The Pause that Distresses
“Women have been scared out of their gourds for no damn good reason. The real tragedy is that thousands of menopausal women are going undertreated because they’re worried about that slight increased risk [of cancer].”
For women who live long enough, menopause—the retirement of our reproductive cycle, signalled by the end of monthly menstruation (occuring naturally or as the result of medical intervention)—is as inevitable as death or taxes. The average age for natural menopause has stayed fairly stable over the last few centuries at 51 years, but as we know, the number of us “living long enough” has risen markedly in the same time period. Nowadays, most women can expect to live at least one-third of their lives post-menopause. How happy and healthy those years are depends greatly on how robustly we greet “the change.”
On the one hand, menopause is a liberating time in a woman’s life: No more running to the pharmacy to stock up on tampons and menstrual pads, no more cramps or PMS or “accidents,” no more worries about getting pregnant. But it brings a whole new set of challenges, largely because our ovaries stop producing the hormones estradiol (a form of estrogen) and progesterone, sending their levels into free fall and playing havoc with bodily functions from the skin to the brain. Resulting problems can include hot flashes, insomnia, memory lapses, mood swings and depression, bone loss, heart palpitations (and elevated risk of heart disease), lowered sex drive, achy joints, dry eyes, incontinence/constipation and, according to a recent survey conducted by the online menopause compendium RedHotMamas.org, even gout.
Up until about 40 years ago, menopause was seldom discussed and even less understood, says Mary Jane Minkin, M.D., author, practitioner and clinical professor of Obstetrics, Gynecology and Reproductive Services at the Yale University School of Medicine. “There’s a theory about 19th-century British literature I’d like to explore in my retirement,” she says, tongue just a bit in cheek, “concerning all those stories about kooky ladies in attics. My guess is that Rochester’s wife in Jane Eyre was menopausal when she burned the house down.”
She credits Phil Donahue’s afternoon talk show—which devoted full hours to the subject back in the 1970s—with being among the first public forums to showcase serious discussion about menopause, even though at the time everyone believed “the change” to be an overnight phenomenon. “You know, you go to bed one night pre-menopausal and wake up the next morning post-menopausal,” says Minkin. “It’s only in the last 30 years that the concept of perimenopause has emerged.” Typically, a woman will go through menopause sometime between the ages of 40 to 55 (though menopause before 45 is considered premature, one percent of all women experience it at 40) but many women struggle with the symptoms of menopause for up to 10 years prior to the total stoppage of their menstrual cycles. Problems like hot flashes and mood swings can be especially intense during perimenopause. “So, for these women the transition is tougher than getting to the other side,” Minkin says.
It’s particularly tough on younger women, especially from a diagnostic standpoint. “If your period hasn’t stopped, a lot of these problems are overlooked or ascribed to mental illness,” she says. “I give a lot of talks to lay audiences, and every time I do, a woman in her late 30s or early 40s will come up to me afterward, sobbing and saying she was labeled ‘crazy’ when her problem was really early menopause. For doctors, this can be tricky to diagnose, because a blood test might not tell you what’s going on. I try to teach my students to recognize the possibility.”
Some fortunate women—about 15 percent—do have smooth, asymptomatic transitions to menopause. While you’ve officially gone through “the change” once you’ve lived an entire year without a menstrual cycle, that doesn’t mean you’re home free. Symptoms can arise post-menopausally, or persist a long time. “I have a lot of patients who come to me a year or two down the road, furious that they’re still getting hot flashes,” Minkin says. “But the reality is, 15 percent of women report theirs lasting 10 years or more.”
Aggravating as the natural menopause process can be, at least it occurs according to the body’s internal clock. Premenopausal women who undergo certain medical procedures, such as chemotherapy or oophorectomy (removal of the ovaries), actually do find themselves thrown into “the change” overnight.
“We used to say that a woman of 45, if she was having any kind of gynecological surgery, should have her ovaries removed,” says Molly Brewer, a gynecological oncologist at the University of Connecticut Health Center’s Neag Comprehensive Cancer Center in Farmington. “That was the paradigm 15 years ago when I went through training—we were obligated to prevent cancer.”
That was before the discovery of a link between removal of ovaries and increased risk of heart disease, particularly dramatic in women under 45. “Without hormone replacement therapy, those women are twice as likely to die young,” Brewer says. “In general, we’re much more conservative now—even in cases of uterine cancer, we may leave one or both ovaries intact. Obviously, the final decision depends on the patient’s family health history.”
After Karen Giblin had an emergency oophorectomy in 1991 at age 40, she found herself suddenly inundated by what she calls “overwhelming” menopausal side-effects: insomnia, mood swings and intense hot flashes that seriously disrupted her life during her third term as Ridgefield’s First Selectwoman. Starved for information on her plight, she went to the local Barnes & Noble where she found only one book on the subject, which she embarrassedly smuggled to the cash register inside a magazine. She soon realized the importance of bringing menopause into the light. “I was always very involved with my women constituents, and they started calling me with questions—we all needed to know more,” Giblin says.
