Managing the Change: Perimenopause and Menopause -- Christiane Northrup, MD -- 06/26/02

WebMD Live Events Transcript

Dreading menopause? Don't! According to Christiane Northrup, MD, "the menopausal transition is actually a profound developmental stage" that "ushers in the springtime of the second half of life." She joined us on June 26, 2002 to answer questions about perimenopause and menopause.

The opinions expressed herein are the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Hello, Dr. Northrup. Welcome back to WebMD Live. We have so many questions for you today. Let's get started.

Member: My question is how to avoid UTIs during perimenopause. Is there a connection between UTIs and thinning vaginal tissue? My "creative way of releasing my sexual energy" isn't working.

Northrup: What happens is the outer 1/3 of the urethra, the tube that goes from the bladder to the outside world, is estrogen sensitive. And when estrogen levels fluctuate, this tissue can get irritated. There are a couple of ways to go about treating the problem:

1) Increase foods that have safe estrogenic effects (soy food). You would need six servings a day. And colorful foods like blueberries and cantaloupe.

2) Depending on the severity of the problem, you can just use estriol or estradiol vaginal cream, just a little dab in the upper vagina at about 12 o'clock (in vaginal circle). After a week or two of daily use, the tissue will thicken and the urinary tract symptoms will go away.

Over the long haul, though, changing your diet and using a high-dose soy can often do the same thing. It depends on how many hormones your body makes (health of ovaries and adrenals is what determines this). But this is easy to treat. No one should have to suffer from this.

Member: I began taking HRT about eight years ago to alleviate nights of poor sleep and increasing occurrences of hot flashes. Gratefully, my periods ceased completely within two years or so, but I seem to perspire so easily nowadays -- just trying to blow-dry my hair or the make the bed -- even eating a meal makes me flush and my nose run. I take very small doses of Lipitor and Synthroid daily. What makes me so hot all the time?

Northrup: We know that hot flashes are essentially from some shift in brain chemicals known as neurotransmitters. And any kind of physical activity can increase them, but they are mostly related to emotional stress. In studies done on hot flashes, there is a 90% response rate from meditating 20 minutes twice per day. And most women notice if they are at a spa and eating a whole-food diet -- in a controlled environment -- their hot flashes are much less.

In the real world we react to things, and when you get past menopause, many women are more sensitive to changes in their environment. The usual treatments that work are things like a 1/4 teaspoon of natural progesterone cream on the skin once per day (about 30 mg), and it's been shown to relieve hot flashes; taking soy as a whole food can decrease hot flashes; and of course the gold standard for decreasing hot flashes is HRT of some kind, usually including estrogen. There are multiple ways to relieve hot flashes, and ultimately you need to choose the one that seems like it's most sympatico with your belief system or lifestyle. I'm a big fan of acupuncture and Chinese herbs -- one of the most effective modalities for treating hot flashes.

Women need to know, however, that mild to moderate hot flashes are fairly normal and not life-threatening. They also go away over time.

So perhaps nothing needs to be done. Hot flashes are often made worse by drinking alcohol (particularly red wine) and eating foods containing refined sugar.

Member: What can you do for heavy perimenopausal bleeding?

Northrup: This is such a common problem. And it results from estrogen dominance, usually. And that means that your body is building up more and more endometrial lining inside the uterus, without the progesterone of regular ovulations to do a monthly cleanout in the form of a regular period. What happens is you get the equivalent of a waxy build up on a floor and it comes out at once or at an inconvenient time. It's one of the No. 1 reasons why women have hysterectomies or other surgery at midlife.

There are medical treatments for the problem, including ablation of the lining of the uterus (a day surgery), but it's always best to start with something simple. Changing your diet so that your body will balance hormones naturally is a good place to start. That means cutting back on or eliminating all refined carbohydrate foods (cakes, cookies, candy, white bread, bagels, pasta) -- all the foods easy to grab on the run -- they are almost always loaded with refined carbohydrates laden with fat. They promote estrogen dominance. On the other hand, a diet rich in protein, such as eggs, turkey, fish, tofu, beans, cottage cheese, etc. and moderate in healthy fats will favor hormone balance and also balance brain chemistry so that your mood is better. (Many midlife women follow diets that are high in carbohydrates and too low in fats, and too low in calories -- and that in itself can lead to hormonal imbalance and even depression). Often you can get your periods under control in about a month of healthy whole-food eating.

