Depression and Perimenopause: Treatment Can Lift Your Mood

Image by ericalaspada via Flickr (Creative Commons License)

Today on Medical Monday, Dr. Megan Riddle provides a thoughtful discussion of depression and the menopausal transition that will be helpful for women who need more than just lifestyle change, meditation, exercise, or even hormone therapy for control of depression. There is a well described association between menopausal hormonal change and depression. However, it is important that the distinction between a low mood and depression be made so that every woman with significant symptoms can find treatment for this period of life that is right for her. Fortunately most women who go through perimenopause do not suffer from depression according to many published reports, although the combination of hot flashes, night sweats and resulting sleep deprivation can cause daytime fatigue and decreased mood in many women resulting in a serious decline in quality of life. Women who have these symptoms, collectively known as menopausal syndrome, may benefit from temporary use of hormone therapy if other non hormonal therapies do not control these symptoms and if there is no medical contraindication to the use of this form of treatment. Dr. Patricia Yarberry Allen, Publisher

 

Dear Dr. Pat,

I’m 48 years old and beginning to go through menopause. I haven’t had a period for nine months now.  I can put up with the hot flashes, but my mood has really taken a turn for the worse. I tend to be a glass-half-full type person, but lately everything has felt overwhelming. Some days, I don’t want to get out of bed. At work, I am having trouble concentrating, but that may be in part because I am so tired. I wake up at about 4 a.m. every morning and can’t fall back to sleep. This has all been going on for about six months. My kids are off to college at this point and my husband and I had made plans about how we would be spending this time, but, really, I’m not looking forward to anything. Before this, I was doing really well, both physically and mentally. I did experience similar symptoms after the birth of both of my children, but each time it resolved after a month or so and I did not seek treatment. Now, though, I think I may need to do something more to deal with all this. Is this common for women of my age? Any suggestions?

Thanks,
Cynthia

 

Dear Cynthia,

We have asked Dr. Megan Riddle to respond to  your concerns and offer diagnostic steps and therapeutic options that you may want to discuss with your health care team. You have already made a valuable first step: you have asked for information and for help. We are here for you.

Dr. Pat

 

RELATED: Age at Menopause and Depression

 

Dear Cynthia,

I am so sorry you are going through such a difficult time. Many of the symptoms you describe – low mood, trouble sleeping, being unable to concentrate, a loss of interest in things you used to enjoy – are consistent with depression. I would encourage you to see your primary care doctor or a psychiatrist for further evaluation. For over a century, we have identified an association between menopause and depressed mood and research suggests that up to 1 in 5 women experience depression at some point during menopause. A study released by the Centers for Disease Control and Prevention showed that you are in a particularly high-risk age group – women between the ages of 40 and 59 had the highest rates of depression of those surveyed.  Many suffering from depression don’t seek the help they deserve. Only about 1 in 5 individuals with moderate depression report seeing a mental health professional in the past year.

There may be a number of factors that contribute to the onset of depression during perimenopause. Hormonal changes occurring during this time – namely a decrease in estrogen and resulting spikes in the release of follicle-stimulating hormone (FSH) – likely play a role.  Estrogen modulates the effects of many neurotransmitters in the brain, including serotonin, dopamine, and norepinephrine, thus impacting our emotional responses to life’s experiences.  

Those who have experienced depressed mood at other periods of hormonal fluctuation – during and after pregnancy, when on contraceptives or at certain points of their menstrual cycle – are particularly susceptible to experiencing depression during the menopausal transition. In addition to the hormonal changes, the resulting symptoms may contribute to depression as hot flashes and night sweats lead to trouble with sleep and result in fatigue and irritability. Finally, various psychosocial stressors can contribute to the onset of depression in this age.   

RELATED: Menopause Is Not a Disease (Ask Dr. Pat)

Reinvention at 45, Part II (Ask Dr. Pat)

Dr. Patricia Yarberry Allen, publisher of Women’s Voices for Change, posts a column 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.

