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Menopause: More Than Just Hot Flashes

Sometime in a woman's 40s she begins the natural transition through menopause. Over the next three to five years, her ovarian production of estrogen, progesterone, and androgen slows dramatically. As levels of these hormones fluctuate, she may experience the same irregular periods and mood swings she felt during puberty. She may also notice other signs of decreased hormone production, such as hot flashes, sleep problems, vaginal dryness, recurrent vaginal or urinary tract infections, and some loss of bladder control.
Most of these changes occur during perimenopause, or the time around (peri in Greek) menopause. Menopause itself is just a woman's last period; one year later, a woman is considered to be postmenopausal.

The Lifestyle Connection

It's up to each woman and her health-care team to put together the individual program that's best for her during this time of transition, because the perimenopausal experiences of women can vary due to differences in lifestyle, attitude, genetics, weight, and ethnicity. Some women sail through menopause, while others struggle to deal with its annoying or even debilitating symptoms. These symptoms will eventually taper off as the body adjusts to new hormone levels. In the meantime, lifestyle factors can help ease the menopausal transition in several ways:

Diet. Your menopausal symptoms may be reduced and certainly your general health improved if you follow a diet that's moderate in fat (30 percent of daily calories) and high in fruits, vegetables, legumes (including soybeans), and whole grains. Avoid saturated and polyunsaturated fats and rely on healthier monounsaturated fats (in olive oil and avocados) and omega-3 fatty acids (in walnuts, flax seeds, and oily fish).

Exercise. Weight-bearing exercise such as brisk walking and dancing can keep your heart and bones strong. As a bonus, regular physical activity also appears to reduce hot flashes, fight depression, improve thinking skills, and promote good sleep. And it counters weight gain, another "gift" of midlife.

Stress reduction Menopausal symptoms—including mental and emotional issues such as mood swings, lack of concentration, fatigue, loss of energy, memory deficits, and depression—can be caused or worsened by the many stresses that can converge on a midlife woman. This is an excellent time to get into the habit of practicing a relaxation technique such as breath work, meditation, or yoga.

You can take a whole-body, or systemic, approach to menopausal symptoms. For example, the conventional systemic approach is hormone supplementation. A low-dose oral contraceptive (for women still having periods) or an estrogen/progesterone hormone-replacement combination (for women with uteruses who no longer have periods) can address many common menopausal symptoms, including hot flashes and urogenital problems.

I'm cautious about the long-term use of hormone replacement therapy (HRT), but I'm not opposed to using HRT during the few years when perimenopausal symptoms are most severe, as the risks for breast cancer appear to rise very little with less than five years of HRT use. I also recommend that women who experience an artificially early menopause due to surgery take HRT until they reach the age of natural menopause (around 51). The dosage, form, and delivery method of HRT will vary according to a woman's needs and preferences, but I usually recommend 17-beta estradiol and oral micronized progesterone, the forms of estrogen and progesterone that most closely resemble the body's natural hormones. 

Two "alternative" medical systems—homeopathy and traditional Chinese medicine (TCM)—also take a systemic approach to menopausal symptoms. A good constitutional homeopath, for example, can determine through an extensive interview which of the thousands of available homeopathic remedies will treat all your symptoms by addressing the basic issues underlying them. You might take this remedy once a year until symptoms go away, or just once. Similarly, a practitioner of TCM might use acupuncture and/or multi-herb formulas to bring the body into a better balance. The practitioner might prescribe these treatments until symptoms are alleviated or go away.

Relief for Four Common Symptoms

The four most common menopausal symptoms can also be addressed separately, with herbs, foods, supplements, or lifestyle changes. For each symptom, experiment with the suggested measures, and see which ones work best for you.

Hot Flashes (or Hot Flushes)
The hallmark of menopause, these "power surges" are felt by about three-quarters of all women. Some still-unknown signal to the temperature-regulating portion of the brain sends blood rushing to the surface of the skin. This flush of blood raises skin temperature as much as seven degrees, bringing a feeling of heat (especially to the upper body), sweating, increased heart rate, and sometimes chills. Hot flashes that occur at night may cause intense "night sweats" that disrupt sleep.

My recommendations:
bulletDress in layers to take clothes on and off as needed. Wear clothes made of cotton and other breathable fibers.
bulletIdentify and avoid personal hot-flash triggers, such as stress, caffeine, alcohol, and spicy foods.
bulletTry a standardized extract of the herb black cohosh. While we're not yet sure how it eases hot flashes, the evidence for black cohosh is convincing, according to menopause researcher Fredi Kronenberg, PhD, at Columbia University. A popular brand from Germany is sold here as Remifemin; follow package directions for dosage.
bulletKeep your cool. A hot environment can cause more frequent and intense hot flashes. Turn on the air conditioning, use a personal fan, and keep cold drinks on hand. I've even had patients tell me they stick their heads in the refrigerator to cool down.
bulletBreathe through them. Studies have found that women could reduce or even stop their hot flashes by deep, slow, belly breathing.
bulletAdd phytoestrogens to your diet. The natural hormone-like compounds in ground flax seeds and soy foods containing isoflavones have been found in some studies to ease hot flashes. Other research has found no effect, but since these foods have cardiovascular benefits as well, one or two servings a day would still be healthy additions to the diet.

