The Menopause Decision



Meet two women who struggled with the question of whether to take hormones. You'll learn through their stories how to figure out what's right for you.
ALL WOMEN FACE A CROSSROADS at menopause: whether or not replenish lost estrogen and other sex hormones. Some women want proven relief from frustrating problems like hot flashes. Others hope to prevent heart disease, osteoporosis, or other signs of aging linked to low hormone levels. Against these positives, any woman must weigh the downsides of hormone replacement therapy (HRT), like weight gain and possible breast cancer risk.

Compounding matters, there are now dozens of natural and synthetic HRT options. How do you choose? Prioritize, says Stephen Sinatra, M. D., the author of Heart Sense for Women (Plume, 2001) and a cardiologist in Manchester, Conn., who has treated hundreds of women approaching menopause. First, consider how menopause-related problems like hot flashes have affected your quality of life. Then find out if you are at increased risk for estrogen-related ailments like osteoporosis and heart disease. And during this process, of course, work with your health care practitioner to find the best therapy for you.

Two women, Susan Graham and Joan Alix, could hardly have predicted the journey they'd take as they faced the crossroads of menopause. Each tried several forms of hormone replacement therapy before finding their direction. Their stories illustrate how to choose your path and make the right HRT decision.

Susan Graham
SUSAN GRAHAM WAS A straight-A student in high school and college, and in graduate school she easily grasped the complexities of neurology. So the Manchester, Conn.-based licensed practical nurse was more than surprised when, in her mid-30s, she couldn't remember the magazine paragraph she had just read.

As Graham was losing her powers of concentration, intense hot flashes began to overwhelm her. “I felt like I had a chronic sunburn,” she says. “[The surges] stopped me in my tracks. I was absolutely drenched.” The hot flashes came daily, slowly at first and by evening, every 10 minutes. She also became severely depressed.

When she passed tests for everything from blood cell counts to heart irregularities, Graham was puzzled. In some ways, being a health care professional made it easier for her to handle the constant evaluations and to talk to her doctors. But it also made the lack of answers harder to bear. Besides hot flashes and the bizarre brain fog, Graham had unusually heavy periods. All three are signs that the ovaries have stopped producing regular levels of hormones, so Graham asked her gynecologist if she could be approaching menopause. Her gynecologist said no. (Typically, symptoms don't begin until a woman is 39 to 45 years old.)

Three gynecologists and 18 months later, Graham remembers begging a doctor, “Please humor me and test me for menopause.” Finally, at age 39, she got a positive diagnosis.

The Search for Relief
Menopause before age 40, or premature menopause, happens to about 8 percent of women. Graham's doctors immediately checked for known (but rare) causes of premature menopause like brain tumors and lupus. Those tests came up negative. “The most likely explanation is that I simply ran out of eggs,” says Graham.

Graham read every book she could find on menopause, which 10 years ago was only a handful of titles. The most comprehensive one touted estrogen replacement. But Graham knew that reports dating from the mid-'70s had associated estrogen with an increased risk of breast cancer. “No women in her right mind takes [that risk] lightly,” she says.

Graham decided to try alternative medicine first because of her interest in natural remedies. “I don't like to start prescription medication unless it's necessary,” explains Graham. “I figure, if I can handle a problem with a BB gun, why bring out a cannon?” She tried soy and the herbs dong quai (Angelica sinensis), black cohosh (Cimicifuga racemosa), and red clover (Trifolium pratense), as well as acupressure, massage, and yoga.

Unfortunately, even after a few months, nothing worked, she says, “not even one bit.”

On to Plan B
Graham decided to try conventional medicine. By then, it wasn't a difficult decision. “I was miserable. My whole being was unraveling—mentally, emotionally, and physically,” she says. “My body was screaming for estrogen.” Graham also knew that the longer she lacked estrogen, the more vulnerable her small frame would be to osteoporosis. Women can lose up to 20 percent of bone mass in the five to seven years after menopause; at 39, Graham had the potential for living many years with brittle bones.

In 1991, she started Premarin, a combination of several estrogens called “conjugated estrogen.” (For a glossary of HRT types, see “The Hormone Options Explained,” page 97.) In a few days, she was sleeping all night and her hot flashes had disappeared. In about two weeks, her brain felt sharp again. She felt better than she had in years. But the bliss lasted only three weeks.

The problems began when Graham started taking Provera, a synthetic form of progesterone. (Progesterone reduces the high risk of uterine cancer that occurs with taking estrogen by itself.) Right away she developed headaches, body aches, bloating, exhaustion, and extreme irritability. Over several tortuous months, her doctor reduced her dose. Finally, with her doctor's permission, she tried micronized progesterone, a natural form that gave her fewer side effects.

One year ago, Graham switched from Premarin to estradiol, a prescription drug that's considered a natural estrogen because it has the same molecular structure as the estrogen made in a woman's body. Today, “I feel great,” she says.