 

Last week, Dr. Pat created a “Lesson Plan” for Caren, a 45-year-old sixth-grade teacher who is beginning menopause, with “irregular cycles and really heavy periods and rare hot flashes.” Caren noted that she is 30 pounds overweight and beginning to have blood pressure problems, though she takes no medication. She acknowledged that she has a “wonderful marriage,” with an appreciative husband, but she is worried about her lack of stamina and her weight gain. Most of all, though, she dreads becoming “really fat, nasty-tempered, and depressed with menopause,” like some of her fellow teachers.

Dr. Pat’s Lesson Plan for Caren comprises six steps. Step One addresses the issue of Caren’s reported “very heavy bleeding.” Step Two recommends getting medical clearance for a weight loss and exercise program. Step Three details the basics of a sensible exercise plan, including advice on where to find videos and individual exercises and stretches that one can do at home, in addition to structured workouts. You will find these steps detailed in last week’s column.
 
Below are Steps 4 to 6 of Dr. Pat’s Lesson Plan for a Smooth Menopausal Transition.

4. Reaching your goal requires the same rules whether you choose to go back to a class for weight loss or do it alone: Re-frame the issues that cause you to choose the wrong foods, eat at the wrong times, and overeat.  You can see a weight-loss specialist or nutritionist, you can join a weight-loss group such as Weight Watchers, or choose an online weight loss program (see “Selecting a Weight Loss Programon the National Heart, Lung and Blood Institute’s website).

RELATED: “Medical Monday: Weight Loss Medications

If your weight loss program is working, then you should lose one pound a week. The most important thing about diets is that most diets fail, and they all fail for the same reason—diets are for life, not just for the period when weight loss occurs.

When you return to teaching in the fall, you can control what to eat for energy between classes; just prepare and bring to school small portions of food that won’t affect your energy in a seesaw fashion.  Protein and vegetables, apples and cottage cheese are great snacks to keep energy steady.

Food at work is for fuel, not fun.  Take a walk and eat your lunch at the same time, to avoid the temptation of being around the other teachers, who may be relishing food that you should not eat.   When you reach your weight loss goal, it will be helpful to continue to keep a journal that helps you be aware of your food choices.  When you choose to have a fabulous meal, control the portions and go back to stricter food control for a week.  Weight loss is a national obsession in this country where obesity is epidemic. Obesity is the root cause of many diseases and disorders, and has spawned a multi-billion-dollar industry, recently joined by Oprah!  Your choice to lose weight may be the most important choice you make in terms of lifelong health.

Next page: Managing menopause Read More »

Reinvention at 45 (Ask Dr. Pat)

Dr. Patricia Yarberry Allen, publisher of Women’s Voices for Change, posts a column 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 had children right out of college.  I am 45 and my youngest child is off to college in the fall.  I am an English teacher at our local public middle school. I am beginning menopause now, with irregular cycles and really heavy periods and rare hot flashes.  I am 30 pounds overweight, like many of the teachers in my school, and starting to have problems with blood pressure, but I take no medications and am otherwise fine. I eat protein bars in between classes in order to have enough energy to get through teaching 25 rowdy sixth-grade students, hour after hour.

I manage the house and meals with a little help from my daughter and husband; then I have to work creating lesson plans and grading tests and essays. I eat at night to keep going.  I rarely drink alcohol, and my sleep is still good.  I have a wonderful marriage and a great husband who appreciates my contribution to the family finances. I know that I have much to be grateful for.  I have two months off this summer and plan to focus on getting in shape—for once—and I don’t want menopause to derail my plans.  So many of my older colleagues at school became really fat, nasty-tempered, and depressed with menopause.  I don’t want that to happen to me.   Where do I start?

Caren

 

Dr. Pat Responds:

Dear Caren,

Menopause is never old news, because there is a new freshman class entering this life stage every year.  Women are now bombarded about the symptoms and the options for management.  However, much of this is information overload, as well as information that may have as its purpose the sale of medicines and products, marketed to your demographic in a way that often leads to more anxiety.

Here is a lesson plan for your summer of reinvention, based on your goals, age, current lifestyle, health issues, and your interest in managing the symptoms of the often decade-long menopausal transition in a positive way.