That spurred her to establish Red Hot Mamas, now Red Hot Mamas North America Inc., the largest menopause education program (run by more than 200 hospitals) in the United States. Giblin had first approached a local district nursing association in Fairfield County, asking them to host a program in which women could get medically sound information. This quickly grew into a monthly series with the participation of Danbury and Norwalk Hospitals. “The sessions became very popular; we drew huge crowds,” says Giblin. “Ultimately, they just became too large for the local community.”
Twenty years on, she believes the organization is an essential resource for women who can’t get all their questions answered satisfactorily by doctors. “There just isn’t enough time allotted in a standard appointment,” she says. “A lot of women will think of questions after they’ve left the doctor’s office, and are too embarrassed to call back. The women who come to our programs bond over their shared experiences, cope and laugh together. You don’t need a prescription for that.”
The medical community’s catchall prescription for menopause symptoms—and a particularly effective one—has been hormone replacement therapy (HRT). For decades, doctors told patients that they could start HRT right from the onset of symptoms and use it for the rest of their lives. And, we were told, it was a good preventive strategy for heart disease, among other ailments.
But in 2002, the conventional wisdom took a serious hit when a study called the Women’s Health Initiative (WHI) reported that a certain form of HRT, known as estrogen progestin therapy (EPT), was connected to an increased risk of breast cancer, stroke, blood clots and, ironically, heart disease. EPT had originally been introduced for use by menopausal women who had not undergone hysterectomies when it was found that pure (or “unopposed”) estrogen therapy (ET) was linked to a higher risk of uterine cancer. Ten years later, according to a statement issued by the North American Menopause Society (menopause.org), it’s generally agreed that HRT is low-risk for women ages 50-59—but higher-risk for older individuals who delay its use for five years or more after menopause—and should only be prescribed after taking each patient’s overall health status into consideration. “Right now, the standard is to prescribe the lowest effective dose for the shortest amount of time it’s needed,” says Stephanie Bowers, obstetrician and gynecologist with the Hollfelder Center for Women’s Health at the UConn Health Center.
Patients remain confused, and doctors divided, about the best course of action. “Women have been scared out of their gourds for no damn good reason,” says Mary Jane Minkin. “The connection between HRT and cancer has been way, way overstressed. All the WHI study showed was that there’s an increase of eight cases per 10,000 women per year for those on EPT for five years or more. The real tragedy is that thousands of menopausal women are going undertreated because they’re worried about that slight increased risk. Currently, most people who need HRT take it for only two to three years, anyway.” Some women—following the lead of celebrities like Oprah Winfrey and Suzanne Somers—have opted for bioidentical hormone replacement therapy (BHRT). Its main distinction from traditional HRT is the use of hormones similar to those produced by human ovaries (HRT derives its hormones from non-human/synthetic sources).
These days, experts are touting the power of good diet and healthy habits in combatting the downside of menopause. “Women who smoke or are overweight have significantly worse hot flashes than their peers,” says Minkin. Certain foods are especially useful in addressing symptoms: The No. 1 food in any menopausal women’s diet should be soy. It’s easy to add in because it comes in so many forms, from beans that can be blended into casseroles to powders to soy “dairy” products (milk, cheese, yogurt) to fermented variationssuch as tempeh and miso. Chockful of proteins and vitamins, it contains phytoestrogens (or “plant” estrogens) that may help relieve hot flashes.
Other important elements that your diet should include: omega-3 fatty acids, helpful to the joints and brain—good sources being fish from bass to anchovies—vegetables (of course) and whole grains. High-cholesterol and processed foods are a no-no.
Dietary supplements like calcium (1,200 milligrams daily) and vitamin D (1,000 to 2,000 mgs daily) are also recommended. The latter is particularly critical for Connecticut women. “Almost everyone in this state is vitamin-D deficient,” says Neag Cancer Center’s Molly Brewer, largely because cold weather drives us indoors so much of the year. Fiber is crucial, too, as constipation can be a serious problem—straining in the bathroom is just as damaging to one’s rectum and pelvic floor as childbirth. “I tell everyone, ‘Unless your diet is tree bark, you should take a fiber supplement like Metamucil or Benefiber,’” says Raul Mendelovici, director of Connecticut Urogynecology in Bloomfield.
According to recent research, nothing surpasses the value of exercise in preserving health. “Strength-training, weight-bearing exercise is great for the heart, as well as an excellent defense against bone loss,” says Minkin. It’s great for mental health as well. “Turns out it’s the highest-rated factor in guarding against memory loss and Alzheimer’s, ” says Mendelovici. “Apparently, the kind of cognitive organizational skills needed for exercise make more demands on the brain than reading or playing chess every day.”