I can’t count how many times I have had a patient sigh and ask me, ” How long does menopause last?”  I want to sigh back and say, “until you die’”, but I cannot be that mean.  Of course what they are really asking is how long do the symptoms last.  I can assure them that hot flashes generally subside over time, even if it takes years.  The craziness of perimenopause with its irregular bleeding and mood swings will calm down as well once  menstruation completely stops.   The thinning of the vaginal tissue is an inevitable consequence of the waning estrogen of menopause but can usually be effectively treated. 

But once these symptoms are addressed there is something very important that I want every woman to know about menopause.   That while the symptoms subside, the effects of menopause do last a lifetime.  The awareness on your body changes is an opportunity for you to reevaluate your health.  The decisions you make about your life style now can make the difference in how well you will live the rest of your life and how long that life will be.  Even more important than addressing the symptoms of menopause is addressing health risks as you age.  This includes the increasing risk of heart disease, thinning bones. cancer ( not just breast but lung, colon, skin as well) and diabetes.    The age of menopause is often a time of other life changes as well.  Managing  the stresses of aging parents, retirement or job loss and relationship issues are common challenges.   There is much you can do with exercise, weight management and nutrition that can add health and vigor to  your life.  Gathering resources, information and social support can make a huge difference as well.  Check out the variety of subjects of the classes and events offered at various  Henry Ford Health System locations.   The link is on the right.  In November we are addressing stress and depression.  Just in time to shore up for the holidays and the long dark days of winter.  It’s all part of the big picture of being healthy and it may be more than you think.

written by Deborah McBain, CNM MSN

In the most recent issue of Obstetrics & Gynecology, Jan Shifren and Isaac Schiff reviewed the literature about the use of hormone therapy (HT) in the menopause. The principle indication for hormone therapy remains the treatment of hot flushes and night sweats. Benefits generally outweigh the risks for healthy women with bothersome symptoms who elect to HT at the time of menopause. Although hormone therapy increases the risk of coronary heart disease, recent analyses confirm that this increased risk occurs primarily in older women and those a number of years beyond menopause. These findings do not support a role for HT in the prevention of heart disease but provide reassurance regarding the safety of use for hot flushes and night sweats in otherwise healthy women at this difficult time of life. An increased risk of breast cancer with extended use is another reason short-term  treatment is advised.

Hormone therapy prevents and treats osteoporosis but is rarely used solely for this indication. Estrogen is as effective as the other treatments for osteoporosis, so most women using HT for menopausal symptoms will not need additional treatment for their bones except for adequate calcium and vitamin D intake. If only vaginal symptoms are present, low-dose local estrogen therapy is preferred. There are creams, pills, and an estrogen ring which can be used to treat vaginal symptoms. They are all equally effective and which is used may be based on the woman’s preference. The risk profile for vaginal therapy is very different from systemic therapies, and there is no data that suggests a link between use of vaginal estrogen and the development of breast cancer or heart disease. There are safety studies up to 1 year showing no adverse endometrial effects, but studies of long-term effects of low-dose vaginal estrogen therapy are lacking. Therefore, women using vaginal estrogen therapy should report any vaginal bleeding and should undergo thorough evaluation.

Contraindications to HT use include breast or endometrial cancer, cardiovascular disease, history of blood clots, and active liver disease. Alternatives to HT is advised for women with or at increased risk for these conditions. The lowest effective estrogen dose should be used for the shortest duration necessary. Women should be informed of the potential benefits as well as the risks of all therapeutic options. Care should be individualized, based on a woman’s medical history, needs, and preferences.

written by Charla Blacker, MD

  Julie has a BFA in dance from the University of Michigan and has been teaching creative movement and ballroom dancing since 1977.  She completed her yoga teacher training and began teaching in 2000.  She has taught a wide variety of classes in the community for all age groups and continues to teach classes at West Bloomfield Parks and Recreation.  In 2008, she completed training in a yoga therapeutic program, “Yoga of the Heart,” based on Dr. Dean Ornish’s study on reversing heart disease.   She feels proud and fortunate to be an employee at Henry Ford Vita Wellness Center, teaching yoga classes which focus on the health benefits of yoga. In addition to the daily yoga classes, she also teachs Zumba, Ballet Stretch and Tone and Dance Your Way to Fitness.  She recently answered my questions about how Yoga may benefit women during menopause and beyond.

