Menopause Is Not a Disease (Ask Dr. Pat)

Dr. Patricia Yarberry Allen, publisher of Women’s Voices for Change, posts a column on medical issues  every Monday. Dr. Allen, a gynecologist, is Director of the New York Menopause Center, a Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and an Assistant Attending Obstetrician and Gynecologist at New York–Presbyterian Hospital.

 

Dear Dr. Pat:

I am 42 years old and am terrified of menopause. My mother, who was a great beauty when she was young, had terrible symptoms with depression and drinking in her late 40s.  She was never easy, but became really bad-tempered beginning during this time. She gained weight, and before she was 50 was a divorced, angry, overweight, stay-at-home woman whose children were happy to be out of the house and away from the mess.  She finally got sober and moved back to her hometown in the Midwest after many unhappy years in a big city. My brother and I rarely see her, because she may be sober but she is still self-absorbed and demanding.  My brother, unfortunately, has a drinking problem and has work and marriage problems as well.

I want to do everything I can to prevent my life from turning out this way. I have two teenage daughters who are doing well, and both will be in college in two years.  I have a really good marriage with a great sex life.  I eat in a healthy way and exercise daily but have noticed that I have begun to gain some weight. I do have a drink most nights, and a bit more socially, but don’t have any other bad habits.  I have a great job where I have the opportunity for advancement, and, of course, I have the usual overwork that everyone complains about.

I now have some night sweats before each period and my periods are less frequent.  In the last six months, the periods occur every eight weeks. I used to sleep a sound seven hours, and now I fall asleep and wake up in the middle of the night.  I am not sure why I wake up, but I have a hard time turning my brain off when I do wake up.  When I wake up in the night, I generally think about never getting back to sleep, being exhausted the next day, and then begin to worry about MENOPAUSE. These symptoms have triggered my fear that I will become like my mother as I become menopausal.  I saw my GP, who did blood tests and an exam, and I have no health problems.  My gynecologist told me that I was too young to have menopause and that these symptoms were nothing to worry about anyway. My girlfriends and I talk all the time about how we will manage menopause. What can I do to prepare for this horrible time so that I don’t ruin my life like my mother did?

Jane

 

Dr. Pat Responds:

Dear Jane:

This is not your mother’s menopause.  You chose early in life to follow a different path from the one your mother chose. However, it can be frightening for women to think about and plan for the menopausal transition when they have had mothers who were such poor role models for the management of this part of life—the beginning of the second half of life.

The menopausal transition is confusing to patients because the language used to describe this often decade-long transition is confusing.  The ovaries produce several hormones, but primarily estrogen and progesterone.  As the ovaries age, there is less predictable production of estrogen and progesterone, with many changes in periods and the development of symptoms that are troubling to many women. Generally, menopause (no periods for a full year) does not happen suddenly. Perimenopause is the time before menopause, and is divided into two stages.

 

1. Early Perimenopause sometimes begins in women in their 30s, but generally begins in your age group:  40 to 45, accompanied by a change in the menstrual cycle and the onset of some symptoms such as hot flashes.

2. Late Perimenopause typically occurs in women in their late 40s or early 50s.  Periods generally become much less frequent, and the symptoms of menopause that each woman may have begin to become more significant.

You are in the early perimenopause stage.  Since each woman is different, and menopause does occur in the early 40s in some women, this is just the right time for you to hone the lifelong skills you have used so successfully thus far to create a personal, marital, parental, and professional life that is different from the template given to you by your mother in order to create a productive menopausal road map that you can follow. Here are some ideas to keep in mind.

1. Fear is useless. This is the time in your life when you can use this period of uncertainty—accompanied by the memories of the poor choices your mother made during her menopausal transition, along with the some very likely unpleasant physiologic and emotional symptoms that may accompany your menopause—as fuel for transformation and reinvention.

2. Menopause is an inevitable and normal physiologic change that occurs in all women who are lucky enough to live this long. It is not a disease. The symptoms can be managed.

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3. Create a new schedule now that gives you some personal time. This is not the time for you to be the perfect wife, the perfect mother, and the perfect friend. Discuss this life stage with your husband and daughters in a positive way.  Remind them that you are going to do all that you need to do for this period of time to avoid your mother’s choices and behavior.  Husbands like yours, supportive life partners with sex as an important component of the relationship, will be grateful to be part of the solution instead of fearing the worst that they have heard from their fathers, their friends, and the media. A frank discussion about making the right choices in the menopausal transition and the belief that management of symptoms is certainly possible is a great life lesson that mothers can give their daughters.  A focus on the positive is so important. Twenty-five years from now your daughters will have the memory of your menopause to guide them through their transition. Explain to your husband and daughters that you will need their help with household management, if you don’t have their help already. Tell them that you will need fewer social responsibilities at times so that you can begin more self-care. Get rid of committees and relationships that take your precious time from you and give little or nothing back.

4. Fix your sleep disorder now.  Use the time freed up from saying NO to find meditation and yoga classes. Daily exercise and small evening meals consumed earlier in the evening are helpful to better sleep. Find a short period of time for evening meditation practice, which will calm your brain before you sleep.  Many people listen to meditation tapes such as those produced by Dharma Seed. Three teachers recommended to us from this organization are Jack Kornfield, Sylvia Boorstein, and Tara Brach.  Tapes can be used before sleep and then again if you wake up, so you can return to sleep instead of engaging in battle with ruminating thoughts. Waking up rested gives everyone a great opportunity to have a more productive day.

5. Stop drinking completely for the next six months. Your mother and brother’s lives were terribly affected by alcohol, and there can be a genetic predisposition to alcohol overuse. In addition, nightly alcohol consumption has become such an expected part of life for women in your demographic that you may not be aware of how much you are drinking.  Ask your husband to support this decision; remember, alcohol overuse is not someone else’s problem . . . but it could be yours. Alcohol affects sleep in many negative ways, causing disrupted sleep and difficulty returning to sleep. In six months you can decide about your relationship with alcohol and develop a more mindful approach to drinking.

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6. Choose to eat mindfully at work. Eat frequently and have small amounts.  Carbs and sugar consumption often affect energy, mood, and concentration.

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7. Create small breaks throughout the day. Find time during lunch to walk outside and be fully present in the joy of this experience.  Take breaks every 30 minutes, if possible, to stretch and breathe deeply for just 2 minutes. Certainly take a breathing and stretching break every hour.  This prevents muscle tension and poor posture and reminds you, even for this short period of time, that you have given yourself the gift of mindfulness.

8. Weight gain is more common as we age, and it often begins in mid-life. The truth is, we need to consume fewer calories and exercise more after 40. Alcohol, processed foods, mindless eating, overeating, excessive nighttime eating, constant socializing where food and drink are the lubricants, all contribute to the problem of middle-age weigh gain.  Some women don’t mind the increase in midlife weight gain or the change in body shape, but weight gain is also a medical problem for many.  Mindfulness and choices that support the goals that are yours will prevent weight gain.

9. As you progress through the years of your menopausal transition there are many therapeutic choices available that you can discuss with a gynecologist who has an interest in the care of women in this life stage.  Each choice you make should be for a specific symptom, and each choice may have side effects that will inform your decision. A complete and current review of options for medical choices available for menopausal management was recently made and written by Dr. Clarisa R. Gracia, in the January 2014 issue of the journal Obstetrics & Gynecology.

Health-care providers must remain current, listen to their patients’ fears and symptoms, and work with patients to create the symptom management necessary for each woman for this period of life when she needs to feel and function at her best.

The interesting thing about menopause management is that the subject is never old, the information never final, and the recruits to this life stage come in day after day, year after year.  Menopause may be old news to women in their 60s and 70s, but to women in their 40s and 50s it is news that is always  “hot off the presses.”

