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What Is Menopause?
I wasn't sure what to expect with menopause, although I certainly looked
forward to not having my period anymore. I have to admit, I'm concerned
about how my body will change. My mother never talked about menopause.
She says her mother never did either, probably because then it was
linked to old age and poor health. Now, you hear about it all the time.
The "baby boom "generation is making menopause a big issue because of
their sheer numbers, and because they'll live with it much longer than
their grandmothers did. Back then, menopause did come near the end of
life. Now I'm going through it, but I feel like I still have my whole
life ahead of me.
More than one third of the women in the United States, about 36 million,
have been through menopause. With a life expectancy of about 81 years, a
50 year old woman can expect to live more than one-third of her life
after menopause. Scientific research is just beginning to address some
of the unanswered questions about these years and about the poorly
understood biology of menopause.
Menopause is the point in a woman's life when menstruation stops
permanently, signifying the end of her ability to have children. Known
as the "change of life," menopause is the last stage of a gradual
biological process in which the ovaries reduce their production of
female sex hormones--a process which begins about 3 to 5 years before
the final menstrual period. This transitional phase is called the
climacteric, or perimenopause. Menopause is considered complete when a
woman has been without periods for 1 year. On average, this occurs at
about age 50. But like the beginning of menstruation in adolescence,
timing varies from person to person. Cigarette smokers tend to reach
menopause earlier than nonsmokers.
How Does It Happen?
The ovaries contain structures called follicles that hold the egg cells.
You are born with about 500,000 egg cells and by puberty there are about
75,000 left. Only about 400 to 500 ever mature fully to be released
during the menstrual cycle. The rest degenerate over the years. During
the reproductive years, a gland in the brain generates hormones that
cause a new egg to be released from its follicle each month. The
follicle then produces the sex hormones estrogen and progesterone, which
thicken the lining of the uterus. This enriched lining is prepared to
receive and nourish a fertilized egg which could develop into a baby. If
fertilization does not occur, estrogen and progesterone levels drop, the
lining of the uterus breaks down, and menstruation occurs.
For unknown reasons, the ovaries begin to decline in hormone production
during the mid-thirties. In the late forties, the process accelerates
and hormones fluctuate more, causing irregular menstrual cycles and
unpredictable episodes of heavy bleeding. By the early to mid-fifties,
periods finally end altogether. However, estrogen production does not
completely stop. The ovaries decrease their output significantly, but
still may produce a small amount. Also, some estrogen is produced in fat
cells with help from the adrenal glands (near the kidney).
Progesterone, the other female hormone, works during the second half of
the menstrual cycle to create a lining in the uterus as a viable home
for an egg, and to shed the lining if the egg is not fertilized. If you
skip a period, your body may not be making enough progesterone to break
down the uterine lining. However, your estrogen levels may remain high
even though you are not menstruating.
At menopause, hormone levels don't always decline uniformly. They
alternately rise and fall again. Changing ovarian hormone levels affect
the other glands in the body, which together make up the endocrine
system. The endocrine system controls growth, metabolism and
reproduction. This system must constantly readjust itself to work
effectively. Ovarian hormones also affect all other tissues, including
the breasts, vagina, bones, blood vessels, gastrointestinal tract,
urinary tract, and skin.
Premenopausal women who have both their ovaries removed surgically
experience an abrupt menopause. They may be hit harder by menopausal
symptoms than are those who experience it naturally. Their hot flashes
may be more severe, more frequent, and last longer. They may have a
greater risk of heart disease and osteoporosis, and may be more likely
to become depressed. The reasons for this are unknown. When only one
ovary is removed, menopause usually occurs naturally. When the uterus is
removed (hysterectomy) and the ovaries remain, menstrual periods stop
but other menopausal symptoms (if any) usually occur at the same age
that they would naturally. However, some women who have a hysterectomy
may experience menopausal symptoms at a younger age, possibly due to a
decreased blood supply to the ovaries as a result of surgery.
I had hot flashes, but they were fairly mild. Sometimes at night I'd
suddenly start to sweat and have to throw all my covers off. But they
never lasted long and I could usually get right back to sleep. During
the day I noticed they tended to come whenever I had a big derision to
make or when I felt a little tense. But they only lasted about 2 years.
I feel blessed. I've had no other problems.
What to Expect
Menopause is an individualized experience. Some women notice little
difference in their bodies or moods, while others find the change
extremely bothersome and disruptive. Estrogen and progesterone affect
virtually all tissues in the body, but everyone is influenced by them
Hot flashes, or flushes, are the most common symptom of menopause,
affecting more than 60 percent of menopausal women in the U.S. A hot
flash is a sudden sensation of intense heat in the upper part or all of
the body. The face and neck may become flushed, with red blotches
appearing on the chest, back, and arms. This is often followed by
profuse sweating and then cold shivering as body temperature readjusts.
A hot flash can last a few moments or 30 minutes or longer.
