Risk Factors for Osteoporosis

Bed rest

Bed rest leads to rapid loss of bone so it is best kept to a minimum if possible. If it is necessary to stay in bed for extended periods of time, physiotherapy and simple exercises will help reduce bone loss.

Caffeine intake

Drinking copious cups of coffee or strong tea during the day has been linked to osteoporosis. It is difficult to state a maximum level of intake, although a ceiling of two to four cups a day is generally recom­mended. Beware of caffeine in other products, partic­ularly canned colas and some health drinks.

Diet lacking in calcium

Adequate amounts of calcium in the diet are essential to maintain bone strength. Women over the age of 40 need about 1,500 milligrams per day if they are not taking HRT. Women taking HRT have a lower requirement of 1,000 milligrams per day as the oestrogen itself helps strengthen bone. After the age of 60, daily requirements fall to 1,200 milligrams.

History of amenorrhoea

Amenorrhoea, when menstrual periods cease, is associated with insufficient oestrogen to maintain the normal menstrual cycle, leading to oestrogen deficiency. In primary amenorrhoea, the first menstrual period occurs several years later than the usual age of 13 but subsequent menstruation is normal. In other cases, secondary amenorrhoea, menstruation starts at the normal age, but then the periods stop. Anorexia nervosa, an increasingly common cause, leads to a marked loss of weight and altered body image.

Young gymnasts are also at risk from over-exercising. More recently, treatments for conditions such as endometriosis (when the womb lining is found in tissues outside the womb) stimulate a ‘medical menopause’ by switching off the ovarian production of oestrogen with a consequent drop in oestrogen levels. All these factors can increase the individual woman’s lifetime risks of oestrogen deficiency illnesses.

Hyperthyroid disease

An overactive thyroid increases the resting metabolic rate, speeding up the normal process of bone formation and breakdown which can lead to osteoporosis. Hyperthyroidism also puts an extra burden on the heart, which beats faster and more forcefully.

Sunlight

Elderly women often stay indoors and get little sunlight on their skin. In certain cultures women are heavily covered in dark clothing and, particularly if they live in Europe, minimal daylight reaches their skin. Sunlight is very important because it stimulates the production of vitamin D in your skin. This vitamin aids the absorption of calcium from food, helping bones to stay strong. Only 15 to 30 minutes in daylight each day is necessary.

Pregnancy

The more times you have been pregnant, the lower your risk of osteo­porosis, because each pregnancy produces a surge in oestrogen. Women who have never been pregnant will not have had this oestrogen surge and their lifetime exposure to oestrogen will be lower, increasing long-term risks of osteoporosis.

Previous fracture(s)

Previous fractures can suggest existing osteoporosis, increasing your chances of further broken bones.

Racial origin

Women of black racial origin achieve a 10 per cent greater peak bone mass than white women, so white racial groups are more likely to develop osteoporosis.

Use of steroids

Prolonged use of oral steroids, over 5 milligrams each day, is linked to osteoporosis. Steroids are usually prescribed for conditions such as severe asthma or autoimmune diseases. In these conditions the body’s protective mechanisms are disrupted and normal tissue is seen as a foreign body which should be destroyed. Short-term courses of steroids, for one or two weeks, are not associated with increased risks unless frequently required.

If you are on long-term steroid therapy, speak to your doctor to discuss possible alternatives and ways in which you can prevent osteoporosis developing.

Menopause Guide – What Hormone Replacement Therapy Can Do for You

Most of the changes that happen to your body when your hormone production slows down can be prevented, and many others can be reversed.

Exciting scientific advances in the last fifty years have given rise to whole new groups of hormonal and nonhormonal medications for use during and after menopause. These are not remedies prescribed over the telephone or obtained over the counter, but ones that must be discussed with and carefully prescribed by your own physician and taken under your doctor’s supervision.

There is nothing new about the theory of “rejuvenation” therapy. Ancient Egyptians introduced organotherapy, or glandular therapy, and ate the penis of the ass for this purpose. Ancient Greeks and Romans changed the prescription to asses’ testicles. Early scientists of the 1800s added other ideas to that kind of treatment. More than one hundred years ago, in 1888, a seventy-two-year-old famous French physiologist, Brown-Sequard, reported that he had rejuvenated him­self by taking injections of “testicular juice.” He wrote that he achieved greater body vigor, improved bladder and intestinal func­tion, and that his wife used the testicular extract to combat feminine discomforts.