We at www.womensvoicesforchange.org believe that excellent and timely information about health and hormonal change; general templates that can be personalized by each woman for her goals for management of symptoms; and a focus on self care and mindfulness, along with a relationship with a thoughtful and informed health care practitioner, will prevent the old news that menopause defined women in only negative ways.

We know that informed management of the menopausal transition offers women the opportunity to move into the next half of life with awareness of confidence based on  personal strengths and perhaps the planned pursuit of new life goals. We are a community where this message is delivered whenever there is news or whenever someone wants to know “how to get it right”, once again.

Shyness That Cripples: How to Recoup? (Dr. Ford on Emotional Health)

March 13, 2014 by  
Filed under Emotional Wellbeing, Health

Cecilia Ford Ph.DCecilia Ford, who has been a psychologist in private practice in New York City since 1987, has addressed emotional issues for Women’s Voices in many articles over the years. Today she counsels a middle-aged woman whose shyness has crippled her life: She never married or had children, she lives at home with her mother, and she has never held a job.

 

3647045776_e8db7f3dd8When shyness is crippling. (Image by rashmi.ravinray via Flickr)

Dear Dr. Ford:

I am 45 and have not had a period for a year. My doctor did tests and told me that I am, in fact, already in menopause. I cannot believe this. I am not married. I never had children.  I live at home with my mother, and I’ve never worked.

I tried to go away to college, but I had such fears of living in a dorm, fear of being called on in a classroom, and, really, fear of being away from home. My mother is a vivacious 76-year-old widow who has tons of friends, goes out all the time, and has too many interests to mention.  She never made me feel bad about just staying at home with her, gardening, reading, and taking walks. She always told me that I was just different, but that she loved me just the way I was. 

This menopause thing has knocked some sense in to me. I realize that my life is half over now and that I have to find a way to fix my shyness and begin to venture out into the world, on my own, not just in my mother’s company. My mother has discouraged me from talking to anyone about my shyness and fears, because “people in our small town will talk.” I have a small inheritance that is safely invested, and Mother has the bulk of my father’s estate. She has told me that as long as I stay at home, I won’t ever have to worry about working. She never said that if I were to leave, she would leave me out of her will, but I have the feeling that she might. She tells me that she counts on me to be with her now that she is growing older. 

I am so confused, and I think I am angry. Shouldn’t my mother have helped me to recover from this paralyzing shyness and move on into the world when I was younger?  At least I have a computer and am quite good at connecting with the world online.  This is how I know that I am not SO different.  I have found descriptions of people who feel like I have all their lives and yet somehow get out and get a life.

Where do I start?

Julia

 

Dr. Ford Responds:

Dear Julia:

Though you are on the earlier side of average, it is normal for women to begin experiencing the symptoms of menopause (or “perimenopause”) between the ages of 45 and 55. It is also common, if not universal, for a woman facing this transition to feel it as a milestone, if not an outright loss, and to find herself asking questions about what she has accomplished in her life and what she would like to do with the years she has left. The loss of the ability to bear children, even in women who have had them and are clearly satisfied by their “parenting” years, at the very least illuminates the fact that our bodies and our capacities are not eternal. For a woman like you, who now realizes that you have not engaged in the world fully and that things have passed you by, this realization can be devastating.

The worst part of this may be your insight that the life you have led has not been entirely by your choice. It is safe to say that you have been the victim of both nature and nurture: born with innate shyness, you have a mother who, rather than having encouraged you to overcome it so as to develop relationships and work outside the home, instead has enabled you to live like a recluse. While she may have been motivated by empathy for your sensibility and a wish to spare you the pain experienced by many socially avoidant people, there is little doubt that your mother ensnared you as a lifelong companion as a result. What is even worse, you have indicated that you are living with an implied threat that if you leave her, you will be disinherited.

Your road ahead involves overcoming these obstacles, and while they may seem daunting, the fact that you are recognizing this now is a very good sign. I have had the unfortunate experience of helping patients who have been kept completely dependent on their parents, only to be devastated and left helpless when they died. If you start to develop coping skills now, including implementing a plan that includes independence, you can begin to live a more fulfilling life—and a life, thanks to our now extended life span, that can include many healthy decades ahead.

If this were a Hollywood movie, such as the classic Now, Voyager  (1942), in which Bette Davis plays a woman whose mother has purposely kept her at home to be “a comfort to her in her old age,” you would strike out on your own, inheritance be damned. But, unfortunately, the modern world is not a kind place for people without money and who have no job experience. You will have to plan carefully if you want your small inheritance to last, and the ideal strategy would be to enlist your mother’s support and endorsement of your plan. Although at the moment you are quite understandably angry, it will be easier for you to start to move apart from her if the two of you can reach an understanding. If not, she will sabotage and/or penalize you, and the anger and guilt you will experience may undermine your efforts.

The first step is for you to seek guidance from a psychotherapist as soon as you can. If you suspect your mother will object, don’t tell her at first, and use your own money. Besides addressing your obvious need for help in sorting out this emotional entanglement, psychotherapy will give you crucial experience with interacting with, and forming a bond with, an ally besides your mother. The therapist can also help you define and implement your plan. It may be that psychopharmacological intervention will be useful as well. Psychiatrist Peter Kramer has written very poignantly about how small doses of SSRI medication (Prozac and similar drugs) have been able to revolutionize the lives of patients with social anxiety. Finally, the therapy should include, eventually, sessions with your mother, or a referral for you and her to a family therapist so you can untangle your relationship as mindfully as possible.

Take these steps, however, even if you cannot enlist your mother’s approval. My hunch is that she needs you too much to cut you off completely, and even if you move out against her wishes, a rapprochement will still be possible. If you are too afraid to live alone, find a roommate or another family member to live with while you are still working on your long-term goal of independence. Meanwhile, find activity outside the home as soon as you can, especially if it can help you to a job, career, or even an abiding interest. Many women find that employment, far from being just a means to gain financial remuneration (as your mother has implied when she says you “don’t have to work,”) is a key element in their sense of identity, self-worth, and satisfaction.

Psychologists who study mental health and the positive aspects of human development have found that people are happiest and healthiest when they are actively engaged in activities that exercise their abilities and help them grow. Even more important, study after study has revealed that degree of support and interaction with other people is one of the greatest predictors of health of all kinds. Quite possibly you have as many years ahead of you as you do behind you. Fortunately, you can take steps to living a life like this beginning today.

Dr. Cecilia Ford

 

Ask Dr. Pat: Is It “Just Menopause?”

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.

 

 

Menopause and Hysterectomy: Ask Dr. Pat


Dear Dr. Pat,

I am 41 years old and am having a really difficult time. I had a hysterectomy for very early cervical cancer in my mid-30s. My gynecologist agreed to leave my ovaries in, since there was no medical reason to remove them. I don’t know if my symptoms are due to menopause or something else, but I hope you can help me.

I have a demanding job, two teenage children, a long commute every day, and a husband who is out of work and depressed. So for a while I thought my agitation, night sweats, and terrible sleep were all related to this stress. But the lack of sleep—or something—is causing me to be exhausted and is now affecting my ability to concentrate at work. I have to do something. I  called my gynecologist, and she said I was too young for menopause and offered me a prescription for Xanax for anxiety and sleep. She never suggested coming in to check my thyroid or any other tests.

How do I know if I am in menopause or if these symptoms are caused by some other medical or stress problem, since I don’t have periods anymore? I have never had any serious medical problem except the early cervical cancer, and there are no cancers or illnesses in my extended family. Believe me, if I am in menopause I would really like to try hormone therapy to see if it helps my symptoms.