Hot flashes occur sporadically and often start several years before
other signs of menopause. They gradually decline in frequency and
intensity as you age. Eighty percent of all women with hot flashes have
them for 2 years or less, while a small percentage have them for more
than 5 years. Hot flashes can happen at any time. They can be as mild as
a light blush, or severe enough to wake you from a deep sleep. Some
women even develop insomnia. Others have experienced that caffeine,
alcohol, hot drinks, spicy foods, and stressful or frightening events
can sometimes trigger a hot flash. However, avoiding these triggers will
not necessarily prevent all episodes.
Hot flashes appear to be a direct result of decreasing estrogen levels.
If there is no estrogen, your glands release other hormones that dilate
blood vessels and destabilize body temperature. Hormone therapy relieves
the discomfort of hot flashes in most cases. Some women claim that
vitamin E offers minor relief, although there has never been a study to
confirm it. Aside from hormone therapy, which is not for everyone, here
are some suggestions for coping with hot flashes:
* Dress in layers so you can remove them at the first sign of a
* Drink a glass of cold water or juice at the onset of a flash.
* At night keep a thermos of ice water or an ice pack by your bed.
* Use cotton sheets, lingerie and clothing to let your skin
Vaginal/Urinary Tract Changes
With advancing age, the walls of the vagina become thinner, dryer, less
elastic and more vulnerable to infection. These changes can make sexual
intercourse uncomfortable or painful. Most women find it helpful to
lubricate the vagina. Water-soluble lubricants are preferable, as they
help reduce the chance of infection. Try to avoid petroleum jelly; many
women are allergic, and it damages condoms. Be sure to see your
gynecologist if problems persist.
Tissues in the urinary tract also change with age, sometimes leaving
women more susceptible to involuntary loss of urine (incontinence),
particularly if certain chronic illnesses or urinary infections are also
present. Exercise, coughing, laughing, lifting heavy objects or similar
movements that put pressure on the bladder may cause small amounts of
urine to leak. Lack of regular physical exercise may contribute to this
condition. It's important to know, however, that incontinence is not a
normal part of aging, to be masked by using adult diapers. Rather, it is
usually a treatable condition that warrants medical evaluation. Recent
research has shown that bladder training is a simple and effective
treatment for most cases of incontinence and is less expensive and safer
than medication or surgery.
Within 4 or 5 years after the final menstrual period, there is an
increased chance of vaginal and urinary tract infections. If symptoms
such as painful or overly frequent urination occur, consult your doctor.
Infections are easily treated with antibiotics, but often tend to recur.
To help prevent these infections, urinate before and after intercourse,
be sure your bladder is not full for long periods, drink plenty of
fluids, and keep your genital area clean. Douching is not thought to be
effective in preventing infection.
Menopause and Mental Health
A popular myth pictures the menopausal woman shifting from raging, angry
moods into depressive, doleful slumps with no apparent reason or
warning. However, a study by psychologists at the University of
Pittsburgh suggests that menopause does not cause unpredictable mood
swings, depression, or even stress in most women.
In fact, it may even improve mental health for some. This gives further
support to the idea that menopause is not necessarily a negative
experience. The Pittsburgh study looked at three different groups of
women: menstruating, menopausal with no treatment, and menopausal on
hormone therapy. The study showed that the menopausal women suffered no
more anxiety, depression, anger, nervousness or feelings of stress than
the group of menstruating women in the same age range. In addition,
although more hot flashes were reported by the menopausal women not
taking hormones, surprisingly they had better overall mental health than
the other two groups. The women taking hormones worried more about their
bodies and were somewhat more depressed.
However, this could be caused by the hormones themselves. It's also
possible that women who voluntarily take hormones tend to be more
conscious of their bodies in the first place. The researchers caution
that their study includes only healthy women, so results may apply only
to them. Other studies show that women already taking hormones who are
experiencing mood or behavioral problems sometimes respond well to a
change in dosage or type of estrogen.
Studies indicate that women of childbearing age, particularly those with
young children at home, tend to report more emotional problems than
women of other ages.
The Pittsburgh findings are supported by a New England Research
Institute study which found that menopausal women were no more depressed
than the general population: about 10 percent are occasionally depressed
and 5 percent are persistently depressed. The exception is women who
undergo surgical menopause. Their depression rate is reportedly double
that of women who have a natural menopause.
Studies also have indicated that many cases of depression relate more to
life stresses or "mid-life crises" than to menopause. Such stresses
include: an alteration in family roles, as when your children are grown
and move out of the house, no longer "needing" mom; a changing social
support network, which may happen after a divorce if you no longer
socialize with friends you met through your husband; interpersonal
losses, as when a parent, spouse or other close relative dies; and your
own aging and the beginning of physical illness. People have very
different responses to stress and crisis. Your best friend's response
may be negative, leaving her open to emotional distress and depression,
while yours is positive, resulting in achievement of your goals. For
many women, this stage of life can actually be a period of enormous
What About Sex?