By the close of the nineteenth century, ovarian therapy started, with ovarian juice, powdered ovaries, and powdered ovarian tablets pre­scribed for surgical menopause, dysmenorrhea, and obesity. In 1926, A. S. Parkes and C. W. Bellerby, two scientists in Great Britain, extracted female hormone from an ovary for the first time. They named it estrin. A few years later, a German chemist, A. Butenandt, isolated and synthesized a pure form of estrogen and progesterone. He won the Nobel Prize for his work. Now that these hormones were available, physicians prescribed them for a wide range of women’s symptoms.

The wholesale prescription of this treatment became so popular that by the 1960s many books and articles ascribed all sorts of value to it, but did not describe any of the risks. The use of these powerful hormones escalated. Physicians and women alike were shocked when, in December 1975, scientific papers were released showing a causal relationship between hormone therapy and cancer of the uterus.

Women became afraid to use these medications. Fear, coupled with confusion and combined with a lack of comprehensive information, reigned. The only redeeming feature of this frightening dilemma was that scientists, physicians, and paramedical specialists finally began to conduct intensive research on the phenomenon of menopause. As a result, today physicians are able to reassure women because they have a fuller understanding of how menopause works. They now know much more about how the hormones function, how they can safely be prescribed, and what other forms of observation and treatment are necessary for their female patients.

While hormone replacement therapy (HRT) for postmenopausal women continues to be somewhat controversial, it is growing in popu­larity. Earlier, we described how the ovary starts to lose certain hor­mones and what happens to women as a result. Remember, too, that this hormone deficiency is more severe in some women than in others. The purpose of HRT is to make up for that deficiency. Not all women can take HRT, and not all women need to. For women who can, and who choose to, HRT holds the promise of preventing or reversing many of the negative effects on the body caused by the lack of estrogen.

What You Can Expect from Exercise

Exercise may enhance bone mass and bone density. To see a good example, compare the arms of your favorite tennis player. You will find that the dominant arm is larger; it has developed more bone and muscle from use. Then think of the astronauts traveling through space with little opportunity to exercise against any resistance in the weight­lessness of space. They lose bone.

Moderate exercise is very beneficial; excess exercise may not be. Let’s look at one more extreme example. Take a woman who is following an overly strenuous exercise program. Let’s say she is a marathon runner. She may lose her menstrual period, because through excessive exercise she has altered ovarian activity and re­duced her body fat so much that her body’s production of estrogen is inhibited. She will then lose bone, as well.

Exercise offers emotional benefit as well as physical energy by alter­ing your state of mood. This alteration probably occurs because exer­cise activates the release of certain hormones within the brain that we call the central endorphins or, brain morphines. They produce that special sense of well-being that we experience after exercise.

Recent studies directed specifically toward menopausal women have shown that vigorous exercise reduces muscle tension and de­creases anxiety significantly. The relief of anxiety is often the result of an increase in the levels of epinephrine and norepinephrine circulat­ing in your blood. These substances improve neurotransmission, or nerve messages. Similar studies have proved that the nature of sleep improves for exercisers and the physically fit.

As we said earlier, a problem with exercise is poor compliance. Women start an exercise program, lose interest, and drop out usually sometime during the first three months of a program. Most studies show that the mood-enhancing results of regular exercise only de­velop strongly after three months, coinciding with when you arrive at a state of physical fitness. Other studies also suggest that good physical exercise, continued late into life, will reduce the aging of your brain and offer you more vigor and consistency of performance into very late old age.

Choosing an exercise activity that is fun for you is as important as getting active, because if it’s not fun you won’t stick with it. Also select a variety of activities, so you are less bored while you enhance your flexibility, strength, and endurance. We know that more women have gotten more active since the 1960s, but we also know that not enough women exercise. Exercise benefits every system in your body, which is probably why it makes you feel so good. There is also a special look to the physically fit woman: a look of strength, confidence, and glowing good health. Her step is lighter, her hand­shake firmer, and her gaze clearer. These are not appearances with­out foundation; they are a direct result of the flexibility, strength, and better oxygenation of the body that a regular and well-defined exercise program begets.