 I know you teach a Yoga for Wellness class now and have offered a Yoga for Menopause class in the past.  What prompted your interest in yoga and specifically yoga for menopause?

When I began my first yoga classes in 1995, I truly had little understanding of yoga.  I was recovering from a dance injury and thought yoga would be a good way to stay in shape while I was recovering.  I quickly recognized that yoga was as much about the body as it was about the mind.  In short order I began to notice the many benefits from practicing yoga.  I was inspired from my earliest classes to become a yoga teacher, guiding others to discover the benefits. The overall benefits of yoga, which include stress reduction, improved focus, mood regulation, improved sleep as well as strength, balance and flexibility have served me well as I have made the transition through menopause.  

 Yoga is well known for its benefits in managing stress.  How is it specifically helpful for menopausal symptoms?

 What  are the other health benefits of Yoga for women as they age ?

Is Yoga safe for everyone?  Are there any precautions women need to be aware of?

How would you recommend someone get started with Yoga?  Do you have any good resources you can share?

written by Deborah McBain, CNM MSN

The longer I live in my body the more amazed I am at how connected my mind and body is.  So many women who are  bothered by hot flashes and even urge incontinence do not realize that they may actually have some control over some of their symptoms by training their minds.  There is good scientific evidence that this is so.  Practice the exercise below during a hot flash or with urgency to urinate.  Concentrate on relaxing your abdominal muscles.  Don’t give up if you don’t see results right away.  Like anything, it takes practice to achieve effective performance.  It is not hard but takes just a little persistence. Good luck.

Paced respiration

With regular paced respiration, women reportedly achieve a noticeable drop in the number of hot flashes they have, as well as a lower average skin temperature (used to measure hot flashes).

Paced respiration takes practice. Try to do paced respiration twice daily, for 15 minutes at a time. Also, when you first feel a hot flash coming on, stop what you are doing, find a quiet place, and practice paced respiration until you are feeling comfortable again.

• Sit in a comfortable, quiet place.
• As you breathe, keep your rib cage still. You will be lowering and raising your diaphragm to fill and empty your lungs.
• Inhale for 5 seconds, pushing your stomach muscles out.
• Exhale for 5 seconds, pulling your stomach muscles in and up.
• Repeat this cycle of breathing until you feel calm and relaxed or your time is up.

To reduce stress, you can also use paced respiration for 1 to 2 minutes in the middle of a busy day.

written by Deborah McBain, CNM MSN

Would you consider paying to allow someone to poke needles in your body?  No?  What if I told you that the result may be less hot flashes, better sleep, return of sex drive and more energy?  Got your attention?  Well,  then read on about acupuncture.

Acupuncture has been around for about 5,000 years.  Very thin “needles” are placed in key areas of the body called meridians to stimulate and balance the flow of energy through the body.  It has been used by an estimated 8.2 million U.S. adults.  Benefits have been published in peer-reviewed western medical literature and studies conducted by the National Institutes of Health

Acupuncture is often used in combination with Chinese herbal medicine and referred to as Traditional Chinese Medicine (TCM).  Increasingly TCM and other alternative health modalities such as mind/body therapy and massage is being combined with conventional ( allopathic) western medicine to achieve enhanced results.  Referred to as Integrative Medicine it is hoped, by practitioners in both camps, to bring the best of both worlds together.  TCM is being used for various women’s health issues such as menopausal symptoms,  cancer support, emotional health issues and chronic disease management.  All issues close to the hearts of many of us of a certain age.

In 2008 Henry Ford Health System oncologist, Dr. Eleanor Walker with the assistance of  acupuncturist, Beth Kohn conducted a study with 47 breast cancer patients.  These patients were all on tamoxifen or Arimidex to reduce cancer recurrence.   Hot flashes are a common side effect of these two drugs.  Half of the women received acupuncture treatment and half were given the antidepressant venlafaxine (Effexor).  Effexor has also been shown to reduce hot flashes.  At the end of 12 weeks both groups reported 50-75%  fewer hot flashes.  The acupuncture group reported no side effect and other improvements such as  improved sense of well being, more energy and higher sex drive.  The antidepressant group did not experience these benefits.