Making Peace with Menopause
Coping with the change of life was especially hard for Graham, because she was so young. “There was no one to talk to about the infertility aspect,” she says. “I felt barren. That was the hardest thing, psychologically.” It took her years to work through the grieving process.

Graham has advice for women of any age: “Read everything you can get your hands on,” she recommends. “The more you know, the more powerful you are.” It's also important to find a gynecologist you can work with and to get regular diagnostic testing (like bone scans, hormonal tests, and mammography). Finally, be open-minded. “I've seen women suffer for years trying to make natural therapies work,” says Graham. “Don't beat yourself up if conventional medicine turns out to be the best option for you.”

Joan Alix
FOUR YEARS AGO, JOAN Alix began waking up nights swimming in perspiration. “I'm a flannel nightgown person,” she says, but the sweats were so intense that she had to sleep practically nude. They came more often, exhausting her. And her periods became heavier and less frequent.

The timing of these health changes could not have been worse: Alix, then 51, was worrying about a father ailing from congestive heart failure; building a new home in Quonochontaug, R.I. (where she now lives); and adjusting to a new position as an elementary and middle school assistant principal. She thought stress brought on the sweats. Oh no, said her gynecologist; Alix was simply nearing menopause and, at her age, she should be taking hormones. She handed Alix a pharmaceutical brochure and three months' worth of sample estrogen-and-testosterone pills.

The kind of person who rarely takes medicine, Alix wasn't about to treat hormone pills lightly, but her father's heart condition prompted her to consider them. (Some evidence suggests that HRT reduces heart disease risk.) So did her gynecologist's demeanor. “It is intimidating when the doctor says ‘Take this,’” says Alix.

Conflicted, she pored over books and articles about menopause. The more she read and thought, the more she realized that one prescription simply couldn't be right for everybody. She threw out her doctor's samples and continued to suffer night sweats and irregular periods.

A month or two later, Alix read a book about natural progesterone cream, a treatment that appeared to relieve fatigue and heavy periods. She also learned about Remifemin, a standardized form of the herb black cohosh that has estrogenlike effects in the body. Armed with this information, Alix starting taking the two remedies without consulting her gynecologist.

Troubling Changes, Again
Alix quickly sensed that something just wasn't right. She felt bloated, she gained nearly 15 pounds in six months, and for the first time in her life she started craving starchy and sugary foods. Her night sweats and irregular periods continued. Fed up with a body that seemed to belong to someone else, she phoned Stephen Sinatra, M.D., a Manchester, Conn.-based cardiologist whose private practice was a short drive from her home. Alix's father had been seeing Sinatra for heart disease, and Alix was impressed by her dad's improvement.

Although Sinatra agreed that progesterone cream was a good therapy for some women, Alix's bloating, weight gain, and cravings led him to suspect that she was applying too much. He first lowered her dose and then asked her to stop using the progesterone cream altogether, so he could monitor her true hormone levels. For this purpose, he also asked Alix to stop taking Remifemin. For reasons still unknown, Alix's night sweats then subsided, a year after they began.

To address her weight gain and remaining symptoms, Sinatra concluded that Alix should try nonhormonal supplements and lifestyle changes. As a bonus, they would also help her manage her heart disease risk, he said. He recommended that Alix take a daily multivitamin plus vitamin E, magnesium, coenzyme Q10, l-carnitine, and omega-3 fatty acids. He also advised her to eat more flaxseeds and cold-water fish and to walk more.

As Alix began trying Sinatra's recommendations, she took stock of her situation. She knew that her image of herself (as a young 125-pound woman who could eat whatever she wanted) no longer matched her reality. She now had to contemplate every piece of food that she put in her mouth and had to face up to a tough fact—she was getting older.

Gathering Her Support Team
Gradually Alix realized she wasn't alone in her struggles. She called three aunts who are in their 70s and early 80s. These women stayed healthy and slim the way that Alix's northern Italian grandparents did—by eating legumes like lentils, lean protein like fish, and plenty of fruits and vegetables, but little processed food. Alix decided to adopt this European way of eating. In a year, Alix lost the extra weight, evened out her cravings, and boosted her energy.

Alix visited her mother, 77, more often and found strength in her optimism and faith. She also looked to her church for support. A spiritual seminar it held, called “Life and the Spirit,” was a watershed event for Alix. As her fellow parishioners shared stories of personal milestones, Alix began to reflect on who she was and what she wanted. The experience was reinforced by a favorite book, The Wisdom of Menopause (Bantam, 2001) by Yarmouth, Maine-based gynecologist Christiane Northrup, M.D. Northrup emphasizes that menopause is an important time in life to stop and regroup. “I look back at those years, and I think of Dr. Sinatra, my parents, husband, and two sons, and my faith, and those good influences are connected in my mind,” says Alix.