—Phyllis

 

Dear Phyllis,
This is an excellent question. Women who have a hysterectomy while they are still having menstrual cycles do not know when they have entered menopause because the usual “loss of menstrual cycles for one year” does not apply to them. This is a case where the use of blood tests for FSH (follicle stimulating hormone) is absolutely the right thing to do.

When the ovaries age and produce fewer follicles that are healthy enough to respond to normal levels of follicle stimulating hormone, then FSH goes up in response to the low blood levels of estradiol that is produced by developing follicles.  The increased FSH then pushes the ovaries harder and harder to produce a follicle that will become “egg of the month and increase the estrogen level.” Eventually the follicles disappear and the FSH remains high permanently. FSH is useful in your situation because if it is elevated (over 30) two times over a six-week period in combination with your symptoms, then we can establish that you are certainly in a symptomatic late peri-menopausal state or in menopause.

 

You should, of course, have a complete physical exam and testing for thyroid hormone levels along with other causes of fatigue such as low iron and B12 levels, and a CBC—test for red and white blood cells. If these tests are normal and your FSH is elevated twice over a six-week period, then beginning a trial  course of low-dose transdermal estrogen is a very reasonable idea. Ask your doctor to prescribe the lowest dose of transdermal estrogen available (I suggest 14 mcg in a patch form) to start with.
If you find that you are feeling somewhat better but still suffering from disturbed sleep with night sweats, ask the doctor to increase the dose in six weeks to a transdermal patch with 25mcg of estradiol. Almost all women function very well on doses no higher than this. Higher doses of estrogen increase the risks associated with systemic hormone use, and the recommendations for hormone therapy are “to use the lowest effective dose for the shortest period of time.”  I remind patients that the goal of hormone therapy is to improve the quality of life, not take away every symptom.  Since you don’t have a uterus there is no recommendation for the use of progesterone.

It would be a good idea to see a counselor with your husband and children, by the way, when you become less symptomatic and are better rested. You are carrying a very heavy burden with all of the financial responsibilities of the family, worries over teenage children and a husband who cannot find work and is depressed. This is not an uncommon description of the lives of many women today who unexpectedly turn out to be the sole financial support of the family and yet still try to manage the home and children as well. Everyone needs to pitch in, and your husband can find new self-worth by taking on the responsibility of managing teenagers and the house. This is an opportunity, Phyllis, to make life better for everyone in your home.

—Dr. Pat

Estrogen and Cognitive Function: Ask Dr. Pat

Dear Dr. Pat:

I am 48 years old. I had infrequent periods a year ago, along with hot flashes and sweating, but, even worse, I had a kind of brain fog. I am a scientist and could not tolerate my own lack of clear thinking and my inability to get the big picture while integrating all the details—this has always been so important in my work.

I saw a neurologist and had a brain scan and checked for all the usual causes of cognitive impairment; thankfully, nothing was found. I thought, “This is the beginning of dementia.”  I cut out alcohol, began a B12 supplement, and increased my daily exercise. Nothing seemed to help. Then, six months ago, my gynecologist suggested that I start hormone therapy. Believe me, I was ready. She gave me a patch with both estrogen and progestin in it, explaining that the levels of hormones would be stable and absorbed through the skin. Within two weeks, I was my old self again.

Two months later, I began to have vaginal bleeding in an unpredictable way and I developed breast tenderness and enlargement. After a month of heavier bleeding I went back to the gynecologist. She did an ultrasound of the uterus; it showed that the lining of the uterus was quite thick. She did a biopsy of this tissue in the office, and it showed no evidence of either cancer or a precursor to cancer. She then told me that if I wanted to stay on systemic hormone therapy, I needed to have a hysterectomy, since the thickening of the lining of the uterus after such a short time of hormone use was a bad sign.

What should I do?  Right now I cannot function without hormone therapy.

                                                                                                                                                 Phyllis

 

Dear Phyllis:

I am certain that it will be heartening to our readers to understand that even scientists have trouble making decisions about their health, especially when the choices presented to them are difficult.

You have had a common reaction to systemic hormone therapy treatment when it is given to women who are still producing unpredictable amounts of their own ovarian hormones. At this stage, women want to have either predictable light vaginal bleeding on hormone therapy or no bleeding at all. Constant and occasionally heavy bleeding is both unacceptable to the patient and of concern to the gynecologist. However, there are some important points to be made in both the choice of your initial treatment and the current recommendation by your gynecologist that at 48 you have a hysterectomy with only a diagnosis of “heavy bleeding probably caused by too much hormone therapy” and a thickening of the uterine tissue.

Though there has been no loss of bleeding for one year during the time of hormonal change, women who need hormone therapy for significant quality-of-life issues often experience abnormal bleeding.

There are steps to take that may decrease the abnormal bleeding in this group.

First step: Take the smallest dose of estrogen. Prior to treatment there should be a measurement of the endometrium (uterine lining). Treatment should begin with the smallest dose of estrogen, given as a patch, as well as the “standard” dose of progesterone—100mg—given by mouth. Most patients find that the lowest dose (0.14mcg) or the next increase in dose (0.025mcg) of estradiol in the patch will control the symptoms well enough for this symptomatic period of the menopausal transition. The goal is to function with the lowest dose possible.

In your case, however, you were given more than twice as much estradiol in that patch. And your own ovaries were most likely episodically producing an estrogen surge, creating both the breast enlargement and the breast pain, along with the constant and heavy vaginal bleeding that began two months after the initiation of hormone therapy.

Second step: Stop hormone therapy temporarily and get a second opinion. You should stop hormone therapy, then get a second opinion and ask for a D&C and hysteroscopy.

Most gynecologists have been well trained to perform this ambulatory surgical procedure. Hysteroscopy is a trans-vaginal procedure in which the hysteroscope, a small telescope, is inserted into the uterine cavity through the cervical opening. It allows the surgeon to visualize the entire cavity and surgically remove any growth that is there. The procedure is then followed by a gentle and thorough scraping of the endometrial tissue from the uterine cavity. The procedure is diagnostic and often therapeutic also. In other words, there will be clarity about the reasons for the abnormal bleeding, and the removal of the excess endometrial tissue should allow the resumption of systemic hormone therapy at a lower dose without unusual vaginal bleeding.

Third step: If appropriate, resume hormone therapy. If the hysteroscopy and the D&C reveal no abnormal tissue, then you may choose to resume systemic hormone therapy at the lowest possible dose.

Fourth step: Add a short-term higher dose of progesterone. Since you may still be in the phase where there is episodic estrogen production by your own ovaries, adding a short-term higher dose of natural progesterone will prevent the impact of too much estrogen on the uterine lining. If this dose of estrogen allows you to function well enough, do not increase the dose.

Fifth step: Repeat the ultrasound. In six months, repeat the ultrasound measurement of the endometrium. If this is normal, discuss lowering the dose of progesterone or taking the progesterone for only two weeks each month. Progesterone is the part of the hormone therapy that seems to be associated with an increase in breast cancer risk, so it will be important to create a treatment plan where there is less progesterone when the abnormal bleeding is no longer an issue.

Loss of cognitive function as a primary complaint of the menopausal transition is not as frequent as temperature disturbance, insomnia, and fatigue; however it is both disabling and frightening to the patient. I am glad you saw a neurologist for an evaluation of all of the other causes of this serious symptom.

As a scientist, you undoubtedly know that we don’t have the answers yet about the long-term impact of systemic hormone therapy on the cause of dementia.  However, we do have some of the questions:

  1. Does long-term hormone therapy increase the risk of dementia?
  2. Do women who do not use hormone therapy have a greater risk of dementia?
  3. Does the timing of the onset of systemic hormone therapy make a difference in the lifelong risk for dementia?
  4. Is there a treatment protocol for the use of estrogen and progesterone that could improve lifelong cognitive functioning?

