The Pause that Distresses

 

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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.”
 

The Pause that Distresses

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