Dr. Pat’s Lesson Plan

  1. See your gynecologist for evaluation of the “very heavy bleeding.” Once you are reassured by appropriate evaluation that there is no reason for surgical evaluation or operative treatment of the heavy bleeding (see our previous Ask Dr. Pat post, “Is Endometrial Cancer Common?”),  discuss the use of a progesterone-coated IUD) for management of this problem.  This form of IUD delivers a low level of progesterone directly to the endometrial lining, which often becomes thickened during the peri-menopause when the ovaries produce too much estrogen and not enough progesterone.  The progesterone IUDs are an excellent contraceptive option for women over 40 and often provide control of the common problem of heavy bleeding during part of the menopausal transition. (See “A Peri-Menopausal Flood). Untreated heavy menstrual bleeding can lead to iron deficiency, which causes anemia, fatigue, and even hair loss.  Untreated heavy menstrual bleeding can even lead to hysterectomies that would often not be needed if this problem had been managed in an early and proactive way. Read More »

A Healthier, More Satisfying Second Half of Life: Bone Health

January 18, 2016 by  
Filed under Health

This is the eighth in our series (40 Things for Every Woman in Her 40s) of Medical Monday articles intended to be useful to all our readers, but pointed especially toward those in their 40s—that in-between decade in which hormonal change has begun but fertility is still possible. Our first article focused on self-care; our second emphasized the need to pay attention to psychological issues; the third provided tips on preventing and repairing skin damage; the fourth focused on “exercise as medicine”; the fifth topic was on sexual intimacy. In the sixth, Dr. Megan Riddle wrote about actions to reduce stress and improve mood. Most recently, in the seventh of the series, Dr. Patricia Yarberry Allen focused attention on the brain and offered four key strategies to protect and improve cognitive function. 

This week the focus is on musculoskeletal health from Dr. Sonal Parr and Dr. James Wyss. —Ed.

 

37.

Bone Health Begins at 40
By Dr. Sonal Parr (read bio on our Medical Advisory Board)

Untitled

The median age for menopause is 51. At this time the loss of estrogen accelerates bone loss. The greatest bone loss occurs is in the first 5 years after menopause. This is what every woman in her 40s should do to optimize lifelong bone health.

1. Know your risk for osteoporosis. 

  1. Family history of osteoporosis, osteopenia, hip or wrist fractures, or other metabolic bone disease.
  2. Personal history of past fractures.
  3. Autoimmune or inflammatory diseases, like ulcerative colitis, Crohn’s, celiac disease, rheumatoid arthritis are associated with accelerated bone loss. 
  4. Nutritional: A diet of excessive animal protein (especially in the absence of adequate plant-based food) or processed foods can increase the risk for bone loss.  
  5. Metabolic: Hyperthyroidism, disordered eating, some kidney and liver diseases.
  6. Medications, including steroid use, chemotherapy, aromatase inhibitors, like femara and arimidex; proton-pump inhibitors, like Nexium or Prilosec; some anti-depressants; overuse of thyroid hormone; and some diabetes drugs, like Avandia and Actos.  
  7. Having a slight build or low body weight—especially if Caucasian or Asian.
  8. Inactive lifestyle
  9. Excessive alcohol consumption (more than two drinks a day).
  10. Tobacco use either current or former smokers (though current smokers have a significantly higher risk than former smokers). READ MORE

Next Page: How you can affect future bone health.

Age at Menopause and Depression

January 14, 2016 by  
Filed under Health, Menopause

Image by ericalaspada via Flickr (Creative Commons License)

Every woman who has experienced the changes in mood that can come with monthly menstrual cycles knows that varying levels of hormones can strongly influence our moods. For some, certain times in the cycle have us feeling resilient, while at other times, tears come far too easily. Similarly, pregnancy and childbirth with their dramatic hormonal changes are vulnerable periods for the development of mental health issues, like peripartum depression. And, the hormonal changes of menopause can have significant effects on a woman’s mental health. Now, a recent study published in one of the country’s leading psychiatric journals shows that the age of menopause affects a woman’s risk for depression as she ages.