Right now, we have increasing rat-brain data and observational data from women followed for decades, but no definitive answers to these important questions. It is unfortunate that women who need relief of menopausal symptoms have to add long-term cognitive function to their list of concerns if they need treatment. Thankfully, the good news is that brain function and hormone therapy are now an area of increasing investigation.


Sex Talk: On Long-Term Relationships and Keeping That Spark Alive

In their final conversation in this round of Sex Talk, Dr. Hilda and Dr. Pat talk about what it takes to keep a long-term relationship—straight or gay—sexually energized, and why it’s worth it. 

Dr. Pat: I have lots of gay couples in my practice, and I think their issues are very similar to the ones that longstanding heterosexual couples have. That all couples have.

Dr. Hilda: They get in a rut like everyone else and need to do something to spice it up.

Dr. Pat: And their relationships get rocky just like all relationships and may end.

Dr. Hilda: They get older, and they have dry vaginas and they have pain and discomfort. So I think most of the topics that we’ve talked about would apply equally whether your partner is male or female.

Dr. Pat: I think when an older gay woman loses her partner through death or the end of the relationship, it must be as hard for her to find a lover as it is for a heterosexaul woman.

Dr. Hilda: The biggest issue I’ve heard from gay women who are aging is something called Bed Death, where they both lose libido. The hormones are going down, their estrogen is going down, the testosterone is going down in both women at the same time, so neither one of them has a libido. Then what do you do? The advice is pretty much the same that I would tell a heterosexual couple: look for something that brings some spice back into the bedroom. Your largest sex organ is your brain, so bring in erotica, for instance, whether it’s something that you read to each other or a video that you watch. It’s something that stimulates the brain.

Dr. Pat: If you have no libido, if neither of you have any libido, how are you going to like get a libido—read the erotica?

Dr. Hilda: You have to force yourself to do it. You have to make it a priority. Otherwise you just go to bed every night, and pretty soon you start to resent each other. So you have to make it a priority.

Dr. Pat: But in a situation like that, you’d also see if there are any health issues, right? Whether an estrogen cream would be useful, for instance

Dr. Hilda: Absolutely. You certainly look for health issues and medications—

Dr. Pat: Depression.

Dr. Hilda: —depression, and all that. Once you rule out all of that, I usually go for the brain. I usually try something like erotica first. I try hormones later, because these days most women don’t really want to go the hormone route unless they have to.

Dr. Pat: But I’m talking about external genital estrogen that is topical. Because when a woman has  a dry clitoris and a dry vagina, it’s is often  unpleasant for her to be touched.

Dr. Hilda: That’s true. I was thinking more on the libido end than the pleasure end, but it is true that if you can increase pleasure, you’re going to increase libido. But usually I tend to separate the two and try to deal with the libido side and then deal with the pleasure side. Because certainly if your vagina and your clitoris are sore because your estrogen is low, you’re not going to want to have sex. So you need to approach the libido-brain connection as well as the physical side—the vulva, the vagina—and make sure those are healthy.

Dr. Pat: Outside the bedroom, if there can be a conscious effort on the part of a couple to do something romantic—something that takes less effort, perhaps, than reading a book aloud. Maybe taking a little weekend sexcation, going for an autumn ride in a Central Park gondola—having a drink, just walking through the park. Taking time for joy.

Dr. Hilda: Or checking into a sleazy hotel.

Dr. Pat: And getting bedbugs. [Laughter]  Don’t laugh!

Dr. Hilda: Pat, you take a sleeping bag!

Dr. Pat: Oh, God. No thank you.

Dr. Hilda: It’s so exciting. It’s so naughty.

Dr. Pat: I’d rather sleep in Central Park.

Dr. Hilda: It’s so naughty.

Dr. Pat: No, bedbugs are not naughty. I will sleep in Central Park before I will sleep in a sleazy hotel.

Dr. Hilda: Well, that’s a thought:  Have sex in Central Park—

Dr. Pat: Right, just next to the gay guys.

Dr. Hilda: —behind the bushes. In the Rambles.

Dr. Pat: Be murdered. Be part of a new crime series.

Dr. Hilda: (laughing) I actually think this is helpful because it recaps a few of the points that we started with in the first conversation. Not sex in The Rambles, but things to look out for when you’re sexually active these days.

Dr. Pat: You’re right. And looking back over the topics we’ve covered, I think part of what’s come through here is women maintaining a sense of themselves as sexual beings throughout the life span. Not just with a partner, and not just as they’re going through menopause, or as a way of coping with menopause, but through the life cycle. And the takeaway is that there’s no real reason for women not to remain orgasmic.

Dr. Hilda: Absolutely. As long as you’re breathing, you should be having sexual pleasure. And it should never end. For women, there’s no reason for it to end.

 





Confirmed: Women Over 50 Want More Sex


There is finally some good news to come out of the famous Women’s Health Initiative, the study that changed menopause management overnight in July 2002. Some of the news reported this weekend from that study is now all over the Internet.

“Patterns and predictors of sexual activity among women in the Hormone Trials of the Women’s Health Initiative” was published in the journal, Menopause in its October issue, just now out.

This current review of the data on sexual activity in the women enrolled in the WHI study confirms an important basic fact: most women who are in decent physical and psychological health, have a reasonable quality of life, are in a partnered or intimate relationship and liked sex before menopause, like sex after menopause. However, the big news is that women who are in sexual relationships reported that their primary complaint was that they weren’t having sex as frequently as they would like. In spite ofrecent reports that have highlighted the high prevalence of hypoactive desire disorder in females”—in other words, women who aren’t interested in sex—“more women in the present study were dissatisfied with their sexual activity because they preferred more rather than less sexual activity.” [italics added]

This most recent evaluation of the incredible WHI database provides information from 27,347 women who were enrolled between 1993 and 1998 at 40 clinical centers across the US. These women—who were between the ages of 50-79 years at the time of their entry into the study—were asked to complete questionnaires on a variety of subjects at the start of the study and again in one year. Three and six years later, a random 8.6% sub-sample of study participants was asked to fill out questionnaires again. The newest evaluation of WHI data “is the first to summarize the responses to all the sexual activity questions in the WHI-HT trials.”

The authors of this report reinforce the knowledge that “previous function and relationship factors are more important than the hormonal determinants of sexual function. The strength of pre-existing sexual activity as a predictor of current sexual activity suggests that women who remain sexually active as they age are able to preserve sexual function despite declining hormone levels at menopause.”

Here at WVFC, we have focused on this issue in many discussions and in answers to readers concerns: The decrease in a partner’s performance or interest, how to improve sexual comfort (which enhances every woman’s interest and pleasure in sex), finding role models for intimacy later in life, and having a positive attitude about sex in long-term relationships.

“Sexual function was not a principal outcome of the WHI study,” the authors report. However, it is important that we know that 60% of women 50-59 were sexually active; that almost 50% of women in their 60s were sexually active and that close to 30% of women in their 70s remain sexually active. Significantly, for many of the women who were not sexually active, the lack of a partner or a partner with illness was the reason most often listed in this study.

We owe a great debt to these scientists and physicians who are continuing to use this information, gathered from this unprecedented number of women followed over time, to help doctors and patients understand who women in this phase of life really are, and how women in this time of life can make choices based on reality, not myth. After all, we ourselves know that menopause does not take your libido away.

