Skin
“Almost overnight it feels as though my skin has become dry and crepey, especially around my eyes.”
The collagen layer of our skin becomes thinner as our hormone levels fall. A wide variety of highly effective skin treatments is now available that help build collagen, resurface the skin, and prevent wrinkles. Systemic or topical hormones; foods rich in phytoestrogens, such as soy; and antioxidant supplements such as vitamin C, vitamin E, glutathione, and proanthocyanidins (from grape seeds or pine bark) also help build collagen and rejuvenate the skin. (See chapter 11, “From Rosebud to Rose Hip.”)
Bone Loss
“My grandmother gets shorter every year, and more bent over. I don’t want that to happen to me.”
For many women, bone loss through the insidious process known as osteoporosis begins as early as age thirty—or even earlier. Because of chronic dieting, undereating, overexercising, lack of nutrients, or anorexia, many women do not reach the peak bone density they should when they are in their teens, twenties, and thirties. (Ideally, osteoporosis prevention should begin in childhood!) So when a woman turns forty and her hormonal levels begin to shift, her bone density may already be compromised. When estrogen, progesterone, and androgen levels start to shift, the collagen matrix that forms the foundation of healthy bone may start to weaken, especially when a woman’s nutrition and exercise regimens are lacking. You can maintain the collagen matrix in your bones and also help rebuild healthy bone in a variety of ways, which include getting adequate phytohormones from foods such as soy, taking herbs, using hormone replacement, adding calcium and magnesium supplements, getting adequate vitamin D from sun exposure or supplements, and doing weightbearing exercise. (See chapter 12, “Standing Tall for Life.”)
Mood Swings
“I find myself crying during television commercials. Then I fly off the handle at my kids for no reason.”
As I pointed out in chapter 2, many women experience an intensification of the kind of volatility in their moods that they once felt primarily before their periods, if at all. Part of the reason for this volatility, or for the increase in dark, negative moods, is hormonal. But it may also be a signal from your inner wisdom, trying to get your attention.
Insomnia
“I just don’t seem to be able to get to sleep at night. When I do, I often wake up soaking wet and hot. So I throw off the blankets, and then get chilled!”
Many women wouldn’t have insomnia if it weren’t for their night sweats and hot flashes. For others, anxiety keeps them from sleeping soundly. And so does a refined-food, low-nutrient diet. If your sleep problems are related to hot flashes, they’ll often resolve with hot flash treatment. If they’re due to anxiety, you may need to make some changes in your life that the anxiety is bringing to your attention. You may also need to clean up your diet. Other sleep problems may be related to the fact that perimenopause, like adolescence, is a time of transition in sleep patterns. Some of us, like teenagers, will suddenly start requiring much greater amounts of sleep than before. Typically, this changes again after menopause, when we need less sleep than during our twenties and thirties. Some women find daytime naps help during the transition. (See the sleep section of “How to Restore Your Adrenal Function” in this chapter, and also see chapter 10, “Nurturing Your Brain.”)
Fuzzy Thinking
“I keep losing my keys. I walk into a room and forget why I’m there. Sometimes my head feels like it’s filled with cotton.”
Many women report a feeling of forgetfulness and “cotton head” during perimenopause. It’s not unusual to have trouble concentrating or to do things like put the cordless phone in the refrigerator. The same thing often happens postpartum when a woman comes home with a new baby and suddenly feels incapable of balancing her checkbook. The difference between the postpartum period and perimenopause is that during perimenopause you’re giving birth to yourself. It often feels as though the logical side of the brain goes to sleep for a while as a way to force us to become more intuitive and more in tune with our emotions and inner wisdom. Herbs such as ginkgo and St. John’s wort can help keep your mind clear. So can following a diet that keeps blood sugar stable. (See chapter 7, “The Menopause Food Plan.”) Some women find that soy isoflavones or hormones such as progesterone or estrogen are also helpful. The main thing to remember is that you’re not getting Alzheimer’s. You’re just rewiring your brain for a whole new way of thinking. (See chapter 10, “Nurturing Your Brain.”)