RELATED: Menopause Is Not A Disease

Analyzing data from 14 previous studies of more than 65,000 women, researchers found that an older age of menopause was associated with a decreased risk of developing depression later in life, with women undergoing menopause at a younger age at higher risk. Overall, they found that a two year increase in the age of menopause was correlated with a two percent decreased risk of developing depression. While the finding was significant from a statistical standpoint, it may be somewhat less important in actual clinical practice, as a two percent change in risk over two years is relatively small. However, the risk appears to be greatest for those who undergo menopause prior to 40 years of age, as they were at about double the risk of those who went through menopause later in life. Of interest, these effects were not significantly changed when the use of hormone therapy was taken into account; previous studies have shown that while hormone therapy may improve perimenopausal depression, it has little impact on post-menopausal depression. READ MORE

Dr. Pat Consults: Treatment Options for Anxiety

November 16, 2015 by  
Filed under Dr. Pat Consults, Health

1191298435_0b95af8b7c_zImage by Ehsan Khakbaz via Flickr. Creative Commons License

 

Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly Medical Monday” column for Women’s Voices for Change.  (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)

This week, Dr. Pat has asked Megan Riddle, M.D./Ph.D.— a psychiatry resident at the University of Washington and a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional M.D.-Ph.D. Program—to address a woman riddled with anxiety, which she likens to a gnawing feeling of dread.

 

Dear Dr. Pat:

I can’t seem to stop worrying.  I feel like I am anxious much of the time.  Sometimes I can pin it on certain things — like needing to give a presentation at work or dealing with my ex-husband — but most of the time it is just there, this gnawing feeling of dread. I find myself getting headaches fairly often, and went to my primary care doctor, but he couldn’t find anything wrong and said it was probably stress. While I can get through my day and do what I need to do, I find myself just not going out and doing things because it makes the anxiety worse.  I am 52 years old and had only two periods in the last year. So, I was wondering whether this might be part of menopause. Looking back, though, this isn’t new. I’ve always been a pretty Type A personality, worrying about getting things right and being somewhat of a perfectionist. That served me well and I’ve been very successful in my career. I am just tired of feeling this way all the time, and I think things are somewhat more stressful at work, which makes the anxiety  much worse. Or maybe I’m just less able to tolerate it. When I was at my last check-up with my doctor, I mentioned it to him and he offered to write me a prescription for lorazepam, but I turned it down because I don’t want to be on anything that could be addictive. What should I do? I feel like I need to do something to relieve all this tension I’m feeling, but really don’t want to just start popping pills. Any advice?

Thanks,
Helen

 

Dr. Riddle Responds:

Dear Helen,

It seems like this is something you have been managing on your own for quite a while and I am glad you are seeking help as it sounds quite miserable to be dealing with that much anxiety all the time.

Anxiety can come in many flavors. For some, it takes the form of excessive worry or irritability while for others the symptoms are predominately physical with headaches, tight shoulder muscles and stomach aches. Anxiety can run the spectrum from actually helpful — at low levels, giving you that extra edge to do your best under pressure — to completely debilitating. You describe that, in the past, anxiety has been a component of your perfectionism and it is not uncommon for people with high levels of perfectionism to also have elevated levels of anxiety. When we try to distinguish between what makes one person perpetually anxious while another is laid back, there appears to be a combination of genetic and environmental factors, including the way you were raised and life experiences.  People who are anxious have been shown to have increased levels of activity in the amygdala, the fear center of the brain.  Studies have also shown that a higher number of traumatic life events is associated with elevated levels of anxiety.

Up to one in ten individuals are thought to meet criteria for a diagnosis of generalized anxiety disorder (GAD) at some point in their lifetime. Having GAD consists of having excessive, difficult to manage worry that causes problems in a person’s life and occurs on most days, lasting for at least six months. GAD is twice as common in women as in men and it is often is not an isolated condition, but is rather an addition to other issues, such as depression, post-traumatic stress disorder, drug and alcohol abuse, or panic disorder.

Anxiety does more than just make you feel miserable and limit your daily activities — it can also have very real effects on your physical health. Anxiety has been shown to worsen heart disease, for example.

