A Woman's Guide to Menopause and Perimenopause

Last Editorial Review: 4/25/2005

WebMD Live Events Transcript

If you have questions about menopause or perimenopause, you've come to the right place. Mary Jane Minkin, MD, joined us from the Yale University School of Medicine on April 6, 2005 to answer your questions about hot flashes, HRT, depression, sexuality, healthy lifestyle choices, and more.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Welcome to WebMD Live. Our guest today is Mary Jane Minkin, MD, co-author of A Woman's Guide to Menopause and Perimenopause. She is here to answer your questions about menopause and perimenopause.

Welcome to WebMD Live, Dr. Minkin. After all of the discussion about hormone replacement therapy (HRT), I'm surprised to see ads for it again on TV. Can you bring us up to date on HRT?

One reason we're seeing more information is the fact that part two of the women's health initiative (WHI) came out about a year ago, and that was for women who had had a hysterectomy and who were being given estrogen alone, no progestins.

That study showed actually a reduction in breast cancer in the women taking estrogen. This caused people to rethink the first part of the initiative as well, and a new set of guidelines came out this past fall from the North American Menopause Society (NAMS).

The web site of NAMS is menopause.org, where you can read that the guidelines have changed and indeed, the experts are now stating that if you need estrogen for relief of symptoms, it is quite reasonable to take it, under a health care provider's supervision.

The symptoms they particularly single out are:

Of course there were problems with the WHI design originally, because it was not designed as a study of younger women going through menopause. It was really seeing if estrogen given to older women helps prevent heart disease.

Indeed, in that study, it did not, but for starters, the average age of women starting the WHI was 63. And of course they also only looked at one preparation of estrogen and progestin, namely Prempro. You should, of course, speak with your health care provider if you have any symptoms of menopause.

"Women can start getting menopausal symptoms way before they hit their last menstrual period and they can get symptoms for five or sometimes even eight years before they hit true menopause."

Can you define menopause?

Technically it's what I call a retrospective diagnosis, because you have to go a full year without a period to officially say you're in menopause. Until that time, you are technically in perimenopause.

Now, women can start getting menopausal symptoms way before they hit their last menstrual period and they can get symptoms for five or sometimes even eight years before they hit true menopause.

These symptoms can include:

All of those can happen way before you hit the final period and go that full year.

I am 45 and still having my period, but I am very irritated at times. Sometimes I am the most irritated with the people I love. Is this normal? Also, almost every night I wake up sweating. Are these all signs of menopause?

The answer is quite possibly, and the problem is it's impossible to say for sure, because there is no true blood test of perimenopause. However, one thing that one could easily try is either a little estrogen or, and this may sound crazy -- low-dose birth control pills.

If all the symptoms resolve, I would think that these were related to perimenopause. Now of course, some of these symptoms can also be related to PMS, which can occur years before menopause. Again, sometimes birth control pills will help.

Of course, good exercise and diet will help also. And for PMS or bad PMS, some people have been using SSRI antidepressants, which can work very well for women with PMS.

I am 54, have gone six months without a period and am using Menostar for hot flashes. I have been feeling premenstrual for three weeks with tender breasts. Is this normal even if I do not have a period?

The answer is yes. First of all, a period could still show up because it hasn't been that full year since your last period.

Also, even though you're not getting your period, the ovaries aren't totally dead. There certainly can be a sort of lower level of ovarian activity, which may give some symptoms without enough hormones around to produce a period. So these are very common feelings.

I have gone almost two full years without a period and still am getting hot flashes every day. How long should I expect to keep getting hot flashes?

Another excellent question. For most people at this point, the hot flashes would tend to get better. The bad news is that a study came out about a year ago looking at women 10 years postmenopausal and indeed, 3% of the women -- even 10 years postmenopausal -- continued to have severe hot flashes, with another 12% having moderate to severe hot flashes.

