fatigue persists after two months of this new regimen, go back to your GP and ask for another evaluation.

Sarah, I hope that you can look at menopause as an opportunity for life reassessment at mid-life. If you choose to focus on what may be causing the symptoms that are destroying the quality of your life, then you may understand what many women know: Menopause is the time for reinvention. The loss of menstrual periods is a marker that the time has come to make healthy choices, to engage in self-care, and to be hopeful that this second half of your life will be better in many ways than the last decade, at least.