How Long Will My Symptoms Last?
Many women believe that the symptoms they are experiencing are what menopause—and life—will feel like from this day forward. The truth is that those symptoms, when present, are labor pains, as it were—part of our adaptation to the hormonal changes that take place as our biological focus switches from procreation to personal growth. In other words, the symptoms of the climacteric are temporary. How long they’ll last depends on a number of factors, including the type of menopause a woman is experiencing (see THE THREE TYPES OF MENOPAUSE), what else is going on in her life at the time, and the ability of her body and soul to support her through this period of transition. In this culture the symptoms of perimenopause, in a natural transition, last anywhere from five to ten years, with a gradual crescendo in the beginning, a peak as the woman approaches the midpoint of the transition, and a gradual decrescendo toward the end as the body learns to live in harmony with its new hormonal support system.
Because all perimenopausal symptoms are interrelated, the treatment of one symptom may alleviate other symptoms as well. Since so many different treatments are effective, an individual woman will want to choose the ones that appeal to her most. Many women select several different treatments at the same time. An example of this would be taking bioidentical hormone replacement along with a soy product and a good multivitamin, and adding an exercise program. The bottom line is this: there’s no need to suffer through perimenopause. As you read through the chapters that follow, choose the treatments that speak to you. Experiment. Your body is constantly changing. You can’t really make a mistake.
5
Hormone Therapy:
An Individual Choice
The science of hormone therapy has been in continual evolution since estrogen therapy was first introduced in 1949 and the first birth control pills hit the market in the 1960s. The pill gave women a magic bullet that enabled them to go about their daily lives without being conscious of their natural hormonal and fertility rhythms. The downside is that these rhythms and the natural wisdom that created them have become pathologized, leading women to believe that synthetic, man-made hormones are safer and better than the “unpredictable” ones found naturally in our bodies. What became known as hormone replacement therapy, or HRT, was an extension of this thinking: that the female body is deficient and needs to be fixed.
Today, however, there are new options that are much more respectful of the body’s wisdom, as well as updated thinking about individualizing hormone levels instead of relying on one-size-fits-all recommendations. Taking hormones is now called HT (hormone therapy) instead of HRT. To understand how the current view of hormones and hormone therapy evolved, it helps to know where we’re coming from.
A BRIEF HISTORY OF HORMONE THERAPY
When I was doing my family practice training in a small Vermont hospital, I remember going to the library and taking down a book that caught my eye, way up on the top shelf. It was Feminine Forever (M. Evans, 1966), by Robert Wilson, M.D. It described in graphic detail how the lack of estrogen at menopause led inevitably to the shriveling of a woman’s body, leaving her old and decrepit.
His solution: estrogen pills to replace what her deficient body no longer produced. This was presented as a sort of magic potion that would leave her “feminine forever”: youthful, resilient, moist, sexy, and desirable. The way Wilson described estrogen’s benefits, I couldn’t imagine a woman who would want to live without it at menopause—a life passage about which my medical trainin
g had taught me virtually nothing.
I was still unconscious about how embedded the devaluation of female bodies is within our culture, and how powerfully this devaluation influences the practice of medicine and the science that supports it. (At the time, anyone having her first baby at the age of thirty or older was referred to as an “elderly primigravida.”) As was true of my peers, my own beliefs were clouded by my cultural legacy: just as male is superior to female, young is superior to old. Salvation would come through denying any differences between male and female, and endeavoring to stay forever young. Our better-living-through-chemistry society was poised to help us control our unruly female physiology through birth control pills during our reproductive years and estrogen during menopause. Not surprisingly, sales of Premarin—the first estrogen to be marketed—began to soar.