Today’s models and movie stars alike aim for healthy bodies that appear strong and sturdy. A woman with well-built shoulders no longer conveys a masculine image, but rather that of a woman who looks like she can take care of herself. With more women than ever before in the rough-and-tumble work force, and with women living longer than ever before, exercise becomes the path to a very impor­tant degree of strength and self-sufficiency.

Note: It is vitally important before you begin an exercise program to have a complete medical checkup to assure that the program you are about to begin is right for you. Let’s review the broad range of benefits that exercise offers women at midlife and how it may offset some of the problems that hormonal changes can cause.

Many physicians suggest exercise as a treatment for depression. Studies show that exercise aids sleep and can overcome a general feeling of nervousness, both complaints of postmenopausal women. Certain kinds of exercises strengthen bone and aid flexibility so that we do not get hurt as often, or as badly, and we heal faster, too. We know that exercise causes the reproductive system to work better, but that it must be pursued wisely, since perimenopausal women who jog or run excessively can lose their periods entirely and, as a result, lose the bone-building benefits of estrogen.

Menopause Diet Tips To Help Manage Symptoms

Natural oestrogens

Some researchers believe that natural oestrogens found in many plant foods, particularly beans and pulses, could protect against osteoporosis, heart disease and breast cancer.

Certainly, the incidence of these diseases is much lower in Japan where oestrogen-containing soya bean products, such as tofu, are an essential part of the diet.

Calcium

Calcium is necessary to ensure bones develop properly and remain strong, so a healthy diet with adequate calcium is essential to good health. Periods of growth obviously increase the relative demands for calcium, so teenagers and pregnant women need greater amounts. Dairy foods, such as milk, cheese and yoghurt, are the best sources of calcium, which is readily absorbed into the blood­ stream. Unfortunately, the current fashion for dieting has meant that many women cut out dairy products as they also contain high levels of fat. The answer is to continue eating dairy products but switch to low fat alternatives – skimmed milk actually contains slightly more calcium than full cream milk. Sardines are also excellent as they contain very fine bones, full of calcium, which are softened during the canning process.

Vitamin D

Dietary intake of vitamin D has declined over the years and may be linked to increasing fracture rates as this vitamin is necessary to aid calcium absorption. Fatty fish, such as halibut and mackerel, are rich sources of vitamin D; studies suggest that two meals of fatty fish a week can reduce the fracture risk by up to 20 per cent.

Supplementing your diet

Calcium supplements are a useful addition to a poor diet, particularly in early life when bones are developing. There is limited evidence that supplements in later life reduce the risk of fractures. However, many women taking calcium supplements also actively prevent osteoporosis by other means so the true effect of calcium alone remains unclear.

Vitamin D is also available as supplements. Do not overdo it – it is unwise to take more than 2,000 mg of calcium or 500 international units of vitamin D each day, as too much can increase the risk of kidney stones. Be particularly careful if your fluid intake is low, or you are confined to bed for any reason. If in doubt, speak to your doctor.

Cut down on alcohol

It is sensible to cut down on alcohol as heavy drinking increases the risk of osteoporosis and heart disease in addition to its effects on general health. The density of hip bone is reduced by up to 12 per cent in women in their late 40s who have more than two alcoholic drinks daily, so try to keep within the current recommended limits of 14 units a week for women, 21 for men. One unit is equivalent to a glass of wine, a single measure of spirits, or half a pint of beer.

Stop smoking

Smoking increases the risk of heart disease, fractures and cancers. Women who smoke have an earlier menopause by one or two years than non-smokers.

Hormonal Aspects of Male Menopause

Over the years, researchers have tried to determine whether there is a male equivalent of the female menopause. As you know, the female menopause is the result of the ovary running out of eggs and being unable to produce the female hormones estrogen and progesterone. Investigators have evaluated the male testis to see whether it goes through the same kind of changes and whether it, like the ovary, reduces production of its sex hormone, testosterone.