For some women, but by no means all, menopause brings a decrease in
sexual activity. Reduced hormone levels cause subtle changes in the
genital tissues and are thought to be linked also to a decline in sexual
interest. Lower estrogen levels decrease the blood supply to the vagina
and the nerves and glands surrounding it. This makes delicate tissues
thinner, drier, and less able to produce secretions to comfortably
lubricate before and during intercourse. Avoiding sex is not necessary,
however. Estrogen creams and oral estrogen can restore secretions and
tissue elasticity. Water-soluble lubricants can also help.
While changes in hormone production are cited as the major reason for
changes in sexual behavior, many other interpersonal, psychological, and
cultural factors can come into play. For instance, a Swedish study found
that many women use menopause as an excuse to stop sex completely after
years of disinterest. Many physicians, however, question if declining
interest is the cause or the result of less frequent intercourse.
Some women actually feel liberated after menopause and report an
increased interest in sex. They feel relieved that the children are out
of the house and pregnancy is no longer a worry.
For women in perimenopause, birth control is a confusing issue. Doctors
advise all women who have menstruated, even if irregularly, within the
past year to continue using birth control. Unfortunately, contraceptive
options are limited. Hormone-based oral and implantable contraceptives
are risky in older women who smoke. Only a few brands of IUD are on the
market. The other options are barrier methods -- diaphragms, condoms,
and sponges -- or methods requiring surgery such as tubal ligation for
women, and vasectomy for the male partner.
Is My Partner Still Interested?
Some men go through their own set of doubts in middle age. They too,
often report a decline in sexual activity after age 50. It may take more
time to reach ejaculation, or they may not be able to reach it at all.
Many fear they will fail sexually as they get older. Remember, at any
age sexual problems can arise if there are doubts about performance. If
both partners are well informed about normal genital changes, each can
be more understanding and make allowances rather than unmeetable
demands. Open, candid communication between partners is important to
ensure a successful sex life well into your seventies and eighties.
For most women, natural menopause is not a major crisis and does not
influence their opinion of their general health.
In a society that places so much value on youth and beauty, it's not
much fun to think about menopause. But when you get there, you find it
doesn't really make that much difference; you concentrate on how you
feel about yourself, not on how you think others see you. I continue
trying to improve myself, to keep learning and keep active. It's not
your age that counts, it's how you handle it.
Long-Term Effects Of Estrogen Deficiency
One of the most important health issues for middle-aged women is the
threat of osteoporosis. It is a condition in which bones become thin,
fragile, and highly prone to fracture. Numerous studies over the past 10
years have linked estrogen insufficiency to this gradual, yet
debilitating disease. In fact, osteoporosis is more closely related to
menopause than to a woman's chronological age.
Bones are not inert. They are made up of healthy, living tissue which
continuously performs two processes: breakdown and formation of new bone
tissue. The two are closely linked. If breakdown exceeds formation, bone
tissue is lost and bones become thin and brittle. Gradually and without
discomfort, bone loss leads to a weakened skeleton incapable of
supporting normal daily activities.
Each year about 500,000 American women will fracture a vertebrae, the
bones that make up the spine, and about 300,000 will fracture a hip.
Nationwide, treatment for osteoporotic fractures costs up to $10 billion
per year, with hip fractures the most expensive. Vertebral fractures
lead to curvature of the spine, loss of height, and pain. A severe hip
fracture is painful and recovery may involve a long period of bed rest.
Between 12 and 20 percent of those who suffer a hip fracture do not
survive the 6 months after the fracture. At least half of those who do
survive require help in performing daily living activities, and 15 to 25
percent will need to enter a long-term care facility. Older patients are
rarely given the chance for full rehabilitation after a fall. However,
with adequate time and care provided in rehabilitation, many people can
regain their independence and return to their previous activities.
For osteoporosis, researchers believe that an ounce of prevention is
worth a pound of cure. The condition of an older woman's skeleton
depends on two things: the peak amount of bone attained before menopause
and the rate of the bone loss thereafter. Hereditary factors are
important in determining peak bone mass. For instance, studies show that
black women attain a greater spinal mass and therefore have fewer
osteoporotic fractures than white women. Other factors that help
increase bone mass include adequate intake of dietary calcium and
vitamin D, exposure to sunlight, and physical exercise. These elements
also help slow the rate of bone loss. Certain other physiological
stresses can quicken bone loss, such as pregnancy, nursing, and
immobility. The biggest culprit in the process of bone loss is estrogen
deficiency. Bone loss quickens during perimenopause, the transitional
phase when estrogen levels drop significantly.