We thank the authors of this important review of WHI data:

Gass, Margery L.S. MD, NCMP; Cochrane, Barbara B. PhD, RN; Larson, Joseph C. MS; Manson, JoAnn E. MD, DrPH, NCMP; Barnabei, Vanessa M. MD, PhD, NCMP; Brzyski, Robert G. MD, PhD; Lane, Dorothy S. MD, MPH; LaValleur, June MD; Ockene, Judith K. PhD, MEd, MA; Mouton, Charles P. MD, MS; Barad, David H. MD, MS.

Report From NAMS: Genetic Testing, Mind-Body Connections

September 27, 2011 by  
Filed under Health, Menopause

 

The four-day annual meeting of the North American Menopause Society (NAMS) ended with several sessions that underscored one of NAMS AND WVFC’s most important messages—that menopause is not just about hormones. The final day focused not only on the physical symptoms of menopause, but on more ethereal topics. Thomas H. Murray, Ph.D., director of the Hastings Center, a nonproft research institute concerned with bioethics, presented the Kenneth Kleinman Memorial Endowed Lecture to a packed audience. In his talk, Murray discussed the role of genetic testing and information in healthcare and research—a topic that has generated much discussion and debate in recent years as it has become possible to determine the likelihood of developing many debilitating diseases. Murray pointed out that as the science has progressed, concerns have arisen about the potential violation of the privacy of genetic information and how that information might be used to discriminate against individuals believed to carry genetic risks. He presented a solid and reassuring case for demystifying genetic information, and also underscored that genetic testing  is not as powerful or predictive in most cases as had been feared (or hoped). Which is not to say that it isn’t useful: It can facilitate genetic research and help clinicians provide better counseling for their patients.

The mind-body connection and its impact on health and disease was the focus of a full plenary session in which menopause was discussed in light of healthy living, dealing with addiction, managing time and money, the power of forgiveness, the spiritual connection, the relaxation response, and more—rich topics that will be explored more fully in practical terms in future posts. Until then, you’ll be able to find more information about the meeting ON the NAMS website.

Ask Dr. Pat: Menopause, Diabetes, and Bone Loss

I’m 68 years old and have diabetes, which I’ve been controlling very well with oral medications since I was in my late 40s. When I was 52, I started having terrible perimenopausal symptoms and so my doctor put me on hormone therapy. Eleven years later he had me quit HRT, which I did, but I still have hot flashes and don’t understand why he took me off medication that was working so well for me. I’m also worried about bone loss: I understand that the absence of estrogen increases the risk of osteoporosis even with exercise and calcium supplements. And now calcium is being scrutinized! If I shouldn’t be taking either hormones or calcium supplements, what can I do to prevent osteoporosis? I’ve never broken a bone, used steroids, or been on chemotherapy, and my last bone density value for the hip was a T score of -1.5.

Peg

 

Dear Peg,

The Women’s Health Initiative, a study of 16,000 women between the ages of 50 and 70, began in 1991 to evaluate the hypothesis that hormone therapy was beneficial in preventing heart disease after menopause. Half were given hormone therapy, half were not. The study was halted when emerging data suggested that the risk of hormone therapy for women was greater than the benefit. Now it is generally thought that women who are older and women who have risk factors for cardiovascular and peripheral vascular disease should not use systemic hormone therapy. In your case, even though you don’t have a history of heart disease, your diabetes means that you’re at least twice as likely as someone who does not have diabetes to develop heart disease or suffer from a stroke. That’s why your doctor asked you to stop hormone therapy. In fact, the current thinking is that women who don’t get relief from significant menopausal symptoms with non-hormonal treatment and have no contraindications for systemic hormone therapy are advised to use the lowest dose of hormones for the shortest period of time and that they begin treatment early in the menopausal transition.

It’s great that you’re concerned about your bone health. The idea that calcium supplements would help to protect against bone loss and osteoporosis has never been thoroughly evaluated, because it was generally believed that calcium supplements weren’t harmful. Now large retrospective studies are questioning this assumption; a vast amount of data suggests that calcium might be implicated in an increase in heart attacks. No one yet knows if this is so, or why it might be. One hypothesis is that the calcium in supplements may bond to the soft plaque that narrows the arteries in many people as they age, making these arteries more vulnerable to clots.

Now to your concern that your family history of osteoporosis means you should still be on estrogen and your questions about calcium supplements. The greatest bone loss occurs within three years of hormone loss or stopping hormone therapy. The good news is, you’re now five years away from hormone use, and according to your one bone density measurement you’ve had very moderate osteopenia (bone loss).There is a continuous gradual loss of bone density in most people as they age, however, so a more complete evaluation at this time is a good idea. Here’s what I suggest you do next to protect your bones:

  • Ask your doctor to do blood tests to measure your levels of calcium, vitamin D, and parathyroid and thyroid hormones.
  • Have a repeat bone density test in which your forearm is measured along with your hip and spine. This more comprehensive measurement will allow your doctor to see if you have a special kind of bone loss issue.

If your bone density numbers are all stable at the current level of osteopenia, your blood test results are all normal, and you don’t have a history of kidney stones, there’s no need for further evaluation. You can treat your moderate osteopenia with exercise, 1200 mg of calcium each day (get as much of it from your diet as possible; if you think you aren’t getting enough, talk to your doctor about a 600 mg calcium supplement), and do take 2000 IUs of vitamin D3.

However, if you have had an increase in bone loss, then further evaluation is necessary with a urine test. Urine NTX is a measure of bone turnover. It is measured from the second voided urine specimen of a given day. A low number is reassuring; a high number means that your doctor may suggest a medication to slow bone breakdown.

A 24-hour urine collection to measure calcium excretion is an important test if it turns out you have severe bone loss. If you have an increased loss of calcium in the urine you are not only at risk for kidney stones but the calcium you consume is not available to be incorporated into the bones. There are well-tolerated medications that can prevent this loss of calcium and increase bone density over time

I understand that everyone wants medical information to be true and permanent.  This is understandable. But medical science is ever changing as new information appears, old hypotheses are disproved, and new ones take their place. I hope that this discussion lessens your disappointment with science and medical recommendations for treatment that must change over time as new information is available.  Thank you for reading www.womensvoicesforchange.org, and for sending in your question so that this important conversation could take place.

Dr. Pat

When Hot Flashes Meet the Heat of Summer: Dr. Pat’s Notebook

July 25, 2011 by  
Filed under Health

Photo: D. Sharon Pruitt

What could be worse than hot flashes in this heat? Menopause specialists are besieged these days with women who were just barely functioning in early June and now are finally overcome with the high and humid temperatures throughout much of the United States over the last few weeks.

Patients have lost patience. They don’t want to hear about cold water and cold cloths. They tell me that nothing is working to control the hot flashes and sweats; the flushed face and chest that lasts now for what seems like hours when it used to be just a few seconds. So there is a rush on for medical relief of menopausal symptoms. When the internal temperature button won’t reset properly, women have sleep disruption from these night sweats, daytime fatigue and the consequences of this cascade: irritability, volatility, fuzzy thinking and yes, occasionally, feeling hopeless. It is hard for women who are suffering these symptoms in this weather to integrate the message of “This is just temporary, it will pass.” They want relief now.

I believe that doctors should listen to their patients and help them with symptom management and symptom relief. We need to counsel patients about the risk of short-term use and avoid giving these drugs to women at risk of serious side effects. But the public and many doctors act like low-dose short-term systemic hormone therapy has a risk profile like that of heroin. Time for some balance here, people.