The testis is to man what the ovary is to woman—a gland with two express functions: reproduction and hormone production. The most remarkable difference between them is that the man’s testis somehow maintains its ability to produce spermatozoa throughout life, whereas the woman’s ovary never produces a single new egg from the time she is born. So the healthy male is able to father children as long as he lives, and the female’s reproductive life ends at menopause. Was this apparent inequity nature’s way of protecting the species, assuring that a woman would live long enough to nurture her young inasmuch as she could only conceive while she had enough years left to care for them? Or is it simply an unfair quirk of nature whose purpose, if any, we do not yet understand?

There has been remarkably little good scientific evaluation of the change in male hormone production throughout the male life cycle. The best studies were conducted only in the last decade. The results suggest that the male hormone, testosterone, exhibits a characteristic pattern throughout a man’s life. Its levels first peak during the male’s intrauterine life, at about fourteen to sixteen weeks into the preg­nancy; then the level begins to drop. There is another brief peak after a boy baby is born; then the testosterone level drops and remains low until puberty. At that time there is a sharp increase in the blood level of testosterone that continues from puberty until a man is in his mid-fifties, or later. From then on, there is a slow decrease in testoster­one levels.

Another important aspect to consider is that both men and women have some hormone of the opposite sex circulating in their blood. So when the blood testosterone levels decrease in men, there is a relative increase in their estrogen levels as they age.

Investigators have found that in the older man, there is a decrease in the actual number of cells that produce sex hormones. However, there is very little data analyzing the sperm of men as they age. Generally, it seems that sperm counts remain unaltered. If we take into account that sexual activity slows down, then sperm production may actually be decelerating with age. Parallel with the decreased sperm production is a reduction in the sperm’s ability to move forward actively (motility) and to get to its destination.

Despite these changes, a man tends to remain hormonally and reproductively normal until he enters his late fifties, or even his early sixties. At that time, some changes occur in testicular function, but the process of change for the male is very slow, and there is no comparison with the abrupt changes that occur in women.

Another fact to consider in exploring the idea of whether or not men undergo a male menopause is that male life expectancy is shorter than that of the female, and the slight reduction in testicular function tends to occur in the last years of his life. Thus, a man is potentially virile and potent—if his health and all other aspects remain equal— until close to the end of life. So these changes are more subtle than a woman’s and often do not make serious inroads on a man’s life.

What Are Possible Symptoms of Male Menopause? What does occur when men are around middle-age? Findings have suggested that some older men complain of reduced libido or sexual potency, increased fatigue, decreasing productivity and concentra­tion, sweating, tachycardia (excessively rapid heartbeat), skin atrophy, sleep disturbances, anxiety, and depression. There also have been reports of male hot flashes! The clustering of these symptoms around the ages of forty-five through sixty ushered the phrase male climacteric syndrome into vogue almost fifty years ago.

The truth is that there is no such thing as the male climacteric syndrome when evaluated in hormonal or psychopathological terms. There are minor chemical changes that do occur but are relatively insignificant. In one study, 10,000 male outpatients claiming to be suffering from the male climacteric were evaluated statistically. No age-related increase in the frequency of depression, fatigueability, and decreased activity was found. The generally accepted conclusion is that certain symptoms do increase in men of advancing age, and these affect sex, memory, and sleep. However, they do not cluster between the ages of forty-five to sixty, but instead just continue to increase slowly with advancing age, and there is no justification for calling any syndrome the male climacteric. These changes are age-related, not sex-related. Since there are no menses, and therefore no cessation of menses in men, the term male menopause is not valid.

Different Ways to Take HRT

HRT can be taken in a variety of ways. There are advantages and disadvantages to each of the different methods.

Pills

The most often prescribed and easiest method of taking HRT is via a tablet or capsule. This traditional method of taking the drug can create a problem. After you swallow the pill, the hormone enters the stomach and intestine, where it is absorbed into the circulatory system that leads to the liver. A problem can occur because the hormone undergoes change within the bowel before absorption and is absorbed as an altered substance with either reduced potency or different ef­fects. Once transported directly to the liver in large amounts, the hormone can again be changed by the liver. It can also stimulate various actions in the liver itself, some potentially good and some possibly harmful. Either way, the hormone, metabolized in the liver, enters the general circulation of the body and begins to work. Its benefits and risks depend on whether its composition was changed in the liver and to what degree. Pros and cons of tablet HRT.