Doctors believe the best strategy for osteoporosis is prevention because
currently available treatments only halt bone loss -- they don't rebuild
the bone. However, researchers are hopeful that in the future, bone loss
will be reversible. Building up your reserves of bone before you start
to lose it during perimenopause helps bank against future losses. The
most effective therapy against osteoporosis available today for
postmenopausal women is estrogen (see p. 19). Remarkably, estrogen saves
more bone tissue than even very large daily doses of calcium. Estrogen
is not a panacea, however. While it is a boon for the bones, it also
affects all other tissues and organs in the body, and not always
positively. Its impact on the other areas of the body must be
Most people picture an older, overweight man when they think of a likely
candidate for cardiovascular disease (CVD). But men are only half the
story. Heart disease is the number one killer of American women and is
responsible for half of all the deaths of women over age 50. Ironically,
in past years women were rarely included in clinical heart studies, but
finally physicians have realized that it is as much a woman's disease as
CVDs are disorders of the heart and circulatory system. They include
thickening of the arteries (atherosclerosis) that serve the heart and
limbs, high blood pressure, angina, and stroke. For reasons unknown,
estrogen helps protect women against CVD during the childbearing years.
This is true even when they have the same risk factors as men, including
smoking, high blood cholesterol levels, and a family history of heart
disease. But the protection is temporary. After menopause, the incidence
of CVD increases, with each passing year posing a greater risk. The good
news, though, is that CVD can be prevented or at least reduced by early
recognition, lifestyle changes and, many physicians believe, hormone
Menopause brings changes in the level of fats in a woman's blood. These
fats, called lipids, are used as a source of fuel for all cells. The
amount of lipids per unit of blood determines a person's cholesterol
count. There are two components of cholesterol: high density lipoprotein
(HDL) cholesterol, which is associated with a beneficial, cleansing
effect in the bloodstream, and low density lipoprotein (LDL)
cholesterol, which encourages fat to accumulate on the walls of arteries
and eventually clog them. To remember the difference, think of the H in
HDL as the healthy cholesterol, and the L in LDL as lethal. LDL
cholesterol appears to increase while HDL decreases in postmenopausal
women as a direct result of estrogen deficiency. Elevated LDL and total
cholesterol can lead to stroke, heart attack, and death.
I started taking estrogen for my hot flashes. They went away
immediately. I've felt no side effects, which I'm thankful for. I don't
think I'll stay on it forever, though -- no one seems to know how long
it's safe! My mother has never taken hormones and she's in great shape
at 87. I hope I'm as lucky!
Hormone Replacement Therapy
To combat the symptoms associated with falling estrogen levels, doctors
have turned to hormone replacement therapy (HRT). HRT is the
administration of the female hormones estrogen and progesterone.
Estrogen replacement therapy (ERT) refers to administration of estrogen
alone. The hormones are usually given in pill form, though sometimes
skin patches and vaginal creams (just estrogen) are used. ERT is thought
to help prevent the devastating effects of heart disease and
osteoporosis, conditions that are often difficult and expensive to treat
once they appear. The cardiovascular effects of progesterone, however,
are yet unknown. Hormone treatment for menopause is still quite
controversial. Its long-term safety and efficacy remain matters of great
concern. There is not enough existing data for physicians to suggest
that HRT is the right choice for all women. Several large studies are
currently attempting to resolve the questions, though it will take
several more years to reach any definitive answers.
In the 1940's when estrogen was first offered to menopausal women, it
was given alone and in high doses. Today, after 50 years of trial and
error, it is well known that estrogen stimulates growth of the inner
lining of the uterus (endometrium) that sheds during menstruation. This
growth may continue uncontrollably, resulting in cancer. Today, doctors
typically prescribe a lower dose of estrogen. However, few doctors still
prescribe estrogen alone to women who have a uterus. Most now prefer to
add a synthetic form of progesterone called progestin to counteract
estrogen's dangerous effect on the uterus. Progestin reduces the risk of
cancer by causing monthly shedding of the endometrium. The obvious
drawback to this approach is that menopausal women resume monthly
bleeding. Once menopause arrives, most women enjoy the freedom of life
without a period. Many are reluctant to begin their cycles again. In
addition, there are other unpleasant side effects of progestin which
often discourage women from continuing HRT. These include breast
tenderness, bloating, abdominal cramping, anxiety, irritability, and
Only about 15 percent of women who are eligible for hormone replacement
therapy are now receiving it. This leaves 85 percent who either do not
want or need it, or do not know about it.
The good news is that researchers are evaluating different schedules of
low-dose estrogen and progestin to completely eliminate monthly
bleeding. Currently most women receive what is called cyclic HRT. They
may take estrogen continually and progestin for the first 12 days of
each month. The use of a continuous combined dose, where estrogen and
smaller amounts of progestin are taken every day is also being studied.
In theory, this use of progestin stems endometrial growth so no bleeding
will occur. Unfortunately, it may take 6 months or more until bleeding
finally stops. In many cases, monthly bleeding has been replaced by more
bothersome irregular bleeding patterns. Obviously, further research is
needed to evaluate and perfect this treatment. Various types of
progestins in different dosages, preparations, and schedules are being
studied in hopes of reducing its other unpleasant side effects while
retaining the known advantages of estrogen.