So if you are one of the many women whose doctor has discouraged you from choosing some form of hormone therapy for relief of your symptoms, find a doctor who understands that you need to function for this period of hormonal transition. Gynecologists who have a special interest in menopause can help you choose a low-dose estradiol and progesterone formulation that is approved by the Food and Drug Administration and can help you find the dose and route of delivery that works for you. Avoid “anti-aging” doctors who test your saliva for hormone levels and change your hormone dose based on numbers. Use the lowest dose available at first and recognize that the goal of this systemic delivery of hormones is to make life manageable, not to take away all symptoms.

Then enjoy the return of an internal thermostat that works again and manage the heat wave like everyone else with common sense, lots of water and sports drinks, simple cool foods and clothing that moves and is made from natural fabrics. When the time comes to take a break from hormone therapy, time the process of weaning from the hormones so it happens in the fall, say 18 months from now. The cooler weather will make the transition off hormone therapy easier. Some women need treatment longer, but many can manage after brief hormone therapy.

The Wednesday Five: A Challenge to Health Journos, The Chevy Volt’s Female Engineers, and President Kirsten Gillibrand?

April 27, 2011 by  
Filed under Media, Newsmakers

This week’s blog assortment includes a smart guide to buying work clothes, moving cross-country after 50, the women behind the Chevy Volt and some super-early speculation about the future of Senator Kirsten Gillibrand.

  • Some of us are still puzzling out our spring wardrobes and wondering how they fit into our sometimes quirky lives. That’s why we’re grateful to Lisa Carnochan at Amid Privilege and her Guide to the Perfect Career Wardrobe.  She warns against the usual system of a group of classic pieces: “What you don’t want is to end up where every outfit you own is 80% appropriate for what you have to do. Starting with a list of pieces puts you at risk for that outcome,” she writes. Instead, she suggests  the “use case” approach used in software design, attending to the cultural context the clothes will be worn in. Her sample outfit for a team meeting, she says, broadcasts “I am reliable, approachable, and flexible. Also, I come bearing free food.” By doing so, the question of what do I wear? will, she writes, be “Fully solved. Not 80% solved.” Click over to see her examples of best-dressed in Bangkok and Idaho, with pictures and witty commentary.
  • Health reporter Liz Scherer, who has long provided smart commentary at Flashfree, calls out the shortcomings in media coverage of our health in this Reporting Health Q&A. ”I don’t believe that most reporters have the time to thoroughly vet and understand their stories because there is a constant race to be the first out of the gate. (Covering) menopause is no different than any other science reporting; if you don’t take the time to thoroughly understand the issue, your reporting is always going to be lacking something. When it comes to menopause, the real story is how women’s health has been approached and ill-treated for decades, if not centuries.”  In the interview, Scherer also gives inside information on ghostwriting in medical journals and some tips on how to contend with the constantly-changing flow of information.
  • Electric cars are the wave of the future, they say. So where are the women? In the engineering hot seat, writes Katherine Rausch at Women’s Enews.  Rausch profiles Britta Gross, director of Global Energy Systems and Infrastructure Commercialization for General Motors, who with four other women helped create the Chevy Volt, an electric car with extended range capability. But the field, Gross tells Bausch, needs even more women: ”I think the only barrier, given you are strong and capable, is getting women past the word engineering. … It sounds stale and not very exciting and I can’t imagine anything more exciting than my career.”
  • President Kirsten Gillibrand? Why not? asks commentator David Mixner, an old friend and ally of former President Bill Clinton, looking for a 2016 contender. “Born into politics, she understand the in and outs of campaigning and is brilliant at the game. Gillibrand is an incredible campaigner, charismatic speaker and a born leader,” writes Mixner, who spoke to WVFC  last year about women and Don’t Ask, Don’t Tell.  We’re not surprised to hear the next part, which we’d guessed would be true from the moment we first interviewed then-Rep. Gillibrand in 2007: “Fear doesn’t seem to be a part of her character as she has challenged some of the most powerful men in Washington to get the job done.” It’s a little early to start handicapping a race five years from now, but we’re certainly looking forward to hearing more.
  • The phrase “moving in midlife” sounds scary to some, perhaps exciting to others. Ronnie Bennett writes at Times Go By about moving long distances  twice in the past year, after she left Greenwich Village after more than 40 years: “Except for missing New York which has become something I just live with, I’m happy with this last move. And maybe I’m not the one to answer since the first move to Maine was a financial necessity and the second one to Oregon was a spiritual necessity. I think there would be different considerations without those imperatives.” Bennett then asks her readers, inspiring us to ask you: “If you are contemplating a move to a new place, how do you feel about it? How are you choosing the new town or city? And, of course, why are you moving?”

Menopause and Excess Body Weight: Ask Dr Pat

Dear Dr. Pat,

I am 58 years old, 5’2” tall, and I weigh 170 pounds. My doctor tells me that I am pre-diabetic and has warned me that I am increasing my risk for heart disease, stroke and cancer because of my weight. I am still having my periods, and they are a bit longer and heavier than they used to be: 8 days and a 8 pads on the heavy days. I miss an occasional period here and there. None of my girlfriends still have their periods at this age, but I figured that I was just hormonally younger than them. I have never had any female problems. There is no gynecologist in my county anymore. My doctor told me that I need to go to the regional medical center to find out why I am still having my periods. That’s a big trip and a big expense for me. Do I really need to go?

Ruth

Dear Ruth,

It is hard for doctors and patients these days in rural America. Costs are fixed, new government regulations have allowed big insurance companies to lower their payments to doctors and hospitals, and there’s been a decrease in Medicaid payments to individual doctors and hospitals. Doctors in high-malpractice categories like obstetrics and gynecology can no longer afford to practice in these areas. It is heartbreaking to hear stories like yours of no obstetrical or gynecologic care without a long drive to a bigger county. And with the costs of travel on the rise, this will only decrease access to basic care.

Your local doctor has given you very good advice on two matters: weight loss and the need to see a gynecologist. Overweight women do have an increase in diabetes, high blood pressure, coronary artery disease, stroke and other vascular diseases. In addition, women who are overweight in the late menopausal transition and after menopause have a real increase in endometrial cancer. Epidemiologic data has found a two-to-fivefold increase in the risk of developing endometrial cancer among obese pre-menopausal and post-menopausal women. In clinical studies, obesity has in fact been associated with at least 40% of endometrial cancer cases.

In an overweight woman, menopause may be delayed, and periods may become heavier and longer because estrogen levels are still high even after the ovaries no longer produce appropriate levels of progesterone. (The high level of estrogen in overweight women is partly the work of fat cells, which turn adrenal hormones into estrogenalong with other hormonal changes that also increase the active form of estrogen.) This hormonal imbalance, with high estrogen and low progesterone, creates an environment in the body that can cause an increase in endometrial hyperplasia and often endometrial cancer.

The most pressing issue for you is to have a clinical exam by a gynocologist, and then a sonogram of your pelvic organs. The gynecologist will then make a decision based on your age and your history—including the delayed menopause, and your long and heavy bleeding—and the information we have about obesity and endometrial cancer. It is likely that you will have an endometrial biopsy, then further surgery based on what is found in that sample.

Then, Ruth, it is time to address the underlying cause of so many health problems that you are beginning to develop: your weight.

Obesity is the major cause of so many preventable illnesses in America. Now that we have less access to health care, each of us must do our part to decrease our risk for developing the diseases that are related to being overweight. Not only are Americans now forced to deal with austerity measures in the provision of basic services, we must all do the hard things that will keep us out of the doctor’s office and out of the hospital.

Life change is always hard, but you have been given two very powerful reasons to get started. So, begin a gentle daily exercise plan, cut out the foods you know you should not eat, control your portion sizes, and eat more frequent small meals.

There is no way out now, Ruth. Just start.

