“This confirms what we at The Rothfeld Center have long believed, that hormone replacement therapy in menopause should be reserved for extreme cases, and only with an awareness of the risks involved”

Menopausal Myths [a recent Boston Women’s Journal article by Dr. Glenn Rothfeld on the subject of menopause]

Myth #1: Menopause signals a time of declining function.
Menopause is a time of process, a time of change, but certainly not a time of decline. Hormones don’t “stop,” but rather there is a shift, with progesterone present throughout the cycle as estrogen is lowered, and the adrenal glands and fat tissues take up the slack of hormone production. Psychologically, many women experience a shift in thought processes, becoming more intuitive, more right-brained, entering into the “wise-woman” modality phase. Many of the possibilities of menopause are described in the popular book The Wisdom of Menopause by Dr. Christiane Northrup.

With the menopausal female being the most rapidly growing segment of the population, the benefits to society are enormous. In fact, in his recent book The Third Chimpanzee by Jared Diamond, he hypothesized that it was the ability of women to live beyond their child-bearing years, and thus impart memories and wisdom to their off-spring, that enabled our species to transition from apes (who, like other animals, do not go through menopause) to a cultured society in which each generation builds on the previous one.

To some women, many of the symptoms associated with menopause are temporary annoyances, while to others they are virtually disabling. One of the factors that affects a woman’s ability to tolerate menopausal symptoms is the health of her adrenal glands and stress response generally. If a woman enters menopause in a depleted, stressed state, the adrenals are less able to make enough estrogen and other hormones to buffer the loss of production from the ovary. On the other hand, working on good health habits and stress management when younger can go a long way toward making the menopausal change simply that: a change rather than a downward slope. In her book, Dr. Northrup describes menopause as a switch from AC current (cycling) to DC current (constant). But, the light still shines.

Myth #2: Sexuality stops at menopause.
We are a society surrounded by reminders of sex: on TV, movies, magazines, billboards and the evening news. More often than not, sex is portrayed as hot, lustful and above all, young. Yet sex, for men and women both, means something different after “a certain age.” It may be slower, less frequent, more familiar. It can be more relaxed as the fear of unwanted pregnancy disappears. It may be more about intimacy, less about fireworks.

Physically, men and women can continue to have sex as long as it’s comfortable for them. For some women, having an orgasm becomes less critical, for others the ability to orgasm is reduced. Still others experience very little change in their sexual response. Lubrication lessens for some women. This can be taken care of by vitamin E oil vaginally (puncture a capsule and rub it in each night). Herbal phytoestrogen vaginal creams can also be used to maintain the health of vaginal tissue, and estrogens (both creams and oral) may help as well.

Some women experience a loss of sexual desire and sensitivity at menopause. Medical research has focused recently on the androgens, or “male” hormones testosterone and DHEA (dehydroepiandrosterone), which are largely responsible for the sexual sensations and desire in women. Having these hormones measured, and replacing them can lead to a return of sexual sensations. Many women find that the few years of adjustment to menopause are times of less sexual desire, and then it picks up again when they readjust to the life change.

Myth #3: Osteoporosis is a TUMS deficiency disease.
We look for simple answers in medicine, even though the human body is extraordinarily complex. So, calcium-containing antacids and synthetic estrogen replacement are touted as the appropriate treatment for osteoporosis.

This is only partially true. First, let’s look at what osteoporosis is. Bone contains calcium in a matrix of connective tissue. As we age, the bones lose their calcium, leading to weaker bone. This is different from osteoarthritis, which is the wearing down of joints, usually without a calcium loss. It’s not painful, and can only show up on a special x-ray called a bone density test, which measures the bone density against that of a younger person. The danger of osteoporosis comes later in life. Gradually weakening spinal bones can lead to collapse of the spine, with shrinking height and spinal pain. Loss of calcium in the hip can lead to hip fractures, dangerous occurrences in the elderly. Thus, we screen for osteoporosis in the peri-menopausal woman, hopefully to prevent problems 20 years later.