This is useful information to those of us who may be struggling with menopausal symptoms but do not want the side effects of hormone therapy or antidepressants.  Although most health insurance companies do not cover the cost of acupuncture, it is eligible for reimbursement from a health care  flexible spending account.  Many large health care organizations around the country have Integrative Medicine Centers were you can be assured of getting well trained, reliable practitioners.  If you are interested in more information and live in  southeastern Michigan, contact Henry Ford Center for Integrative Medicine  at 248-380-6201.  Tell them you are “poking around” for some answers.

written by Deborah McBain, CNM MSN

Test your knowledge of menopause.  Learn all this and more at one of our Menopause Support Circles.  Meetings are held in 4 locations and 4 dates this month. Facilitators are expert  Henry Ford Health System physicians and nurse-practitioners ready to answer your questions.

1.  You know you have reached menopause officially when:

A.  you have not had a menstrual period for 12 months.

B.  you can’t remember when you had your last menstrual period

C.  you’ve had it up to here with your husband, your kids, your boss, your life…

D.  you can’t remember…

2.  The cause of menopause is:

A. a natural decline in estrogen production by the ovaries

B. surgical removal of  the uterus

C. surgical removal of the brain

D. a natural shriveling of the brain

3.  Perimenopause is:

A. a time immediately before menopause  and when symptoms of menopause are occurring.

B. when symptoms are often more severe than actual menopause

C. characterized by heavy, light, short, long, irregular, regular, painless or painful  periods.

D.  Hell

4.  Hormone  therapy is:

A.  the only good treatment for menopause

B.  dangerous therapy for any woman unless “bioidentical”

C.  prescribed to keep the heart, bones and skin healthy.

D.  reasonably safe  for healthy women whose hot flashes are bothersome.

5.  Once menopause is reached it will last until:

A. you stop having hot flashes, about 6 years

B.  you die.

C. you go on hormone therapy.

D. Age 70

Answers:

1.  A, natural menopause is diagnosed retrospectively after no menstrual period for one year.  There is no reliable blood test for menopause.  2.  A,  surgical menopause occurs with removal of the ovaries.  3.  A is most correct.  B, C, D can be true for many women but some women just sail through these changes without a lot of problems.  4.  D,  see the other posts on this blog for more information on hormone therapy and alternatives. 5. B,  Menopause means menses ( periods) stop.  You never go back.  You will be there until you die.  That’s not a bad thing.  It’s a natural part of the life process.  Understanding the process of menopause will help you develop a strategy for coping with the physical changes and recommit to a healthy life style.  Although change can be challenging, it is also a time for reflection and re-evaluation.  Approach menopause with positive thinking.  Science has confirmed this can be helpful in reducing hot flashes, insomnia and pain.

written by Deborah McBain, CNM MSN

Among the myriad of perimenopausal and menopausal symptoms, hot flashes seem to be among the most troublesome.  This post will address this burning issue (burning, get it?).  Ahem, yes, well what causes hot flashes?

What causes hot flashes is a question that even the experts continue to debate!  Although why hot flashes occur is not fully understood, it is generally agreed it is related to decreasing estrogen in the body.  There are hot flashes and then there are HOT FLASHES.  Some women have just a few and can live with them and some have frequent and severe flashes and are totally incapacitated by them.  Some women may not experience hot flashes at all.   Many women learn to recognize certain things which trigger hot flashes or make them more severe and frequent.  Stress, alcohol, spicy foods, hot foods, warm temperatures are common triggers to hot flashes.  Some medications or cancer treatments may cause hot flashes or make them worse.  Hot flashes may start years before the actual menopause (remember, that is 12 months after the last menstrual period)  and some women may continue having hot flashes ad infinitum!  Experts estimate an average of 6 years of hot flashes. (But I know someone who shall remain nameless who is going on 10 years)

Many women may be able to lessen hot flashes by avoiding triggers mentioned above.  Dressing in layers and keeping homes cooler is a common sense solution.  Slow, controlled deep rhythmic breathing, known as paced respiration, practiced twice a day can decrease hot flashes. Take a slow, deep breath, hold it for a few seconds, and exhale just as slowly. Paced respiration may also help relieve a hot flash when started as the hot flash begins.  Herbs have not been shown in studies to be particularly helpful and may have side effects.  Herbal supplements are not well regulated and some brands may not have very much of the herb in them at all.  Although Black Cohosh has been shown to help some women with hot flashes, long term effects are not known.  It has been associated with irregular uterine bleeding and is not recommended to be used longer than 6 months.