Best,

Dr. Pat

Hysterectomy Update: Think Twice About Those Ovaries

You’re having a hysterectomy. Should your ovaries be removed, too?

Until quite recently, women over the age of 40 to 45 were routinely recommended to have their healthy ovaries removed at the time of hysterectomy. The common wisdom was, “Just take them out, what do you need them for anyway?”

Well, we now know our ovaries produce meaningful hormones for us both before and after menopause. So why remove ovaries?

The only reason to remove normal, healthy ovaries is for the prevention of ovarian cancer and for hormonal ablation (ridding a woman’s body of estrogen). For most healthy women who are facing a hysterectomy or other pelvic surgery in which a bilateral oophorectomy (removal of both ovaries) is being entertained, a thorough discussion with the surgeon should be undertaken in which the risks, benefits, and alternatives to surgical options are reviewed.

In the not-too-distant past, women whose ovaries were routinely removed at the time of hysterectomy were also recommended to use hormone replacement therapy to control menopausal symptoms and prevent cardiac disease. But this was in the days before the Women’s Health Initiative Study. This study not only raised significant safety issues concerning the use of post-menopausal estrogen, but also raised issues concerning the ability of estrogen to protect against cardiac disease.

In 2009, the routine removal of ovaries could no longer be recommended. A sentinel study was published that demonstrated that removal of the ovaries can increase the risk of cardiac disease and death long term.

It is important to remember that cardiac disease is still the leading cause of death in women—not cancer. Each year 14,700 women will die from ovarian cancer, but heart disease causes 327,000 deaths a year—more than 20 times the ovarian cancer death rate. This study of 30,000 women found that in women whose ovaries were removed, the risk of long term death overall increased by 12%, the risk of heart disease increased by 17%, and the risk of lung cancer increased by 26%. These adverse effects of bilateral oophorectomy are presumably due to the lack of estrogens and androgens that are produced by the ovary, even after menopause.

It’s true that the risk of ovarian cancer and breast cancer is decreased if women remove their ovaries. But for most healthy women who are not at elevated risk for breast or ovarian cancer, the risks of routinely removing the ovaries may outweigh the benefit. Any woman who is considering having her ovaries removed should thoroughly review with her physician and surgeon her individual risk for developing breast and ovarian cancer. The evaluation of risks and benefits of removal of the ovaries should include a discussion of cardiac risk and elevated risk for death overall of the ovaries are removed. Women who have a genetic predisposition to ovarian cancer or breast cancer, a family history of breast or ovarian cancer, or a personal history of breast cancer will need to carefully consider bilateral oophorectomy.

Alzheimer’s Alert: Pour Yourself a Glass of Wine, Hop on the Treadmill, and Read This Book

Jean Carper has written a timely book of advice about Alzheimer’s disease for the lay person—and WVFC regular Roz Warren has written a witty account of her experiences with it, which we know you’ll enjoy. But after conversation with neurologists who specialize in Alzheimer’s research and treatment, I want to offer a few caveats.

Most of the information that Carper cites comes from association studies, not causality studies, so the findings have not been rigorously proven. Recent research on the use of medical marijuana does not support its ability to decrease the risk of Alzheimer’s. Nor is the nicotine patch a well-established method of decreasing risk. Many of the food and wine suggestions are based on the assumption that antioxidants decrease the risk of Alzheimer’s. Again, that has yet to be definitively proven. In terms of wine, it has to be red wine, not white or rosé. And we can’t say with certainty how much wine is safe for women to drink—certainly no more than one 4-ounce glass a day.

On the other hand, Carper’s book does outline many changes in health and lifestyle habits that could decrease the risk of this terrible disease, and would in any case contribute to a healthier lifestyle in general.

So by all means, pour yourself a glass of (red) wine and see what Roz has to say about Carper’s book.  —Patricia Yarberry  Allen, M.D.

Like most women, I don’t know if I’m going to get Alzheimer’s. Like all women, I know that I don’t want to. Which is why I picked up medical journalist Jean Carper’s latest book, 100 Simple Things You Can Do To Prevent Alzheimer’s and Age-Related Memory Loss ($19.99, Little, Brown & Company).

Doing simple things is something I’m good at. And while I’m usually skeptical about advice givers, Carper is reassuringly credentialed. She’s written 23 health-related books and penned USA Weekend’s “Eat Smart” column for 14 years. Besides which, she’s got a personal reason to get this one right—the book’s dedication notes that she and two sisters share the ApoE4 susceptibility gene. (“Know About The ApoE4 Gene” is one of the things she recommends we do.)

100 Simple Things is a grab-bag of advice to follow if you want to stop the Big A in its tracks, from the predictable (“Eat Antioxidant-Rich Foods”) to the unexpected (“Consider Medical Marijuana”). (I’d be glad to! But first they’ve got to legalize it.)  Each recommendation is presented in a concise chapter, which includes scientific data to back it up.

The book is packed with fascinating and potentially useful facts, such as:

  • How long you are able to balance on one leg is a predictor of how likely you are the develop Alzheimer’s.
  • Women who drink only wine—no other type of alcoholic beverage—are 70 percent less apt to develop dementia.
  • Some people with Alzheimer’s temporarily become more lucid after taking antibiotics.

I began reading the book on the treadmill, which took care of items 99 (“Walk. Walk. Walk.”) and 37 (“Enjoy Exercise”). How difficult could it be to cover all 100? I decided to try to incorporate as many of Carper’s suggestions into my life as possible.

Some were easy. For instance, “Beware of Being Underweight.” Being underweight isn’t something most menopausal women need to fret about. Then there are “Google Something,” “Be Conscientious,” and “Say Yes to Coffee”—those three things pretty much describe my life in a nutshell.

Working in a public library, I’ve got “Have An Interesting Job” covered. But that makes it a challenge to “Avoid Stress.” The next time a patron hollers at me for refusing to waive his fines, I’m going to say, “What are you trying to do, pal? Give me Alzheimer’s?”

“Get a Good Nights Sleep?” No problem. Sleeping is something else at which I excel.  But my sweet tooth is going to make “Cut Down On Sugar” difficult. Luckily, there’s “Treat Yourself to Chocolate.” (Cocoa increases blood flow to the brain.)

Thankfully, some of the advice just doesn’t apply to me: “Think About a Nicotine Patch.” “Overcome Depression.” “Get Help For Obstructive Sleep Apnea.” And there are other things I just won’t do, however useful they may be: “Play Video Games.” “Put Vinegar On Everything.” “Embrace Marriage.” (Been there, done that. Never again. )

Some advice is more easy to give than to follow. “Try to Keep Infections Away”? Good luck with that when you deal with the public all day. (Many of whom think nothing of sneezing on their library card, then handing it to me.)

It’s no surprise that much of Carper’s advice is about food and nutrition. “Eat Berries.” “Eat Curry.” (Not together, thankfully). “Drink Apple Juice.” “Drink Wine.” “Eat Fatty Fish.” “Go Nuts Over Nuts.” “Don’t Forget Your Spinach.” I thought about preparing one gigantic meal with all the recommended foodstuffs, but came up against “Count Calories.” Not to mention “Worry About Middle-Aged Obesity.”

It was fun to see how many of the non-food items I could combine. For instance, I was able to “Be Easygoing and Upbeat,” “Keep Mentally Active,” “Beware of Omega-6 Fats” and “Drink Tea” all at the same time.

But I’m afraid that “Be An Extrovert” will forever be beyond my capacity.

Most items, like “Beware of Bad Fats,” make sense at first glance. Others are more mysterious.  What does “Have Your Eyes Checked” have to do with preventing Alzheimer’s? Read the book and find out! If you do, you can cross one recommendation—“Find Good Information”—off the list.