Estrogen and Your Bones
Estrogen therapy is the most successful method of combatting
osteoporosis. As previously discussed, estrogen halts bone loss but
cannot necessarily rebuild bone. Long-term estrogen use (10 or more
years) may be required to prevent postmenopausal bone loss. Why estrogen
helps protect the skeleton is still unclear. We do know that estrogen
helps bones absorb the calcium they need to stay strong. It also helps
conserve the calcium stored in the bones by encouraging other cells to
use dietary calcium more efficiently. For instance, muscles require
calcium to contract. If there is not enough calcium circulating in the
blood for muscles to use, calcium is "borrowed" from the bone. Calcium
is also needed for blood clotting, sending nerve impulses, and secreting
various hormones. Prolonged borrowing from bone calcium for these
processes speeds bone loss. That's why it's important to consume
adequate amounts of calcium in your diet.
Estrogen's Effect on Your Heart
The majority of past clinical studies have shown that women who take
estrogen substantially reduce their risk of developing and dying from
heart disease. One or two studies demonstrate conflicting evidence, but
they are far outnumbered by the positive reports. Results from a 1001
study showed that after 15 years of estrogen replacement, risk of death
by CVD was reduced by almost 50 percent and overall deaths were reduced
by 40 percent. Some researchers credit this reduction to oral estrogen's
ability to maintain HDL and LDL at their healthier, premenopausal
levels, through its interaction with proteins in the liver. Others
believe it is estrogen's direct effect on the blood vessels themselves
(through receptors on the vessel walls) which creates this benefit. In
the latter case, both oral estrogen and the skin patch would be
effective. Studies are underway to determine which mechanism contributes
most to a healthy heart.
Clearly, estrogen appears to benefit women at high risk for heart
disease. The high risk group includes women with a strong family history
of CVD, those with high blood pressure, smokers, and obese women. One
study observed fewer cardiovascular deaths among estrogen users compared
to nonusers. Women whose ovaries had been surgically removed had the
greatest reduction of risk. The same study also confirmed, as expected,
the link between smoking, obesity and cardiovascular disease.
At any time of life, women who smoke are much more likely to develop
heart disease or have a stroke than women who do not smoke. But after
menopause, a smoker's risk climbs dramatically. Low estrogen levels and
smoking are separate risk factors for CVD. When the two are combined,
the risk is much higher than either one alone. Smoking also raises your
risks for some types of cancer and for chronic lung disease, such as
emphysema. Fortunately, quitting smoking--at any age--can cut the risk
of disease almost immediately. Studies have shown that when older people
quit, they increase their life expectancy. Their risk of heart disease
goes down, their lungs function better, and blood circulation improves.
So quitting smoking, whether before, during or after menopause, can have
a definite impact on both the length and quality of your life.
Should women be treated with a drug to prevent a disease they might
never get (osteoporosis, heart disease)? Some people will be placed at
higher risk, while others will benefit. Each woman should make a
decision about HRT based on her own family history and life experiences.
To me, exercise is the key to staying healthy. Some of these ladies have
been coming to this class for 10 years. I think that really says a lot.
Do you think they'd get up at 7:00 a.m. to jump around if it didn't make
them feel better?
Many women who have quit smoking say they found support in group
counseling sessions. Local chapters of the American Cancer Society and
the American Heart Association are good places to start looking for a
smoking cessation group. Nicotine gum and nicotine patches prescribed by
a doctor may also help.
While we know that HRT users have a decreased risk of CVD, it is not
clear how or if women with preexisting heart disease can benefit.
Because uncertainty exists, some of these women may be advised by their
doctors not to take estrogen. Researchers hope to further investigate
nonhormonal methods of preventing heart disease such as weight reduction
or control, exercise, smoking cessation, and dietary modification.
According to a 5-year study reported in 1988, weight gain (a common
occurrence among many menopausal women) significantly raises blood
pressure, total and LDL cholesterol, and fat levels. Together, these
make up a dangerous recipe for heart disease. Several other studies also
noted that moderate alcohol consumption, about one drink per day, had a
protective effect on the heart. Physicians advise caution in this area,
however, as excess alcohol can increase risks for other serious problems
such as brain hemorrhaging, liver disease, and certain types of cancer.
While cardiovascular benefits associated with oral estrogen are fairly
well-known, there is surprisingly little information on the
cardiovascular effects of progestin combined with estrogen. Some studies
suggest that progestins counteract the favorable HDL and LDL effects
achieved by estrogen alone, while other studies show no such effect.