The good news is this gives us more than a decade of working on the good health habits that can prevent and reverse osteoporosis, before problems usually become risky. The current practice of using medications in peri-menopausal women who show early osteoporosis on x-ray needs to be examined in this light. The bad news is that bone loss begins early, before menopause, and accelerates around the time of menopause, so this becomes a concern at any age. In my office, we frequently screen for osteoporosis well before menopause.

So what can you do besides swallowing TUMS? First of all, most antacids contain calcium in the form of calcium carbonate. This is not the most absorbable form of calcium, and anyone with digestive problems (which is probably why you had the antacids in the first place) is limited in her absorption of calcium and other minerals. Calcium citrate, lactate, aspartate, gluconate or other “chelated” calcium are better absorbed. Recently, some products have appeared containing calcium in the form that it is utilized in bone, called microcrystalline hydroxyapatite concentrate or MCHC, and there are studies that suggest that this form of calcium gets into the bone faster.

Calcium is not the whole nutritional story, however, Magnesium, boron, vitamin K, zinc, B complex and vitamin C are all involved in the production of bone and the prevention of its loss. And of course, vitamin D, either oral or from natural sunlight, is critical for calcium use in the body. A good book on the natural treatment of osteoporosis is Preventing and Reversing Osteoporosis by Dr. Alan Gaby.

Estrogen also is not the only hormone involved in bone health. Estrogens prevent the breakdown of bone (osteoclastic activity) but they do not produce bone growth (osteoblastic activity). Other hormones, including progesterone, testosterone, and DHEA, all have osteoblastic activity, and these hormones should be assayed at menopause as well.

Exercise has been strongly shown to prevent bone loss, and light weight training can be started at any age. We recommend Strong Women, Strong Bones, by Miriam E. Nelson and Sarah Wernick. But there’s another lifestyle factor that is overlooked in its contribution to bone health. Stress, and lack of sleep specifically, is probably the single-most contributing factor to bone loss. Chronically elevated stress hormones block bone growth, and increase osteoclastic activity. This is why osteoporosis is a side effect of prednisone, a powerful synthetic version of the stress hormone cortisol. The proper hormonal rhythms that come with restful sleep reset our bone balance so that, the day after a restful sleep, new bone is produced significantly more. We can now test cortisol, melatonin and other hormones on saliva samples to examine how the sleep-wake cycle is functioning.

For those women who already show severe bone loss at menopause, there are innovative new medications now available which help to stem this loss and even build new bone. But, these medications have not been used long enough to assess whether it is wise to take them for 20 years or more. So, in our office we usually reserve them for older women who are already approaching the age where fractures become significant risks. This allows us to focus on the more natural ways of supporting bone health in our peri-menopausal and menopausal patients.

The average U.S. woman lives almost 30 years past menopause. To put it another way, we are getting to the point where woman will live more than half their lives without their periods. Statistics show that about 38% of U.S. postmenopausal women use hormone replacement. This means that we need to be careful that hormone replacement is not merely addressing short-term issues at the expense of the 2-3 decades of remaining life.

To make things more complex, many women are now being put on hormone replacement, not at menopause, but during perimenopause, the few-year period before periods actually stop entirely. Most women who go through menopause recognize that their worst symptoms occur, not after years without their period, but when the periods first start being irregular and when they first stop. Most perimenopausal symptoms actually are due to fluctuating estrogen levels from high to low, rather than the consistently low levels of menopause. In perimenopause, estrogen levels can become higher than any time outside of pregnancy, and then plummet to menopausal levels.

Estrogen, and other sex hormones, have receptors throughout the brain and neurological systems. It appears that the rapid changes in estrogen levels can decrease serotonin in the brain, leading to some of the emotional symptoms like depression and moodiness. Possibly by affecting serotonin in the hypothalamus, estrogen fluctuations affect temperature regulation, leading to hot flushes and night sweats. Frequently, doctors are responding to perimenopausal symptoms by treating with hormones.

Myth #4: Conjugated estrogens (Premarin and others) are the best (or only) options to respond to declining estrogen levels.
The most common estrogen replacement is Premarin, which is made from the urine of a pregnant horse (pre-mare-in) and then altered or conjugated. The body must convert this form of estrogen, called estradiol, to a recognizable form before it’s active. Other estrogen replacements contain estradiol in its natural form (the estrogen patch commonly used contains this form). Still others, used by physicians who are natural medicine oriented, contain all three estrogens that are natural to the body (estriol, estradiol, estrone) since this is a more natural combination, and estriol is reported to have some anti-cancerous properties. Giving estrogens in the form and balance found naturally in the body (called bio-identical) is thought to give a more balanced replacement in menopause.