Sex Talk: Women, Body Image, and the Bedroom

In this installment of the ongoing conversation, Dr. Pat and Dr. Hilda talk about feeling sexy, attitudes that can get in the way, and how to get past them.

Dr. Pat: Hilda, you asked some interesting questions about women who don’t like their bodies or body parts as they age. And one of them is about a woman who has large breasts. Those breasts are perhaps no longer as perky as they once were, and she feels uncomfortable because she has large, pendulous, sagging breasts. And a question is, how can a woman feel better about herself so that she will feel sexier? Because when we’re constantly judging how we look in the act of lovemaking, it certainly will impede the capacity to have an orgasm, and it certainly would have a big impact on libido.

I think the answer to that is that, we live in a time when there is absolutely fabulous lingerie that’s fun for any woman to wear, fun for her to have on in bed. And they make wonderful lingerie for the full-busted woman. I think that’s a great way of turning what she is feeling ashamed of into an asset.

Dr. Hilda: Certainly, bras now not only lift, but separate [laughter] pendulous breasts, and they’re beautiful. So you can find bras for a full-breasted woman that are absolutely gorgeous, and  that she can feel confident and comfortable in when she goes to bed with her partner. And I often tell my patients to put on sexy negligees with the bras built in them—

Dr. Pat: Yes, they’re wonderful.

Dr. Hilda: —and wear that to bed. If that makes her feel sexy, then that’s something she should do. The other thing I tell them is that when a man gets to that point where he has you in bed, he’s not worried about your sagging breasts, your midriff bulge, or the dimples in your thighs. Men have a way of focusing on—

Dr. Pat: What’s to come.

Dr. Hilda: [laughter] —what’s to come.

Dr. Pat: And when I’ve talked to men about this issue, they say that they don’t really focus on parts. They focus on the totality of the experience. They’re interested in a woman sexually not just for how she looks by any means, but, you know, is she a lot of fun? Does she have a great personality?

Dr. Hilda: And does she like sex. [laughter]

Dr. Pat: Does she like sex!

Dr. Hilda: Exactly. Enjoying sex is the most important thing.

Dr. Pat: Many women focus on the change in their skin, the muscle loss, the less taut abdomen and begin to resist going to bed naked, resist making love with the lights on, and worry that they will not be seen by their partners as sexually desirable. The partner, one assumes, is in the same age range and is very likely to have a paunch, less hair on the head, and visual changes to his genital tissue as well.  Men get droopy down there as they age too, you know.

I suggest that women be realistic about some bodily change and create an action plan for changing what can be changed. Start an exercise program if you are not in one. Focus on toning and developing aerobic endurance exercise, as long as there are no contraindications to a more vigorous exercise program. Start slow and build on this. It is well known that exercise improves the blood flow to the brain, the skin, and all those other parts. Feeling in charge of one’s own body is itself invigorating. And always remember that sexy lingerie makes most women feel good, and most men are delighted that their partner made the effort to “dress for the occasion.”

Dr. Hilda: I think one of the things that things that makes women feel uncomfortable with their bodies is their worries or concerns about how other people view them—how men view them, how their partners view them. And that’s why I spend time trying to convince them that he’s not so worried about your breasts, so you can just push that out of your mind. If that affects how you see yourself, then let’s try to deal with that issue. And then you also need to work on how you view yourself and why you see yourself in a negative way.

Dr. Pat: But you know, there’s a limit. As gynecologists who are interested in sex therapy, there’s a limit to what we can do or should do. I’m not a relationship expert. I’m not a psychologist. So I do discuss the basics. I try to provide information and cheerleading. But if the issue is unresolved unhappiness about body change as a woman is growing older—

Dr. Hilda: You certainly can give tips, right?

Dr. Pat: Oh, many tips.

Dr. Hilda: One is lingerie . . .

Dr. Pat: Right.

Dr. Hilda: Another is choosing positions. If your breasts are your biggest concern, and you’re worried about how your breasts look, then you might not do the woman-on-top position because that gives a fuller view of your breasts. Or if you are going to do woman-on-top, you’re going to keep your little nightie—a little see-through teddy with a formed bra inside—on when you’re on top, if that position makes you uncomfortable and you can’t get that out of your head.

Dr. Pat: And also there’s the side entry, where the man and woman, usually from the rear—

Dr. Hilda: Yes, from the rear. Rear-entry positions might make you feel a little bit more comfortable.

Dr. Pat: And men like that because they get to hold and caress the breasts.

Dr. Hilda: Exactly. So you might choose positions in which you feel that you’re not being exposed as much. It’s little tricks that people can do to make themselves . . .

Dr. Pat: Information from older friends who have remained sexual is so empowering. Patients who are still very sexual in their 60s, 70s and 80s have made it a priority. They also learned to get past the change in their bodies. But the truth is many of these women do work hard at looking sexy, acting sexy, and staying sexy. Ignorance about how you might feel about body change is a bad choice. Ignorance about how the body changes in each life stage is avoidable. You know, it’s like when I found out about having my first period. Believe me, it was a shock because nobody told me what to expect. I was absolutely appalled. There is nothing about menopause that appalled me nearly as much [laughter] as growing up in the South and having—

Dr. Hilda: [laughing, nodding] —in the South and having nobody tell you …

Dr. Pat: —nobody tell you anything about what’s to come. So at some point, you just have to make peace with it, and have some common sense. I mean, when so many people we know lose their breasts completely because of breast cancer or disease, the fact that somebody has healthy breasts is already a plus. You know, looking at the positive, if you have generally good health and you have someone with whom you might share your sexual self, these are already fabulous gifts.

Dr. Hilda: But I think it goes beyond breasts for most women. Breasts are one part. But I see women who worry that their belly’s not as flat as it used to be. They’ve got stretch marks because they’ve had kids. Or now they’ve got fat on their hips that they didn’t have when they were 18. Or they’re 20 pounds heavier than they would like to be. They don’t look like the models in the catalogues. They’re overweight.

Dr. Pat: But may we point out that their husbands don’t, either.

Dr. Hilda: Well, most of them—

Dr. Pat: You know, men age as well.

Dr. Hilda: Most women just don’t think about that, though. [Laughs]  They really don’t. They don’t think about the fact that he doesn’t look the way he looked 20 years ago, either. And he’s not usually focusing on his quote-unquote “imperfections” in the same way that we do. We’re a lot more critical of our bodies and how we look and less accepting of aging. Men don’t spend a billion dollars on Botox and fillers in the same way that—

Dr. Pat: Some do.  [Laughs]

Dr. Hilda: Well, a few. But most of them don’t do that, or hair pieces, or any of the things that we do. But most of my patients don’t think about that part of the equation.

Dr. Pat: But I do bring that up. I say, “Excuse me. Does he look just the way he did?”

Dr. Hilda: Well, certainly we do that. We bring that up when we’re talking to our patients. But they don’t usually think about it. And there are so many issues. We’re very, very hard on ourselves. The whole issue of weight. Now, I’m a woman who’s overweight but I don’t feel that I’m not sexy. I feel very sexy. Yes, I’d like to be 20 pounds lighter than I am right now. But I feel that I’m sexy, and I don’t hide in the bedroom.

Dr. Pat: And you don’t hide in clothes.

Dr. Hilda: No. And I talk to my patients about that. Just because you don’t fit that stereotypical mold that we have in this country about what is beautiful, it doesn’t mean that you’re not sexy. And that has to do with how you feel inside. And so you have to change those messages that you’ve received from whatever—the media, or wherever you’ve received them. You have to change them into positive ones and find the things that make you feel good about yourself.

In the next Sex Talk: Stretching and fitness for the post-menopausal vagina.