A Shadow Crosses over Premarin
When I was a third-year medical student, one of my mother’s close friends confided to me that she had to stop taking her Premarin because she had started to have bleeding. She was later diagnosed with a condition known as adenomatous hyperplasia of the endometrium—indicating that her uterine lining was being overstimulated by the Premarin. Although she never resumed taking Premarin, her bleeding didn’t return, and she didn’t suddenly shrivel up, either. She was climbing mountains and going on long hikes with her friends right up to the end of her life at age ninety.
My mother’s friend was not alone. In the mid-to late 1970s, study after study appeared that proved beyond any doubt that taking estrogen resulted in an up to fourfold greater risk for developing uterine cancer. At about this same time, birth control pills were shown to increase the risk of stroke, pulmonary embolism, and heart attack—deadly complications in young women. Premarin sales plummeted. Women grew afraid of the pill. It would take several years before new studies of lower-dose pills, and major marketing efforts, quelled these fears—though never entirely.
Premarin Sales Revive
Then studies began to appear showing that estrogen could help prevent osteoporosis. I was intrigued. My then-husband was doing his training in orthopedic surgery, and he spent many nights repairing hip fractures in older women, many of whom never walked or lived independently again.
I researched the link between estrogen and bone health and did a presentation on it for the OB-GYN staff at the hospital. Many of my professors were dead set against Premarin for any indication—they had been burned too badly by the uterine cancer findings. And although I was convinced that estrogen replacement could help prevent osteoporosis, I was far more interested in alternatives such as calcium supplementation and exercise. A colleague and I even discussed setting up a long-term study involving diet and exercise, but we were far too busy just trying to complete our residencies, and it would take another twenty years for those ideas to be proved and accepted by mainstream doctors.
Meanwhile, other studies showed that endometrial cancer could be prevented if a woman was given progesterone along with her dose of estrogen. Estrogen replacement slowly but surely made its way back onto the scene—this time in combination with Provera, a synthetic form of progesterone, which was given to all women on estrogen unless they had had hysterectomies. (In that case, doctors reasoned, there was no reason to give it.) Progesterone’s role was thus reduced to that of a uterine vacuum cleaner—one that prevented excessive buildup of the uterine lining but had no inherent benefits of its own.
Premarin Becomes Synonymous with
Hormone Therapy
Premarin is composed of estrogenic compounds derived from the urine of pregnant mares. Since its introduction in 1949, it has maintained its place as the queen of the hormone therapy world. In fact, when you say “hormone therapy,” most people, including doctors, still think Premarin—end of discussion.
Its sales hit an all-time high during the 1980s and early ’90s, when study after study (many supported by Wyeth-Ayerst, the maker of Premarin) began to support estrogen’s role in keeping the cardiovascular system healthy. For example, it was shown to lower LDL cholesterol, which the famous Framingham study had identified as a risk for heart attack. Given that cardiovascular disease was also emerging as the number-one killer of women past menopause, doctors everywhere became convinced that all menopausal women needed estrogen to protect their hearts. Some even refused to care for women who wouldn’t take it.
Other benefits were also touted. Premarin seemed to do everything: lift depression, thicken vaginal tissue, stop hot flashes, prevent heart disease, prevent osteoporosis, and even ward off Alzheimer’s disease. Premarin was prescribed freely in a one-size-fits-all manner—the same dose for every woman, regardless of her size or her medical history. Provera was added for ten to twelve days of every month to protect the uterus. Later, Premarin and Provera were combined into one pill known as Prempro or Premphase. That was hormone therapy.
The End of the Premarin Empire?
But then a big fly found its way into the ointment. Multiple studies began to support an incontrovertible link between estrogen supplementation and breast cancer. This link makes biological sense, since estrogen is well known to stimulate the growth of estrogen-sensitive tissue, such as that in the breast and uterus. Still, the cardiovascular benefits seemed so strong that many women were persuaded to override their fear of breast cancer and continue to take Premarin or Prempro.