Changes in Vaginal Tissues
As estrogen levels decrease, vaginal tissues become thinner, drier, and more fragile. This can cause itching and burning, as well as painful sex. In addition, the vagina becomes more alkaline and less acidic, making it more susceptible to overgrowth of bacteria or yeast.

My recommendations:
bulletDrink eight glasses of water and other healthy liquids a day to help keep vaginal tissues moist. Avoid dehydrating antihistamines, cola drinks, coffee, and alcohol.
bulletTry to stay sexually active, alone or with a partner. As the saying goes, "Use it or lose it." Kegel exercises also help keep pelvic-floor muscles toned and help maintain sexual function.
bulletUse a vaginal moisturizer two or three times a week to plump up the tissues. The new "bioadhesive" gels are less messy and more effective—products such as Replens that maintain the pH of the vagina at healthier levels and discourage bacterial or yeast infections.
bulletApply a water-soluble personal lubricant like Astroglide or Lubrin at the time of sexual activity.
bulletTry localized estrogen. A vaginal cream, vaginal tablet, or an estrogen-releasing vaginal ring (Estring) may work more quickly than systemic forms of HRT like the pill and the patch. If you're taking estrogen and have a uterus, talk to your doctor about using progesterone periodically to prevent a buildup of uterine tissue that can favor endometrial cancer.

Urinary Tract Changes
Estrogen loss also causes a thinning of the tissues at the base of the bladder and lining the urethra, as well as a loss of tone in the muscles that control the bladder. The result can be urine leakage and recurrent urinary tract infections (UTIs).

My recommendations:
bulletKegel exercises improve urinary control by strengthening the pelvic muscles around the urethra.
bulletReduce or eliminate caffeine and alcohol, which irritate the urinary tract.
bulletDrink lots of water to keep the system flushed. Be sure to empty the bladder completely when you urinate, so bacteria cannot multiply in any urine retained in the bladder.
bulletFor recurrent UTIs, take an extract of cranberry or blueberry in capsule or tablet form. You can use either of these berries to treat or prevent infections since they contain potent compounds that prevent bacteria from gaining footholds in the urinary tract.
bulletApply estrogen creams locally or have an estrogen ring inserted, which may improve the quality of urethral tissue and reduce the risk of urinary tract infections.

Many women lose sleep due to nighttime hot flashes or the need to urinate, both of which can interfere with restorative REM sleep. Getting a handle on hot flashes, then, should ease insomnia too. But midlife insomnia can also be caused by stresses or physical changes due to aging in men and women.

My recommendations:
bulletPractice good sleep hygiene: Set a regular bedtime, use your bed only for sleep and sex, keep the bedroom cool, use a white-noise machine or a sleep mask if the environment makes sleep difficult, take a hot bath an hour before bedtime, use a bedside notepad to write down any thoughts that are keeping you awake, have a serotonin-boosting nighttime snack such as turkey or nonfat cottage cheese, and get up and do something if you can't fall asleep within 20 to 30 minutes.
bulletAvoid coffee, cola drinks, and other stimulants all day, not just at night.
bulletHave a relaxing cup of chamomile tea at bedtime. It's okay to use an extract of valerian or a valerian-and-hops combination as an occasional sleep aid, but try not to use valerian on a regular basis, or you may become psychologically dependent on it.
bulletGet regular daily exercise, which improves sleep quality. But exercising near bedtime can have the opposite effect.
bulletAsk a family member for an evening back massage, or massage your own feet before bed. Try massaging with a nut or vegetable oil (like almond or olive oil) mixed with a few drops of sleep-promoting lavender or vanilla essential oils.
bulletChange your attitude about being awake at night. Savor this time alone for journaling or personal reflection.

Resources: For books, see The Wisdom of Menopause by Christiane Northrup, MD (Bantam, 2001), and Menopause, Naturally by Sadja Greenwood, MD (Volcano Press, 1996). For websites, see Power Surge at www.power-surge.com, and the North American Menopause Society at www.menopause. org. The latter group also sells an informational packet for $5 shipping and handling. To order, call (800) 774-5342. 

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* These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease. This information is nutritional in nature and should not be construed as medical advice. This notice is required by the Federal Food, Drug and Cosmetic Act.

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Last modified: June 28, 2015