For those women whose hot flashes are disrupting their ability to function, estrogen therapy may be a saving grace.  HT has gotten a bad rap since the Women’s Health Intitiative (WHI) stopped a study of  women on estrogen and progestin therapy (EPT) in 2001 after they had a larger than expected number of cardiovascular complications.  The women in the study who had a history of hysterectomy and were on estrogen therapy (ET) alone, without progestin did not experience these side effects.  Women with a uterus and taking estrogen need progestin to prevent cancer from forming in the lining of the uterus.  Since that time there has been a better understanding about how EPT effects heart and blood vessels in women in different age groups.  There is evidence that women starting EPT in perimenopause or within 5-10 years of reaching menopause do not have the same risks on EPT as women starting at an older age.  It also appears that it is the progestin in combination with the estrogen which may contribute to a slight increase in breast cancer, but only after 5 years of use.  Clinicians and researchers are looking at different ways to give progestin to minimize this risk.  HT is considered by menopause experts to be reasonably safe for many women and can dramatically improve quality of life for those who suffer severe symptoms.  Some women are not good candidates for HT because of health conditions such as a history of blood clots, heart disease or breast cancer.  For those women, relief can sometimes be found in non-hormonal medications such as clonidine, gabipentin or effexor.  Beware of individually compounded bioidentical hormones.  There is no evidence that these are safer or more effective than FDA approved products.

written by Deborah McBain, CNM MSN

What symptoms are normal and what is not normal during menopause?
During the perimenopause, irregular menstrual periods which may be longer or shorter, heavier or lighter, skipped periods or periods starting every three weeks are all within the norm. Periods coming less than every 21 days or lasting over 7 days should be reported to a health care practitioner.   Spotting between periods or after intercourse should also be evaluated.  Once menopause is reached, any vaginal bleeding should be investigated by a health care practitioner.  Often these irregularities are a result of  hormonal changes but occasionally they can herald more serious problems which should be ruled out.

Some women sail through perimenopause and menopause with nary a problem. Some have all the symptoms in the book.  Hot flashes, mood swings, trouble sleeping, skin changes, dizziness, heart palpitations have all been attributed to the hormonal changes of perimenopause and menopause.  Many women find these things manageable and do not need treatment.  It is best to discuss symptoms with a health care provider.  He or she can determine if any symptoms are suspicious for diseases like thyroid disease which may minic menopausal symptoms.

Symptoms of depression, weight gain, decreased sex drive, sleep disorders and memory loss are commonly atributed to menopause.  Studies do not show a strong relationship between these symptoms and hormonal levels.  These symptoms are often more related to stress or aging.  Unplanned weight gain or loss for which there is no explanation should be looked into.  Any symptom effecting one’s ability to function at home or at work should be investigated.

Coming- Part 3- ”Ok so now what do I do?”- Remedies and Solutions.

written by Deborah McBain, CNM MSN

The month’s theme for the support group meeting on Thursday, September 18 is the Mystery of Menopause. Over the next few weeks I will be addressing common questions about menopause, symptoms and treatment. I welcome your comments and questions.

Every so often a woman will come to see me and complain that her periods are getting irregular, she is having hot flashes, maybe some moodiness.  “Can you give me a blood test to see if I am in menopause?” she will ask.   The fact is that no women knows the exact moment when natural menopause occurs in her life. It is only after a year of no menstrual periods that anyone can know that she has reached menopause. No blood test, hormone test, medical professional or exam can tell her.  Before that time she is perimenopausal (and those symptoms can last for several years).  After that time until she dies, she is post menopausal (and hopefully that will last for many, many years). That single moment when the exact balance between hormones occurs and stops the monthly ebb and flow which results in menstrual bleeding is a mystery.  Any blood tests done are simply a snap shot of where hormones are at that moment in time.  And hormones can flucuate wildly  during the perimenopausal years.  Just as adolecence is a process that occurs over several years so is menopause.  Perimenopausal symptoms may begin in the 30s. Natural menopause generally occurs between ages of 45-55, average 51.  Before age 40 it is considered early menopause. Menopause can also be induced by surgery and with medications. Sometimes blood tests are appropriate to rule out other problems whose symtoms can mimic menopause, such as thyroid disease.  If a woman is in her 40s or 50s and having typical symptoms I usually don’t need a blood test to tell her what is going on, but I certainly can help her understand the natural process and help her develop strategies to manage symptoms. 

Coming, Part 2- What is normal and what is not during perimenopause and menopause.

written by Deborah McBain, CNM MSN