Now that's 15% of all women, even 10 years into menopause, who will continue to get significant symptoms; 85% of women will get much better. But it's unfortunately not all that rare to have symptoms this long.

As far as therapy is concerned, simple things like layered clothing and avoidance of triggers -- like alcohol and hot beverages -- can be helpful. Of herbal type of approaches, soy and soy products can be helpful, as can flax seed. Also black cohosh will help some people.

Of course there are always hormonal approaches with estrogen. For women who don't want to take estrogen -- but for whom things like soy and cohosh don't work -- again certain antidepressants have been shown to be helpful. Most notably Effexor has been shown to help with hot flashes, and there are also a few new studies looking at Neurontin for hot flashes.

"I think that there are very few women who absolutely cannot take HRT."

Do the symptoms you experience during the perimenopausal period go away after menopause?

Some definitely should get better. In general, hot flashes do for most people get better. Sleep sometimes does, and sometimes doesn't. Unfortunately the one that can get worse, and I hate to be honest, is vaginal dryness, as estrogen levels go lower and lower. The good news is we can fix all that.

What can you recommend for vaginal dryness? I use lubricant when having sex, but my biggest problem is the itch because of the dryness. It's making me miserable.

Don't be miserable. Lubricants are terrific, and one my patients like a lot is Astroglide. I love the name. As far as other approaches, there are some very nice little vaginal tablets called Vagifem that you can pop into the vagina a couple of times a week. They dissolve and moisturize the vagina very nicely and they don't significantly give you estrogen in your bloodstream.

You can also use a vaginal cream of estrogen like in Estrace and Premarin, and you can actually rub that around the vulva and the opening in the vagina if you're itchy.

These are safe to use and I think you should talk to your health care provider about getting prescriptions for some.

How do I know if HRT is for me?

I think that there are very few women who absolutely cannot take HRT. For example:

  • If you have active blood clots, phlebitis, you shouldn't take HRT.
  • If you have active breast or uterine cancer you should not take HRT.
  • If you have strange vaginal bleeding that has not been explained you shouldn't take HRT.
  • If you are too anxious about HRT, worrying about getting breast cancer, you shouldn't take HRT.

But most other people can consider it. Basically I think for most other people it should be an option to think about.

What can be done waking up at 3 a.m. and not being able to go back to sleep?

This is a huge problem. I think the sleeplessness is the worst problem for most women. Help for the problem might include:

  • Estrogen works fairly well for the sleep issues.
  • Soy and cohosh may help.
  • One could try sleeping medicines. (The problem with sleep medication is a concern about habitual use.)

About sleeping medicines: one my patients seem to find helpful is Sonata, a prescription medicine. The advantage is that it is fairly short acting. That means for a typical menopausal woman who goes to sleep at 10 p.m. but then wakes up at 1 a.m., sweating, taking a Sonata is OK and she should still be able to get up at 6 a.m.

If you have decreased or zero sex drive and cannot take estrogen, are there any other options?

Another excellent question. One question I would first ask is, is the vagina OK? Because if the vagina is very dry and sex is uncomfortable, most women don't want to have sex. I would address that first if that's an issue.

You can use vaginal estrogens, even if you cannot be on systemic estrogens. So something like Vagifem would be OK with most doctors. Now, if the vagina is totally happy but you still have no libido, then one can consider other options, like testosterone, which can be made up at a compounding pharmacy, and some doctors recommend DHEA.

Those are other options that may be involved in libido. The problem is that in women, libido is a much more complex issue than it is in guys.

"The good news is that some of the things that help both perimenopause are the same things that help PMS."

How can I tell if it is PMS or perimenopause?

The answer is: you can't, unfortunately. The good news is that some of the things that help both perimenopause are the same things that help PMS.

  • Getting your heart rate up three to four times a week for 45 minutes or so will help.
  • A good balanced diet will help.
  • Some find calcium supplementation will help. (You want to make sure you are getting in 1,000 milligrams a day of calcium.)