You ask specifically whether your anxiety might be related to menopause. Given higher rates of anxiety in women, there has long been a proposal that hormones may be playing a significant role. Some studies in fact have shown that, while pre-menopausal women develop anxiety disorders at higher rates than men, this actually equalizes after menopause. During the menopausal transition, the jury is out as to whether rates of anxiety are higher.  Some studies have shown that those with lower levels of anxiety may experience a slight uptick in symptoms, with those with higher levels noting no change.  In contrast, other researchers have found no such connection between anxiety and the menopausal transition, or even lower than average levels.  The bottom line? Individual results may vary. Given what you describe, being anxious for much of your life, menopause may be a piece of the puzzle, but is less likely to be the primary cause of your current experience.

Next Page: Treatment Options

Ask Dr. Pat: Is hormone replacement therapy dangerous?

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.

5406671749_d48271664cImage from Flickr via

Dear Dr. Pat

I am fifty years old and an adjunct instructor at a small college in the northwest where I work part time. I used to love my work.  I am married with two late-in-life middle school children and am in menopausal hell. I have unpredictable hot flashes and night sweats.  I lose my focus when teaching or counseling a student.  I expend enormous energy managing my moods. I find that I need two glasses of wine most nights just to get through dinner. I can’t believe that I am trapped with young children, a no longer rewarding job, and a good enough marriage to a man who is thoughtful and a good provider but who has expectations of behavior that I am having trouble living up to.

I could ruin my professional life, my personal life, my marriage and my daughter’s lives if I don’t get my menopause under control. I don’t care about vaginal dryness and bone loss.  I need to function. 

I saw my holistic nurse practitioner (NP) twice in the last three months.  She did all the right blood tests and told me that everything was normal and that I was in late peri-menopause. All she offered me  was “life style change”—better nutrition, more exercise, meditation, and of course, vaginal estrogen for the genital atrophy. My NP is about forty and is staunchly opposed to hormone use.  I never thought I would be one of those women who needed to take estrogen but I don’t see how I am going to get through this without something.  I don’t have any personal or family  history of cancer or heart disease.  Is hormone replacement as dangerous as I have heard that it is? And don’t tell me to see a shrink.  I don’t have the time.

Ruth
Dear Ruth,

Women who had fulfilling  professional and personal lives first, then had children later in life, often find themselves in the menopausal transition with demands for the care of younger children, personal relationships, and work that leaves no time for self care. Something has to give, Ruth.
  
First, you should see another health care professional who will listen to your symptoms of menopausal syndrome and the narrative of your day-to-day existence. Find someone who will work with you to design a plan for evaluation and treatment of your symptoms.

Low dose estradiol and progesterone are a reasonable choice for someone with your significant symptoms.  You are clearly aware that there are some risks associated with hormone therapy but use of low dose preparations for a limited period of time is appropriate. Hormone therapy should decrease the hot flashes which may help with sleep. Improved sleep may lead to improvement in cognitive ability and mood swings.  If hormone therapy does not control the mood swings and the negative way of  looking at your life, then you will need further evaluation of this mood disorder.

The NP you saw was right in recommending exercise, thoughtful eating to control blood sugar, and meditation to improve sleep and concentration.  In addition, I strongly encourage you to stop all alcohol for the next six months.  Alcohol won’t fix your moods and it may impede cognitive function and  make sleep worse. 
.
Hormone therapy  and some small life style changes may not work if you can’t make real adjustments in the rest of your life. You describe everything in your life, at this point, in a negative way, Ruth. I do encourage you to see a therapist for help in creating a more manageable life.  Your work is part time and at this point you describe it as not rewarding.  Perhaps this is an area of your life that where you can find more time.

Each generation of women who enter the menopausal transition faces its unique challenges.  The women in Gail Sheehy’s The Silent Passage were the women who were given estrogen whether they had symptoms or not. The pharmaceutical industry and doctors added to the shame that surrounded the word menopause by promoting the use of drugs to keep women “forever young.” Women of your generation, Ruth, understand that medical management of menopause is a choice but not a necessity. The good news, then and now, is that most women have mild manageable symptoms that are temporary.  Patients who have significant symptoms do best with an individualized approach with reassurance that this transition is normal and transitory.  

 

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.