This remains just one more gray area where questions outnumber reliable
Cautions to Estrogen Use
Recent heart attack
Breast cancer (current or family history)
Acute liver disease
Gall bladder disease
Recent blood clot
Undiagnosed vaginal bleeding
Benign breast disease
Benign uterine disease
Source: R.L. Young, N.S. Kumar, and J.W. Goldzieher, Management
of Menopause When Estrogen Cannot Be Used, Drugs,
Drawbacks of HRT: The Cancer Risk
As discussed previously, there is evidence that in women with an intact
uterus, estrogen may provoke growth of the tissues lining the uterus and
increase the risk of uterine cancer. Also of great concern is the
influence of estrogen on breast cancer. Researchers believe that the
longer your lifetime exposure to naturally occurring estrogen, the
greater your risk of breast cancer. It has not been proven, however,
that estrogen administered at menopause has the same effect. There is
disagreement on the many trials conducted to date because of wide
variations in the populations studied and the doses, timing, and types
of estrogen used. A recent analysis of previous studies suggests that
low-dose estrogen token on a short-term basis (10 years or less) does
not pose an increased risk of breast cancer. Long-term use (more than 10
years) at a high dose may significantly increase the risk. By how much
is still a matter of heated debate. At the very most, researchers think
long-term use could possibly increase the risk of getting breast cancer
by 30 percent. This means that incidence would rise from 10 women per
10,000 each year to 13 women per 10,000 each year. To reach any
consensus, however, more women need to be monitored for an extended
period of time. The fear of cancer is one of the most common reasons
that women are unwilling to use HRT. Interestingly, actual death rates
for breast cancer have not risen at all. This is probably because
estrogen users have more frequent medical visits and obtain more
preventive care including yearly mammograms.
While no one can determine who will eventually develop breast cancer,
there are certain risk factors you should be aware of when considering
HRT. A family history of breast cancer (sister or mother) is probably
the most important risk factor of all. You may also be at an increased
risk if: you menstruated before age 12; delayed motherhood until later
in life; have a late menopause (after age 50). Also, the older you are,
the higher the risk. Most doctors believe that if you are not in a high
risk category for breast or endometrial cancer, the benefits of HRT far
outweigh the risks. However, for some women, the side effects of therapy
make it impossible to use. This is a personal decision to be made by
each woman with help from her doctor.
Research shows that most women are concerned more with quality of life
than quantity of life. They give higher priority to the short-term
effects of hormone therapy (relief from hot flashes and vaginal dryness)
than to long-term concerns (preventing osteoporosis).
Physicians usually caution women not to use HRT if they are already at
high risk for developing blood clots. Obesity, severe vericose veins,
smoking, and a history of blood clots put you in this category. A
history of gall bladder disease could also be cause to avoid HRT, as
women taking estrogen may have a greater chance of developing
Happiness is when the last tuition is paid for, the youngest moves out
and the dog dies. Now I can concentrate on what I want to do. My doctor
puts everyone on estrogen, so I tried it for a while -- but it brought
my menstrual flow back just as heavy as before. Who needs that mess
again? So now I just exercise, try to eat well, and generally, I feel
Good nutrition and regular physical exercise are thought to improve
overall health. Some doctors feel these factors can also affect
menopause. Although these areas have not been well studied in women,
anecdotal evidence is strongly in favor of eating well and exercising to
help lower risks for CVD and osteoporosis.
There is no consensus within the medical community about the risks and
benefits associated with hormone therapy. There is no agreement on
normal hormonal changes associated with aging.
While everyone agrees that a well-balanced diet is important for good
health, there is still much to be learned about what constitutes
"well-balanced." We do know that variety in the diet helps ensure a
better mix of essential nutrients.
Nutritional requirements vary from person to person and change with age.
For instance, the Recommended Dietary Allowance (RDA) for calcium as
determined by the National Research Council is 800 mgs per day for a
healthy man. A healthy premenopausal woman should have more, about 1,000
to 1,200 mgs per day. The Council suggests that a postmenopausal woman
consume 1,200 to 1,500 mgs per day to help avoid bone loss. Foods high
in calcium include milk, yogurt, cheese and other dairy products;
oysters, sardines and canned salmon with bones; and dark-green leafy
vegetables like spinach and broccoli. If you are lactose intolerant,
acidophilus milk is more digestible. Vitamin D is also very important
for calcium absorption and bone formation. A 1992 study showed that
women with postmenopausal osteoporosis who took vitamin D for 3 years
significantly reduced the occurrence of new spinal fractures. However,
the issue is still controversial. High doses of vitamin D can cause
kidney stones, constipation, or abdominal pain, particularly in women
with existing kidney problems. Other nutritional guidelines by the
National Research Council include:
* Choose foods low in fat, saturated fat, and cholesterol. Fats
contain more calories (9 calories per gram) than either
carbohydrates or protein (each have only 4 calories per gram). Fat
intake should be less than 30 percent of daily calories.
* Eat fruits, vegetables, and whole grain cereal products, especially
those high in vitamin C and carotene. These include oranges,
grapefruit, carrots, winter squash, tomatoes, broccoli,
cauliflower, and green leafy vegetables. These foods are good
sources of vitamins and minerals and the major sources of dietary
fiber. Fiber helps maintain bowel mobility and may reduce the risk
of colon cancer. Young and older people alike are encouraged to
consume 20 to 30 grams of fiber per day.
* Eat very little salt-cured and smoked foods such as sausages,
smoked fish and ham, bacon, bologna, and hot dogs. High blood
pressure, which may become more serious with heavy salt intake, is
more of a risk as you age.