You can also use birth control pills as a stopgap measure while you are cleaning up your diet. But remember, birth control pills simply mask the underlying imbalance and they do not cure it. And you need to be sure that you are checked out for the presence of fibroid tumors. These benign and very common uterine growths can also result in heavy bleeding, depending on their position in the uterine wall. They can be surgically removed, shrunk through medication, or shrunk through a radiology procedure known as uterine artery embolization. In many cases, even if you have fibroids, dietary change will improve heavy bleeding.

Member: Can you have estrogen dominance even with a regular period? I have heavy bleeding the first two days of my menses (I can at times go through a super plus tampon in an hour). I also have suffered from terrible PMDD for a good 15 years.

Northrup: Yes. You definitely can have heavy bleeding even with regular periods, especially at midlife. The reason for this is that even though hormone ovulation has not stopped, it has become irregular and so you get a number of eggs growing at the same time, which increases the estrogen production. It's clear since you have had PMDD for so many years that you have a hormonal imbalance, both in the body and the brain, which of course are intimately connected. I would recommend you read a book called The Diet Cure by Julia Ross, which is a manual for how to improve your mood with the right kinds of foods and supplements.

I would also recommend natural progesterone at least from just before ovulation until the first day of your period (two to three weeks per month) either as a cream or transdermal drop. The creams are available without prescription at the lower doses. It would be ideal to work with a physician who understands how to treat you both nutritionally and hormonally.

Member: Dr. Northrup, I am a 41-year-old woman trying to conceive. I just had CCT results come in and they aren't good: day 3 FSH 19.4, day 10 48.5. I was told I am in perimenopause. Anything I should be doing for the perimenopause while I pursue IVF?

Northrup: During perimenopause, which is roughly defined as a 13-year process during which the ovaries change their function and begin to produce fewer eggs, you can measure FSH (follicle-stimulating hormone), a small protein produced in the brain that tells the ovaries to ovulate. The longer you go toward menopause, the higher FSH becomes as it tries to get a signal that is strong enough to get the ovary to produce an egg. Now, contrary to what most people believe, FSH levels during perimenopause are not static. They change almost daily. And you can help them come down to a more fertile zone through changing your diet, changing your thoughts, and changing behavior, and changing your expectations.

Forty-one is NOT necessarily too late to conceive. We know statistically that fertility for a whole population begins to decline at 27 or 32 (no one knows). In an individual case, though, this may be completely irrelevant. That's why I have personally seen many women conceive babies when they were 40, 42, 45, 47 -- it has to do with biological age, not chronological age. So what you want to do in this case is decrease your biological age. I would check out the web site www.fertileheart.com, which is the web site of Julia Indichova. Her book is Inconceivable. She was told that she could never get pregnant because her FSH was too high and she was too old. She intuitively knew this needn't be the case and went on to have a perfectly normal little girl. She runs retreats for women who want to do what she did.

Another person's work I respect is Niravi Payne -- and Niravi has a wonderful book called The Whole Person Fertility Program. I have referred dozens of patients to Niravi over the years, and she helps them get in touch with the cultural and family "script" they are unconsciously following that is affecting their fertility. In the case of many baby boomers, we believed we could have it all. Only we didn't know any way to have it all except the way that men had it all. And you might say that this entire epidemic of women in their late 30s and early 40s having trouble conceiving is in part related to an overarching belief we all have that "I told you so -- you weren't a good girl and didn't follow the biologic script of your mother, grandmother, of the last 5,000 years of human history. So now you are being punished."

The mind-body connection is so powerful that it truly can affect fertility just as diet affects fertility. So while you're going through the technology of fertility enhancement, you can aid the process by being open to these other aspects of the entire subject. Niravi's web site is www.niravi.com.

