DR. MURRAY’S APPROACH TO MENOPAUSE

         Currently, there is much controversy regarding how to manage a woman’s menopausal symptoms. From my perspective, managing menopause has always required a very individualized approach. One size does not fit all, and never did! Frankly, I am happy the recent revelations of the Women’s Health Initiative in the US and the Million Women Study in the UK have made physicians and patients stop looking at menopause as a disease that requires medication, and that one or two drug options are the “right” prescription for everyone. Now we must actually have a conversation with patients about their lifestyle, their options, their priorities, risk factors, goals and fears. No knee jerk prescriptions for everyone. Nor is the answer that hormone therapy is wrong for everyone because of some risks associated with their use. These are the kind of conversations I have advocated and practiced for many years now. (see editorial in American Family Physician journal:http://www.aafp.org/afp/20000301/editorials.html )

         So, first we need to find out how a woman is experiencing her change of life. Are there problems with sleep, mood, sexual functioning, hot flashes or night sweats that interfere with daily functioning? Are there memory or other cognitive problems? Are there palpitations, anxiety, depression, and irritability? Is vaginal dryness a problem or are urinary incontinence or infection occurring? Hormones can help with many of these symptoms, sometimes locally, such as vaginal estrogen if vaginal and bladder symptoms predominate. Sometimes systemically using prescription pills, patches, transdermal creams, transmucosal lozenges or even suppositories are helpful. Even some non-prescription hormone preparations may be warranted. If a hormone therapy is indicated, my preference is to use something most like the body has been making – so called “bio-identical hormones”.

         For estrogen these bio-identical hormones include estradiol, estriol and estrone. All the commercial patches in use today, and many commercial pill forms of estrogen are “estradiol”. Others are not bio-identical, but are touted as “natural” because they come from plant or animal sources – these are from nature, thus they are “natural”, or so the argument goes. Estrogen from horse urine may be from nature, but it is not “natural” to the human female. Likewise plant hormones may be from nature, but do not fit human hormone receptors exactly right, as do human bio-identical hormones.

         For progesterone, there are commercially available prescription pills and transvaginal gels of bio-identical progesterone. There are also many brands of non-prescription, low dose transdermal creams of bio-identical progesterone available. Those that indicate they use “USP progesterone” and indicate how many milligrams or grams are available in the product are more likely to be reliable brands. (See article I wrote in Women’s Health in Primary Care journal on natural progesterone:www.womenshealthpc.com/9_98/pdf/671Progest9_98.pdf.

         Testosterone is a bit trickier, as research on its use in women is somewhat sketchy. However, problems with low libido, muscle weakness and general low energy along with a documented low testosterone level can sometimes be ameliorated with careful use of testosterone by prescription.

         Hormone therapy also has shown value in preventing and treating osteoporosis, and may be beneficial in preventing colon cancer and slowing the onset of Alzheimer’s Disease. Some studies on estrogen for improving cognitive function have been disappointing.

         The biggest risks of estrogen use include a slightly higher incidence of breast cancer and stroke in users vs. non-users. Some women report weight gain on estrogen and weight loss when stopping its use, although large studies have indicated that women gain an average of 5 pounds around menopause, regardless of hormone usage.

         But, not everyone wants or needs hormone replacement. More importantly at midlife, women need to evaluate their lifestyle choices. Smokers have a much higher incidence of hot flashes and other menopausal symptoms, as do heavy drinkers (more than 7 alcoholic drinks per week.) Women who exercise regularly have far fewer hot flashes than those who are sedentary. Stress is a big factor in worsening menopause symptoms; especially hot flashes/night sweats, anxiety/palpitations, low energy and mood disorders. Trying to “do it all” at midlife has its physical consequences.

         Nutritionally, women should limit their sugar, fat, alcohol, caffeine and refined carbohydrate intake. We should increase our intake of whole fruits, vegetables, whole grains, water and possibly soy. Cruciferous vegetables (cabbage, broccoli, cauliflower, bok choy, brussel sprouts) have properties that protect us from breast cancer (and prostate cancer for our male friends/spouses!)

         We need to exercise regularly: at least a 20-minute walk 3-4 times a week and strength/flexibility exercised 2-3 times a week. Yoga, breathing exercises, meditation, journaling, and psychotherapy all can help us with stress management. Finding our purpose in life and setting priorities to care for ourselves is key at midlife.

         Sometimes support for other aspects of the endocrine system – especially the thyroid and adrenals – can be crucial to feeling great at menopause. Neurohormones – substances found in the brain and in nearly all tissues of the body as well – are often out of balance. Some women find Chinese Medicine – especially certain individualized herbal formulations to help enormously in re-balancing the system to achieve wellness. Certain other foods, supplements and herbs can also be useful to not only manage specific symptoms, but also help achieve overall balance.

         If one decides to pursue a hormonal approach, baseline hormone levels are often essential. Once on a hormone regimen, periodic evaluation with hormone levels can help determine optimal dosing and route of delivery. Hormone levels can be tested using blood, urine or saliva. Each method can be useful, and each has limitations.

          In summary, menopause is a life transition full of challenges and opportunities for growth. It is not a “disease” requiring medical intervention, but sometimes symptoms can be significant enough to warrant intervention for some period of time. Each woman’s menopause journey will be different, and their choices and needs require individual attention.

Best wishes in your journey!