Investigative reading and keeping in touch with her general practitioner and Sinatra remain Alix's top menopause strategies. “Women's bodies don't stop changing when they're 55,” she says. “So you have to keep paying attention.” Since the events of September 11, Alix has continued to connect with others; she prays regularly with friends and family. “Today more than ever, I'm making a conscious personal effort to be thankful,” she says.

The Hormone Options Explained
GET TO KNOW YOUR TREATMENT OPTIONS so you can ask your doctor specific questions. Here are seven common versions of hormone replacement therapy (HRT).

ESTROGENS (NATURAL) Called natural because they mimic the hormones in your body, these estrogens are synthesized from plants or animals. There are three natural estrogens: estrone, estriol, and estradiol.
ESTROGENS (CONJUGATED) A mixture of several forms of estrogen (some of them are natural to animals, but not humans). Premarin, the most widely prescribed of this type, comes from pregnant mares' urine.
ESTROGENS (COMPOUNDED) Prescription combinations of natural estrogens. They are prepared by special compounding pharmacies and are available as “biest” (estrone and estradiol) or “triest” (estrone, estradiol, and estriol).
PROGESTERONE (CREAM) A topical treatment synthesized in a lab from plants such as wild yam (Discorea composita). It is considered natural because it is structurally identical to the progesterone in your body. Note: Wild yam cream does not contain progesterone.
PROGESTERONE (MICRONIZED) A natural progesterone made up of tiny coated particles that prevent your stomach from destroying the hormones. It appears to have fewer side effects than synthetic progesterone.
PROGESTERONE (SYNTHETIC) Form of the hormone that differs chemically from what your body produces. Sometimes known as progestin, it may be derived from natural sources. Provera is the most common synthetic form.
TESTOSTERONE The main sex hormone in men is also produced in women's ovaries and dwindles after menopause. Supplemental testosterone may increase libido. Available in synthetic pill form and as a natural cream or gel.
How to Know If HRT Is the Right Treatment
TO FEEL YOUR BEST AFTER MENOPAUSE, YOU MAY NEED HORMONE replacement therapy (HRT). Additionally, HRT can lower the risk of some diseases that become more prevalent after menopause. But not everyone should take hormones. We asked Stephen Sinatra, M.D., a Manchester, Conn.-based cardiologist who treats menopausal women, to recommend treatments for 10 typical scenarios. He advises all women to take a multivitamin and regularly do weight-bearing and aerobic exercise. Before you decide on a treatment plan, talk to your health care practitioner.

Legend for Chart:

B - AND MENOPAUSE BRINGS ON … No Menopause Symptoms
C - AND MENOPAUSE BRINGS ON … Hot Flashes, Night Sweats,
or Vaginal Dryness



No Risk
To slow aging and stay at no disease risk, try only
lifestyle changes, including exercising and eating
cold-water fish, flaxseeds, and soy, foods rich in
healthy fats and protective plant estrogens.

Start with lifestyle changes (described at left). If
you get no relief, try natural HRT (like estrogen
cream and micronized progesterone). If ineffective,
consider conjugated estrogens and synthetic

Risk of Heart Disease

For 90 percent of cases, no HRT. If tests have shown
high blood levels of fibrinogen and lipoprotien
Lp(a), consider HRT if lifestyle changes cannot
alter these factors.

Same as no risk (above). If tests have shown high
blood levels of fibrinogen and lipoprotein Lp(a),
consider HRT if lifestyle changes cannot alter these

Risk of Breast Cancer

Try only lifestyle changes (avoid soy if you have
had breast cancer).

Try only lifestyle changes (avoid soy if you have
had breast cancer).

Risk of Osteoporosis

Try only lifestyle changes (consider HRT only if you
have poor bone density). Also, get 10 to 15 minutes
of sun exposure daily and take calcium and

Same as no risk (top), and include sun exposure and
minerals described at left.

Risk of Alzheimer's

Try only lifestyle changes. Also, take alpha lipoic
acid, coenzyme Q10, vitamin B complex, and
vitamin E.

Same as no risk (top), and include the supplements
described at left.
PHOTO (COLOR): “Don't beat yourself up if conventional medicine turns out to be the best option for you.” —SUSAN GRAHAM, 49, who tried an array of natural therapies but ultimately found relief in prescription hormones.

PHOTO (COLOR): “It is intimidating when the doctor says, ‘Take this.’ But no one pill is right for everyone.” —JOAN ALIX, 54, on why she refused to take the pills her gynecologist gave her and instead investigated other options.


By Dahpna Caperonis

Photographed by Amy Etra

Daphna Caperonis Senior editor at Natural Health.

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It's a one hard struggle for women. Well, it can't be prevented but it can be pass easily. It's natural stage can be tough but with proper knowledge how to deal with it can help every women surpass it lightly gynecologist.