Member: I am a small, petite, 5' woman who is going to be 57 in July and have been in menopause for five years now. It was not too bad until last year, when I noticed that I was too dry. Sex started to become impossible. I went to my annual physical and my doctor prescribed Estring to insert into the vagina. It helped with the dryness, but sex was still painful. Since it was only good for three months, I was too relieved to remove it. But now, I suppose that there is something else that I should be able to use. I do not like to swallow estrogen pills for fear of any form of cancer. I would like something that is effective and can help me enjoy sex. I am in pain every time my partner and I do it. He joked that I turned into a virgin!

Northrup: This is a perfect situation for a small amount of estriol vaginal cream. You start with a daily application (prescription -- and it's available from all formulary pharmacies). And I have information where doctors can get it in my books. You use it daily for a week. Then every other day for a week. Then every three to four days thereafter.

In addition to that, and possibly to replace it over time, I would recommend Revival soy (either a bar or drink) that you take daily made from whole soy. After a month or two of being on it daily (it's very, very good for protecting the male prostate, too) it actually will thicken the collagen layer of the skin in both the body and in the vagina. The vagina and urethra are estrogen sensitive. You can visit the Revival web site at www.revivalsoy.com and you will see the studies on this product. I've taken it daily for three or four years and have not needed any other supplement for menopausal needs.

Also, don't stop having sex. The more you use the vagina, the more functional it will remain. For a week or two while thickening the vaginal lining, you may want to avoid intercourse though. After that you should be fine.

Member: Will the estriol vaginal cream affect fibroids?

Northrup: It does not appear to. That's one of the nice things about estriol is that it has a potent local effect, but it doesn't have much systemic absorption, so for women who have had breast cancer and fibroids -- anyone who has a problem with estrogen -- a small amount of estriol is negligible in terms of estrogen effect.

Member: I have skipped my period for two months in a row. My FSH level shows I am postmenopause. I had hot flashes for the first month I missed, but only a few now. I'm 36. Is it possible to be postmenopause so soon?

Northrup: It is possible but not likely, and I'm so glad you wrote in. You represent a subset of women who appear to be going through menopause sometimes because of severe stress in their lives. Their ovaries turn off a bit. Then when stress abates, they go back to having regular periods for years. We are taught once the FSH is in the postmenopausal range, that's it. It's over and you're past menopause. This is simply NOT true. If you were in my office I would ask you what has been going on in your life for the last couple of years, and I know that together we could figure out why your ovaries are doing this, unless you are one of the relatively rare people who comes from a family where all the women go through menopause between 35 and 40.

Member: It is normal to have frequent spotting and hard periods nine years into perimenopause?

Northrup: It can be. It's not the norm, but we certainly see it. Again, what I would want to know in this case is what is the endometrium -- uterine cavity -- like? Sometimes you can have endometrial polyps that cause the spotting. During this entire perimenopausal transition all kinds of things can happen because you are really going through adolescence in reverse, with the same kinds of hormonal and mood swings that went on when you got your period in the first place. If you have not already done so, and assuming you have been thoroughly checked out by your doctor, I would recommend seeing a good acupuncturist or herbalist (with a master's in acupuncture) and who is regulated in all of the states.

Member: I am 47 years old and in perimenopause. From hindsight, it has been going on for nine years. Since April I have been spotting continuously, and a few days ago I had a flow from hell. Will this ever stop? I have heard perimenopause can go on for 15 years. I don't know that I will make it. I had a physical last September but will be going in for another in 2 weeks. I'd appreciate any insight you might have for me.

Northrup: If you just had a difficult period but the periods have not been this bad up to now, chances are good you are reaching the end of the process. When women look back to the storminess of both their lives and their periods during this transition time, they are often thrilled by the peace and calm that awaits them on the other side. This is such a perfect time, however, to improve your diet, to include exercise, to clean up all your relationships. Your life and your body are demanding it. That's what the symptoms are related to. All the work you do for improvement now will pay off a hundredfold in the next decade of your life. Use this time as the wake-up call that it truly is.

Member: I had a partial hysterectomy about 10 years ago. According to my doctor, I have already gone through menopause and by his recommendation I continue to take a low dose of Premarin. I have heard negative things about Premarin due to the cancer concern. Is there something safer out on the market, herbal, that would give me the benefits of taking the estrogen, just not the possible risk? Your input would be greatly appreciated. Also, my doctor doesn't know anything about the "saliva" testing of the hormone levels. Could you expand on that subject as well?

