Menopause

The following summarizes what menopause means, and how I have approached its treatment in my practice using an integrative model.

 

MENOPAUSE: SYMPTOMS AND SOLUTIONS, USING A "PYRAMID" APPROACH

SYMPTOMS

Why they happen: as we age, the first change to the menstrual cycle is loss of ovulation (and progesterone). Next come  fluctuating  estrogen levels (lowest at menses), and eventually both estrogen and progesterone go low and stay there. The whole process takes several years, almost never less than two and sometimes six or seven.

What: hot flushes, night sweats, poor sleep, irritability, joint aches, heart palpitations, sadness, anxiety, memory and word loss, irregular and sometimes heavy periods, vaginal dryness, loss of libido, weight gain around the midsection, etc, etc

When: can start at age 40 or even before; typically late 40s to early 50s

SOLUTIONS: I recommed a "pyramid" approach, working upwards from foundational health measures to more targeted products and therapies.

1.      Lifestyle

Diet (fresh organic whole foods; quality protein, lots of produce, some whole grains, nuts and healthy oils; limit refined carbs…think South Beach, Mediterranean, or Whole 30)

Exercise (toning and strengthening the core and limbs; aerobic, stretching, balance)

Stress management (sleep, recreation [play and fun], meditation or spiritual practice, support system, saying “no”, setting boundaries, self care and self appreciation)

2.      Supplements (basic)

Multivitamin (food based, high potency, capsule better than tablet)

Calcium with magnesium and vitamin D (preferably not calcium carbonate; liquid or gelcap best absorbed)

Fish oil (second choice: flaxseed oil) for omega-3 fat source; enteric coated if necessary; 1000 mg or more daily.  Hard to overdo!

Probiotics (healthy bacteria): yogurt or kefir, Good Belly or Kombucha drinks, pill form (Visbiome is a good brand)

3.      Helpful herbs (here are a few of the most popular)

Black cohosh (hot flashes): 80 mg daily; may take 8 weeks for full effect

Valerian (sleep): no set dose; tincture or tablets better than tea

Licorice (adrenal support, energy): can’t use this if you have high blood pressure

Dong quai (Chinese herb): “chi builder” to help with energy; may worsen hot flashes

Vitex/chastetree berry (boosts body’s own progesterone): can help with PMS and cycle regulation; takes awhile (up to 6 months)

Soy (best as food rather than pill; fermented forms like tofu, miso and tempeh are best; sometimes helps with hot flashes; probably does NOT affect breast cells to any significant degree)

4.      Alternative therapies

Acupuncture: helpful at least 50% of time; plan 6 to 8 visits; cost $60-80 each

Homeopathy: can be good for those extremely sensitive to medicines or herbs

Energy work (Reiki, healing touch, etc): especially for mood issues and general fatigue

5.      Hormone replacement therapy (see next section!)

HORMONE REPLACEMENT THERAPY

Terms: bioidentical (though made in a sterile lab, the end result is identical to the chemical compound your body makes), synthetic (generally used to mean NOT bioidentical), commercial (made by pharmaceutical companies), compounded (custom made to order), “natural” (means different things to different people)

Types: transdermal (patches, creams, gels, lotions, spray), transvaginal (cream, tablet, suppository, ring), sublingual (tablet or “troche”), oral (pills), injection

 Risk data:

1.      Use of at least one type of hormone replacement (brand name Prempro) for over 5 years  results in a small increase in breast cancer.

       This data is based on a good quality controlled trial (the Women's Health Initiative, or WHI); it used a pill form of HRT called Prempro. In the group of 10,000 women that took this combined estrogen and progestin (NON bioidentical) pill, there were 8 more breast cancers than expected in the last year of the study. So this type of HRT appeared to confer an additional breast cancer risk of 8 per 10,000 per year. The World Health Organization considers any health risk of less than 10 per 10,000 per year to be "rare". Interestingly, the group of women in this study that used only the Premarin (estrogen derived from mares' urine) portion of the HRT, because they were post hysterectomy, had NO increased risk of breast cancer when followed up to 7 years.

2.      Use of Prempro which is begun more than ten years after menopause, OR at over age 60, leads to higher stroke and heart attack risk, BUT use of HRT within ten years of menopause lowers cardiovascular risk. Route of estrogen use is bound to be important as well, as transdermal (patch and gel forms) may confer lower risk for clotting. The recent "KEEPS" trial confirmed that in healthy women just entering menopause, HRT caused no increase in any cardiac risk factor nor in any type of cardiovascular disease after 4 years of use. Some types of HRT helped decrease insulin resistance, a precursor to diabetes.

3.      Poor quality evidence suggests increase in Alzheimer’s disease if HRT is begun more than ten years after menopause; newer study data suggests protective effect if begun earlier and used for longer. The KEEPS trial showed no effect of HRT on memory in newly menopausal women after 4 years of use.

 

Benefits:

1.      Bone protection (from osteoporosis and related risk of hip and spine fractures)…well established

2.      Lower risk of colon cancer

3.      Heart disease protection (above)

4.      Skin, joint, urinary and vaginal health

5.      Improved libido and sexual satisfaction

6.      Better quality sleep

7.      Relief of hot flushes/night sweats

8.      Improved short term memory, cognition and mood

Bottom line: use of HRT is a personal choice between risks (or fear thereof) and quality of life; many women compromise by using HRT to get through the worst of symptoms, for a limited time.  Most sources would agree there is little risk to use lasting less than five years.  Many of my patients have chosen to continue their HRT use indefinitely, because of the profound improvement in their quality of life. Others do fine without using any HRT.

IMPORTANT: It is important to realize that all of the above information applies to SYSTEMIC (whole body dose) HRT. There is another type of HRT, which is used for vaginal/vulvar/urinary health and comfort. Most of these products are some form of bioidentical estrogen, while some contain the hormone DHEA or a synthetic estrogen. There are vaginal creams, tablets, and suppositories. All are very low dose, and because of the tiny dose, they confer NO increased risk of breast cancer, endometrial cancer, heart attack or stroke. Many women feel just fine after menopause, except that their vaginal and/or urinary tissues have become dry and sensitive, leading to (for example) painful intercourse or frequent urinary infections. These women can use a low dose vaginal estrogen product, usually with complete resolution of their symptoms, and with minimal medical risk.

 

SUMMARY

Work your way up the pyramid.  Hormones are at the top, and many women never need to go there.  Excellent self care (mental, emotional, spiritual as well as physical) is your best bet to move smoothly through this important life change.

 

Many traditions believe the time of life after menopause brings special gifts of wisdom and freedom.  What gifts will you discover?