Those are all good things for PMS and perimenopause. Birth control pills may be helpful for both. One pill in particular that has been shown to be helpful for PMS is a pill called Yasmin. Again, SSRI antidepressants may help with PMS.

So many of these things are quite reasonable to try for either one.

What makes one antidepressant better for hot flashes than others?

As far as hot flashes are concerned, there is more data on Effexor. It does seem to be a better drug for hot flashes. SSRIs are a bit peculiar, because for some women, certain SSRIs may actually lead to more sweating, whereas for other women, these same medications may take care of the hot flashes.

In general, if I have somebody whose chief complaint is hot flashes without depression, I usually go to Effexor.

How does exercise help perimenopause and how much do you suggest each day?

Certainly exercise increases the happy hormones in the brain - endorphins -- and they make you feel better. As far as sweating is concerned, it's interesting, exercise probably won't prevent sweating, but it may make you feel better dealing with the hot flashes.

But the other thing that a good aerobic exercise program will produce is probably a better night's sleep. As we know, sleep disruption is a major problem for many perimenopausal and menopausal women. Of course, the two biggest conditions that women need to think about postmenopausally -- from a strictly health perspective -- are heart disease and osteoporosis. Both are helped substantially by exercise.

Now as far as how much exercise, usually the more the better. So if someone says to me that she can do only 10 minutes, three times a day, I say that's terrific. If she says to me that she can do an hour and a half every day, I say that's very terrific.

The government has recently issued a report saying they actually recommend an hour-and-a-half exercise every day to promote weight loss. Now realistically most of us can't do anything near that, so I would recommend just doing as much as you possibly can.

Please talk about bioidentical hormones, the possible side effects, and any information you have on women who are currently taking them.

I think bioidentical hormones are great. What I tell my patients is that I have been prescribing bioidentical hormones for over 20 years.

The oral tablet of Estrace, which is 17 beta estradiol, is exactly the same active estrogen that our ovaries make. It is also available in transdermal patch form. We also have been using natural progesterone for many years, and that is available as a medication called Prometrium.

Women in general seem to be doing well with bioidentical hormones. The problem that can be voiced is, "Do the results of the WHI pertain to 17 beta estradiol and Prometrium, since the WHI used only Prempro?"

Unfortunately, we do not know the answer. As an aside, I can tell women that there is a new study starting shortly called the Keeps trial, and that will involve looking at transdermal patches, Climara patches, and Prometrium, but unfortunately, we won't have data from that study for another five years. To reassure women, there are ongoing new studies coming out.

"If your gynecologist doesn't feel comfortable dealing with estrogen in this situation, you might want to contact the North American Menopause Society (menopause.org) to find a menopause clinician in your area to talk with."

I had a hysterectomy at age 36; because I have a clotting disorder I can't take HRT. What will help me with the side effects of menopause?

Discuss with your gynecologist and doctors about using a patch form of estrogen, because there is data now that shows that patch estrogen does really not significantly increase the risk of clotting.

So you may actually be able to take a small dose of a transdermal estrogen, but I would talk to your doctors about it first. In general, for women who do not have clotting disorders and are as young as you, we would usually recommend taking estrogen. That's because we do have a lot of information on such young women experiencing much higher risks of heart disease and osteoporosis if they are not given estrogen.

If your gynecologist doesn't feel comfortable dealing with estrogen in this situation, you might want to contact the North American Menopause Society (menopause.org) to find a menopause clinician in your area to talk with.

I also have IBS. Do you think it may totally disappear after menopause? I understand menopause can aggravate symptoms of IBS.

There are a couple of old studies looking at IBS and the menstrual cycle, and there certainly are reports of women who have as a manifestation of their PMS symptoms irritable-type bowel symptoms.

Now, for these women, usually their symptoms will get better with menopause, because there is less fluctuation in hormones during the cycle. So yours may. I don't see too many women getting worse with menopause. Much of the time it will stay the same.

Can a hot flash also be just an overall burning hot sensation from head to toe without sweating?