* Avoid food and drinks containing processed sugar. Sugar contains
empty calories which may substitute for nutritious food and can add
excess body weight.
For people who can't eat an adequate diet, supplements may be necessary.
A dietician should tailor these to meet your individual nutritional
needs. Using supplements without supervision can be risky because large
doses of some vitamins may have serious side effects. Vitamins A and D
in large doses can be particularly dangerous.
As you age, your body requires less energy because of a decline in
physical activity and a loss of lean body mass. Raising your activity
level will increase your need for energy and help you avoid gaining
weight. Weight gain often occurs in menopausal women, possibly due in
part to declining estrogen. In animal studies, scientists found that
estrogen is important in regulating weight gain. Animals with their
ovaries surgically removed gained weight, even if they were fed the same
diet as the animals with intact ovaries. They also found that
progesterone counteracts the effect of estrogen. The higher their
progesterone levels, the more the animals ate.
Exercise is extremely important throughout a woman's lifetime and
particularly as she gets older. Regular exercise benefits the heart and
bones, helps regulate weight, and contributes to a sense of overall
well-being and improvement in mood. If you are physically inactive you
are far more prone to coronary heart disease, obesity, high blood
pressure, diabetes, and osteoporosis. Sedentary women may also suffer
more from chronic back pain, stiffness, insomnia, and irregularity. They
often have poor circulation, weak muscles, shortness of breath, and loss
of bone mass. Depression can also be a problem. Women who regularly
walk, jog, swim, bike, dance, or perform some other aerobic activity can
more easily circumvent these problems and also achieve higher HDL
cholesterol levels. Studies show that women performing aerobic activity
or muscle-strength training reduced mortality from CVD and cancer.
Just like muscles, bones adhere to the "use it or lose it" rule; they
diminish in size and strength with disuse. It has been known for more
than 100 years that weight-bearing exercise (walking, running) will help
increase bone mass. Exercise stimulates the cells responsible for
generating new bone to work overtime. In the past 20 years, studies have
shown that bone tissue lost from lack of use can be rebuilt with
weight-bearing activity. Studies of athletes show they have greater bone
mass compared to nonathletes at the sites related to their sport. In
postmenopausal women, moderate exercise preserves bone mass in the spine
helping reduce the risk of fractures.
Exercise is also thought to have a positive effect on mood. During
exercise, hormones called endorphins are released in the brain. They are
'feel good' hormones involved in the body's positive response to stress.
The mood-heightening effect can last for several hours, according to
some endocrinologists. Consult your doctor before starting a rigorous
exercise program. He or she will help you decide which types of
exercises are best for you. An exercise program should start slowly and
build up to more strenuous activities. Women who already have
osteoporosis of the spine should be careful about exercise that jolts or
puts weight on the back, as it could cause a fracture.
To gather more data to help women make a well-informed decision
regarding hormone therapy, researchers at the National Institutes of
Health (NIH) launched the Postmenopausal Estrogen/Progestin
Interventions Trial (PEPI) in 1989. With 127 women enrolled at each of
seven medical centers, PEPI will address the short-term safety and
efficacy of various methods of HRT. The study will compare women who
take estrogen by itself to those who take it with different types of
progestin. It will also examine the effects of both cyclical and
continuous progestin on cardiovascular risk factors, blood clotting
factors, metabolism, uterine changes, bone mass, and general quality of
To date most large-scale studies have not fully reported on normal body
changes as women move from pre- to post-menopause. This lack of data has
been one problem in assessing the value of HRT. Without knowing what
"normal" is, scientists have difficulty judging the effect of a
particular treatment. Another problem with past studies is the "healthy
user effect." In many trials preceding PEPI, the HRT users studied had
freely chosen to begin treatment, with advice from their doctors. In
general, most physicians discourage women with a preexisting illness or
long family history of breast cancer from taking HRT. This factor could
skew study results to appear that nonusers became ill or died more
frequently simply because they failed to take estrogen. Only by randomly
assigning study participants to the treatment can this bias be overcome.
Until more random trials are completed, the jury is still out on HRT.
Many women feel that their physicians do not listen to their concerns.
Nor do they give them enough information to make an educated decision
about hormone therapy. Women's Health Initiative include:
Another NIH study, begun in 1992 is the Women's Health Initiative, a
multicenter trial involving 70,000 postmenopausal women ages 50 to 79.
The study will assess the long-term benefits and risk of hormone therapy
as it relates to cardiovascular disease, osteoporosis, and breast and
uterine cancer. It will also help determine the effects of calcium
supplementation, dietary changes, and exercise on women in this age
group. Some of the specific questions to be addressed by the Women's
Health Initiative include:
* How long is estrogen effective for each system of the body
(skeletal, cardiovascular, nervous, endocrine)?
* What is the best dose and route of administration of estrogen and
progestin to prevent side effects yet maintain efficacy?
* How long is estrogen safe to take?
* Does estrogen act the same way in older women as in younger women?
* Are there effective alternatives to HRT?