At the turn of the millennium, however, several large prospective studies challenged the heart-protection gospel. In the large HERS (Heart and Estrogen/Progestin Replacement Study) trial of women who already had heart disease, hormone therapy in the form of Premarin and Provera not only did not decrease their risk of subsequent heart attack, it actually increased that risk significantly in the first year of use, after which the risk leveled off.
Then, in July 2002, one branch of the huge Women’s Health Initiative, a long-term government-funded study of hormone therapy, was stopped abruptly because the data showed that the risks of long-term Prempro use clearly outweighed the benefits. The study followed 16,000 initially healthy postmenopausal women randomly assigned to take either Prempro or a look-alike placebo. Those on the synthetic hormone combination were found to suffer more breast cancers, heart attacks, strokes, and blood clots than the women on placebo.1 A second study from the National Cancer Institute, released on the same day, reported that women who used estrogen-only hormone therapy for longer than ten years doubled their risk for ovarian cancer.2
When this information was released, it created mass confusion for the millions of women and their doctors who had been convinced for over a decade that taking estrogen for life was the key to heart disease prevention, good skin, healthy bones, and a great sex life. Virtually overnight, there was a revolution in the way our culture views hormone therapy in general and Prempro in particular. Women stopped taking it in droves, and as a profession, we doctors realized that we needed to individualize our care.
Then, in early 2006, a reanalysis of the data from the Nurses’ Health Study and the Women’s Health Initiative (WHI) study indicated that younger women who started taking hormones within ten years after menopause experienced an 11 to 30 percent decreased risk for heart attack—the kind of result that researchers had hoped to see when the WHI started. But those who started later (ten years or more after menopause—the majority of women in the WHI) experienced an increased risk for stroke, heart attack, and even Alzheimer’s disease. Younger women on estrogen alone had a 44 percent decreased risk for heart disease as long as they started within ten years of menopause.3 (At the time, I suspected that the difference between the risk of the younger HT users and that of the older ones had something to do with hormone therapy’s ability to prevent the kind of vascular damage that tends to result from years of stress, high blood sugar, a nutrient-poor diet, and not enough exercise.) Yet another reanalysis of these studies published in 2010 added a new wrinkle: even the younger women who took estrogen-plus-progestin hormone replacement therapy slightly increased their risk of coronary heart
disease within the first two years of starting their hormone therapy—although this increase was not statistically significant.4 After six years of use, however, the increased risk disappeared, at which point, researchers found that hormone therapy might actually confer some protection. However, most women who use HT don’t take it as long as six years anyway, so the potential protection claim may well be a moot point.
At the end of the day, here’s what we’re left with. After decades of trying to convince all women that menopause was a deficiency state that could be “cured” by hormone therapy, we finally realized the truth. There is no magic bullet, one-size-fits-all hormone prescription or drug regimen of any kind that is right and healthy for all or even most women to take indefinitely. And because each of us is an individual with differing needs, constitution, beliefs, and environment, there never will be—no matter how many studies are done. Quite frankly, I consider that good news.
On the other hand, there’s no reason to throw out the baby with the bathwater. The science of hormone therapy is still evolving. The latest evidence-based position statement from the North American Menopause Society reports that, on the whole, the benefits of HT outweigh the risks for women who begin HT close to menopause (although the position paper also notes that those benefits decrease in older women and with time since menopause in previously untreated women).5 And the newest data from the reanalysis of the WHI and Nurses’ Health studies is encouraging. Hormone therapy has some very real benefits. Even in the Women’s Health Initiative study of older women, the women who were using Prempro (which I consider the least desirable form of hormone therapy) were at decreased risk for bowel cancer and fractures compared to those who were on the placebo. And no one would disagree that hormone therapy offers many women one of the best ways to get relief from perimenopausal symptoms such as hot flashes. Thankfully, there are ways to get the benefits of hormone therapy while decreasing the risks and side effects.
The Wisdom of Menopause Page 19