Hot flashes can show themselves in many, many ways. The typical hot flash usually involves the "neck up" area, face getting red, and feeling flushed. I have a couple of patients who get what I call the "Mr. Spock hot flash" -- just their ears get red. Some people get a hot flash that involves their whole bodies. It can be very variable.

I'm 56 and my last period was in May 2004. I am experiencing all of the above-mentioned symptoms. What happens after I am officially "in menopause"? Will any of the symptoms subside without HRT?

Well, usually the hot flashes for most women get better in two or three years, and the mood issues get better.

For some women, unfortunately, they don't. The question then is: is it worthwhile switching to something like Effexor? And again, one can always consider HRT. I don't think women should rule that out, especially the very low doses which we have now; they seem to be very effective for many women.

Do you think coffee and chocolate aggravate symptoms of perimenopause?

They may aggravate certain symptoms, particularly if you get things like palpitations and sweats. Caffeine can cause palpitations and of course coffee and chocolate have their share of caffeine in them.

I think that one piece of chocolate or two will not produce a lot of bad symptoms for women. And now we have data that dark chocolate is good for you. Maybe a piece or two of dark chocolate is a nice thing to do for yourself.

I would avoid an entire chocolate bar because I think that would aggravate symptoms. When talking about PMS, the example I use is the plant Audrey, in The Little Shop of Horrors. She says, "Feed me, Feed me!" but unfortunately, what Audrey asks for may make us feel worse, particularly things like a lot of chocolate and potato chips.

"It is not a disease; it is a natural state of affairs. However, some women can be absolutely devastated by hot flashes, sleep disorders, irritability, things of that nature, and they can be really compromised with their life's functions."

I'm 49 and have been taking evening primrose for my night sweats and hot flashes. It really seems to have helped. Have there been studies on this?

Yes, and they haven't shown great success. However, I find evening primrose oil for my patients with PMS. I also have them take vitamin B6 as well and I find the combination works very well for them.

My patients say that the evening primrose oil will help them for hot flashes and if it works, I encourage them to continue with it because I think it is a very safe substance.

You mentioned getting testosterone at a compounding pharmacy. Do you need a prescription? And what about testosterone causing facial hair and deeper voices in women?

Yes, you do need a prescription, and yes, the major side effects of testosterone are masculinizing side effects.

However, my standard line to my patients is that what you will notice, if you get some side effects from the testosterone, would be a few stray facial hairs and that I can promise you will not wake up looking like Osama Bin Laden.

My favorite story about this is about a patient of mine who I put on testosterone many years ago. After about six months she called me up to say she had noticed a few stray facial hairs.

I told her to start using her testosterone every other day. I will never forget her voice when she said, "Uh-uh, oh, no!" She really loved what the testosterone was doing for her libido and she was extremely reluctant to cut down the dose at all.

What do we have to do to get people to look at menopause as a stage of life and not a disease? I understand some women experience some symptoms ranging from mild to severe, but it really isn't a life-threatening illness. It's a part of the life process.

It is not a disease; it is a natural state of affairs. However, some women can be absolutely devastated by hot flashes, sleep disorders, irritability, things of that nature, and they can be really compromised with their life's functions.

Don't forget that in the year 1900, the average female life expectancy was 48 and the average age at menopause was 48. So as I say to my patients, we were biologically supposed to go through menopause and die.

Fortunately, thank goodness, we are now surviving, God willing, hopefully into our 80s or 90s and we want to live healthy and productive lives. For many women, menopausal symptoms and postmenopausal health problems really can compromise this.

So I think the most important message I would like to convey is that all of us are wonderfully individual and many of us will need no guidance and help and do well without intervention, but for some women a little help from our friends can be very helpful.

Our thanks to Dr. Mary Jane Minkin for joining us today. For more information, please read A Woman's Guide to Menopause and Perimenopause by Mary Jane Minkin, MD and Carol Wright, PhD.

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