Whenever estrogen replacement is given, progesterone should accompany it. This is because progesterone helps to counter some of the heavy stimulation of estrogen receptors that can lead to uterine cancer, and perhaps other cancers as well. The problem is that progesterone is not really used that widely. Progestin, the substance in PremPro and in ProVera, is a synthetic hormone that is close, but not exactly, like progesterone. Studies of progestin’s help in balancing estrogen effects are actually mixed, but the switch to using natural progesterone has been a slow one, and not studied well enough.

For a medication used in 38% of the menopausal population, hormone replacement is remarkably controversial in its long-term effects, and confusing as to what a course of therapy is.

Several medical reasons have been advanced as reasons for HRT long-term therapy. Improvement in cardiovascular function and lowered risk of heart disease has been suggested. But, more recent, large-scale studies have doubted this, even raising the possibility that HRT increases the rate of heart attacks in the first year. Early reports that HRT prevents Alzheimer’s Dementia have also been largely unsupported by later research.

Estrogen replacement is still an early intervention for osteoporosis, but as we have seen in the last issue, Menopausal Myth #2, estrogen does not build new bone, and there are better drugs for treating osteoporosis. Any preventive effect of estrogen on osteoporosis will take at least 10 years, at which point the risk of breast cancer becomes significant.

The clearest reason to use HRT is to manage the symptoms of perimenopause and menopause. But when we’re talking about hormones to control symptoms, we have to look at the risk versus benefits. Most studies find a significant increase in breast cancer after about 7-9 years of estrogen replacement therapy. Increases in ovarian cancer show up after about 10 years of replacement. This means that, if we are using HRT to treat perimenopausal symptoms, we are shortening the amount of time that we can use hormone therapy later in the menopausal years, before significantly increasing the risk of cancer. It’s a dangerous trade-off, and one that does not have enough information to make comfortably.

At The Rothfeld Center, as elsewhere, we try to take all factors into consideration in this decision. Here is our general approach, meant more as a point of discussion than a statement that ours is more valid than your own physician’s. This decision must be made with the current information at hand, and in frank discussions between a woman and her physician.

Other risks of breast cancer, like occurrence in a family member, generally rules out ERT. So does history of blood clotting and stroke. Then, we will try to control menopausal symptoms in a variety of natural ways, including herbs like black cohosh, red clover and vitex, nutrients like vitamin E and bioflavonoids, food substances like flax, alfalfa and soy, acupuncture and Chinese medicine, relaxation and yoga techniques, and medications that address specific problems like sleep and depression. Vaginal dryness can be treated locally without fear of increasing cancer risk.

If symptoms are not controlled, we might choose hormone replacement, usually a natural form of triple estrogen and progesterone. Sometimes progesterone alone can control symptoms. At other times, the estrogen patch is chosen and, less commonly, a conjugated estrogen/progestin product. We usually will treat for about 2-3 years, presumably not enough time for cancer risk to show up. Meanwhile, we try to add the natural treatments so that, when HRT is stopped, symptoms will be minimized.

We’ve also been interested in a recent test that looks at breakdown products of estrogen. The liver actually breaks estrogens into a variety of metabolites. One, called 16-hydroxyestrone, is particularly carcinogenic and is increased by various pollutants, drugs and pesticides. Another, 2-hydroxyestrone, appears to be cancer-protective and is stimulated by soy, flax, and various nutrients and antioxidants. The active ingredient in broccoli and similar vegetables, called indole-3-carbinol, also strongly promotes this estrogen metabolite, which may explain those vegetables having cancer-preventive properties. Now, through a urine or blood test it is possible to measure the metabolites and, through diet and supplementation, modify the breakdown of estrogens and, hopefully, have a beneficial effect on both cancer risk and menopausal symptoms.

All books mentioned in this article, as well as Dr. Rothfeld’s published books, are available through The Natural Apothecary.