Northrup: It's always good when you are on an HRT regimen to have a hormone level checked in the blood and saliva. There are many labs that do these. This prevents overdosing on estrogen. And one of the big problems we have with HRT research is that most of the women have been given Premarin at standard doses that don't address wide individual variations between different women who are on exactly the same dose.

You can have a 20-fold difference in blood levels between two women on the same dose. It's good medical practice to check the dose and your levels so you are not being overdosed. In time, you can tell by how you feel, but in the beginning, it's just good to get that information.

In terms of types of estrogen, Premarin is a hormone designed to support a pregnant horse. And it was historically the first estrogen that was ever available for human females. As such it was the only choice. We now have the ability to make estrogen to match exactly the estrogens found in the human female body. And these are known as bioidentical estrogens. Now, there are also plant estrogens that are very safe. Humans evolved ways to take plant substances into their bodies. I am not sure we were designed to process hormones from horse urine, and it's hotly debated.

It seems to me the safest way to proceed is to get your estrogen through something like soybeans and plants as the safest thing, but I don't like soy in capsule form. I like soy as food. That is not strong enough for some women, so my second choice is to take small amounts of estradiol as the estrogen. Some brand names are Estraderm patch or the pill Estrace. The main thing to remember is that HRT is an art as much as it is a science. And you just have to work with it a little bit and change the dose. Don't be afraid to experiment until you come up with what works. Many times when you improve diet and lifestyle, you find you don't need much in the way of dosage because your body has the ability to manufacture hormones at any age with health adrenals and ovaries.

Member: I am way past menopause and have been on Premarin for over 20 years ("good for bones," the doctor said at the time). I am getting worried about cancer (it is in my family) and would like to stop taking Premarin. Can this be done "cold turkey"?

Northrup: Don't stop cold turkey or you will create all kinds of symptoms you don't need to suffer from. Here's how you do it:

  • You want to replace it with something like black cohosh or Revival soy. Get this (one or the other) in your system first. Get some kind of hormonal support in your body first.
  • Then you choose a day, and every third day, stop your Premarin, but resume it the next day. That's one less pill per week.
  • Then the following week do two fewer pills for two weeks.
  • Then on the third week you take it about every other day. You drop three pills for three weeks.
  • And then on the fourth week you take it about twice per week. Keep it going for four weeks.

After that you can probably stop altogether, but that way your brain and your body have gotten gradually used to a different hormonal level, and in the meantime the estrogen receptors are being stimulated by the soy or herbs so they won't be screaming at you. You should be relatively symptom free from then on, but you may have a few hot flashes. It's OK.

Member: Dr. Northrup, my mom is going through menopause and she did not have her period for about a year, and now she is spotting and she is afraid that she has cancer. Is it normal for her to all of a sudden get her period again?

Northrup: Yes, it is. It happens all the time. What is common is that you will go like nine or 10 months and then because of some kind of family event or change you get your period. With me I took my daughter to college and got my period. I know it was taking my youngest to college. Many women say the same thing, like when their mother died or their daughter gave birth. In this case what you do is see if there is some family event that could be related. If it continues, get it checked out. Modern medicine is good at making a diagnosis. In all my years of practice of testing thousands of women with this pattern, I think I picked up one cancer.

Member: Dr. Northrup, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Northrup: Midlife turns out to be one of the most important rites of passage we have during our entire lifetime, and more changes happen to a woman during midlife than at any other time in her life cycle. It feels like all is coming together and hitting the fan at the same time.

Out of this chaos can come almost like an entire new life -- an entire new healthier life. A new physical body and new healthier relationships. So you can trust your body and what it's telling you during this time. It's leading you toward health and freedom and joy. Please trust that. I know it doesn't feel like it.

Moderator: We are out of time. I'm sorry we couldn't get to all of your great questions. Our thanks to Christiane Northrup, MD, and thank you, members, for joining us today. For more information, please read The Wisdom of Menopause and Women's Bodies, Women's Wisdom, both by Christiane Northrup, MD. You can also visit Dr. Northrup's website at www.drnorthrup.com. Please check out our news stories, features, and archived interviews with experts -- visit the Menopause Center and Living Better: Healthy Women on WebMD.

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