Clearly, no one has all the answers about menopause. Medical research is
beginning to give us more accurate information, but some myths and
negative attitudes persist. Women are challenging old stereotypes,
learning about what's happening in their bodies, and taking
responsibility for their health. The important thing to remember as you
go through menopause is to be good to yourself. Take time to pursue your
hobbies, be they gardening, painting or socializing with friends. Have a
positive attitude toward life. Sharing concerns with friends, a spouse,
relatives or a support group can help. Don't fight your body -- allow
the changes that are happening to become a part of you, a part that is
natural and that you accept.
angina -- a disease marked by brief attacks of chest pain
biopsy -- removal and examination of living cells from the body
cardiovascular disease -- disorders of the heart and circulatory system
endometrium -- the tissues lining the uterus
estrogen -- one of the female sex hormones produced by the ovaries
HDL -- high density lipoprotein cholesterol, the "good" cholesterol
thought to have a cleansing effect in the bloodstream hysterectomy-
surgical removal of the uterus
IUD -- Intrauterine birth control device, which prevents implantation of
an embryo into the uterus should fertilization occur
LDL -- low density lipoprotein cholesterol, the "bad" cholesterol
believed to be linked to fat accumulation in the arteries
menopause -- the point when menstruation stops permanently
oral contraceptives -- pills which usually consist of synthetic estrogen
and progesterone that are taken for three weeks after the last day
of a menstrual period. They inhibit ovulation, thereby preventing
osteoporosis -- a disease in which bones become thin, weak and are
perimenopause -- the time around menopause, usually beginning 3 to 5
years before the final period
progesterone -- one of the female sex hormones produced by the ovaries
progestin -- the synthetic form of progesterone
tubal ligation -- a surgical procedure in which the uterine tubes are
cut and tied to prevent pregnancy
urinary incontinence -- loss of bladder control
vasectomy -- in males, the surgical removal of part of the sperm duct
(vas deferens) to induce infertility
National Institute on Aging (NIA)
9000 Rockville Pike
Bethesda, MD 20892
North American Menopause Society (NAMS)
Department of OB/GYN
2074 Abington Road
Cleveland, OH 44106
National Women's Health Network
1325 G Street, NW
Washington, DC 20005
American College of Obstetrics and Gynecologists (ACOG)
409 12th Street, SW
Washington, DC 20024
Alliance for Aging Research
2021 K Street, NW, Suite 305
Washington, DC 20006
Older Women's League (OWL)
666 11th Street, NW
Washington, DC 20001
National Women's Health Resource Center (NWHRC)
2440 M Street, NW
Washington, DC 20037
Wider Opportunities for Women (WOW)
National Commission on Working Women
1325 G Street, NW
Washington, DC 20005
American Dietetic Association (ADA)
216 West Jackson Boulevard
Chicago, IL 60606
American Heart Association (AHA)
7320 Greenville Avenue
Dallas, TX 75231
National Heart, Lung, and Blood Institute (NHLBI)
9000 Rockville Pike
Bethesda, MD 20892
National Arthritis and Musculoskeletal and Skin Diseases
9000 Rockville Pike
Bethesda, MD 20892
National Osteoporosis Foundation (NOF)
2100 M Street, NW
Washington, DC 20037
Sex Information and Education Council of the U.S. (SIECUS)
130 West 42nd Street
New York, NY 10036
DEPRESSION Awareness, Recognition, and Treatment Program
National Institute of Mental Health
D/ART Public Inquiries
5600 Fishers Lane
Rockville, MD 20857
National Mental Health Association (NMHA)
1021 Prince Street
Alexandria, VA 22314-2971
National Cancer Institute
Cancer Information Service
9000 Rockville Pike
Bethesda, MD 20892
American Cancer Society
1599 Clifton Road, NE
Atlanta, GA 30329
Managing Your Menopause, Wulf H. Utian, M.D., Ph.D., and Ruth
S. Jacobowitz. New York: Prentice Hall/Simon & Schuster, 1990.
The Menopause Self-Help Book, Susan M. Lark, M.D. Berkeley:
Celestial Arts, 1990.
Ourselves Growing Older, Paula Brown Doress and Diane Laskin
Siegal. New York: Simon and Schuster, 1987 (in cooperation with
the Boston Women's Health Book Collective).
Estrogens: The Facts Can Save Your Life, Lila Nachtigall,
M.D., and Joan Rattner Heilman. New York: Harper & Row, 1986.
Choice Years, Judith Paige and Pamela Gordon. New York: Villard
Change of Life: The Menopause Handbook, by Susan Flamholtz
Trien. New York: Fawcett, 1986.
Menopause: A Positive Approach, Rosetta Reitz. Penguin Books,
The Menopause, Hormone Therapy, and Women's Health-Background
Paper. 'Congress of the United States, Office of Technology
Assessment, May 1992.
Who, What, Where? Resources for Women's Health & Aging,
National Institute on Aging, March 1992.
Information provided by NIH.