Shots (Intramuscular Injections)

One method of bypassing the liver is to inject the hormone directly into the muscle. The hormone can be mixed into other substances that will cause it to absorb into the system slowly, which helps to lengthen the intervals between shots from daily to once a month. There are some disadvantages to this method. The main one is that there is a high level of hormones in the blood shortly after the injection, which diminishes over time. Thus, there is an imbalance in the treatment‘s overall benefit, because there may be too much hormone in the blood right after the shot is administered and too little later in the cycle. At present, shots cannot be spaced more than a month apart, and some women find that having to go to the doctor’s office to get an injection that often is disadvantageous because of the extra expenditure of time and money.

Implants (Subcutaneous Pellets)

Implants were popular in the 1960s and 1970s. They are outdated today. Since they may return in a new form, you should know how they work. The hormone combines with a solid material and is shaped into a pellet. The physician inserts the pellet into the subcutaneous fat through a small incision in the woman’s lower abdominal wall or the top of her buttock. The pellets dissolve slowly and the hormone is absorbed through the fatty tissue. Over the years, there were many different strengths and mixtures of hormones used as implants. There are potential disadvantages. First, they may be difficult to remove, if removal becomes necessary because of possible side effects such as infection at the site of insertion. Further, the lifespan of the implant is capricious, so it is very difficult to know how long they will work and when they should be replaced. Research is underway to create better release mechanisms for implants, and it is likely that implants will be one of the practicable methods of the future. Pros and cons of HRT implants.

Vaginal Creams (Vaginal Application)

Hormones can be applied directly to the vaginal area. Women who experience localized vaginal discomforts, such as dryness or itching, can obtain relief with this method. When women take estrogen vaginally, the hormone is absorbed through the vaginal epi­thelium into the blood system, which can be an advantage if the estrogen is needed, or a disadvantage if they should not be taking estrogen anyway, as is the case with women who have breast cancer and who therefore are not candidates for HRT. Because of this absorption, vaginal creams are not prescribed for women who should not take estrogen, but they can even be a problem for women who can take estrogen. These creams are impractical, because the amount of estro­gen absorbed is so variable and the body may absorb too much.

Patches and Creams (Transdermal Systems) Research in France in the early 1970s led to a breakthrough in the understanding of the absorption of hormones. It proved that estrogen creams rubbed onto the skin would be absorbed easily, enter into the circulatory system, and work well. The result is the availability of two newer ways to replace estrogen: a cream and a transdermal, or through-the-skin, patch.

The percutaneous cream contains specific strengths of hormones to be applied over a specified area of the body. In this way, a specific dose of the hormone can be administered on a daily basis. The hormone gets into the circulatory system without going through the liver so that the side effects generated by liver metabolism can be avoided. One disadvantage is that it can be messy. Moreover, a woman may acciden­tally vary the amount of skin she covers when applying the cream, which would result in a dose that is different one day from the next. Or the cream could be rubbed off before it is fully absorbed, with the same poor result.

Interestingly, there were early complaints by male partners of women using these creams because the men began to notice breast growth in themselves! This growth was presumably from couples lying close together and the cream accidentally being rubbed onto the man’s chest. The newer formulations of the cream have a rapid drying property that practically eliminates these rubbing-off and transfer problems.

Transdermal skin patches are the most recent breakthrough in estro­gen therapy. These specially devised patches place estrogen directly on the surface of the skin without the messiness or uneven coverage/ dosage of creams. The patches are similar in appearance to those that heart patients wear containing ever-ready nitroglycerin. The estrogen transdermal patch is a multilayered system. Beneath an outer imper­meable layer of plastic lies a reservoir of estrogen dissolved in alcohol, covered by a layer of permeable plastic.

This design is ingenious: It prevents the estrogen from seeping through the outside of the patch, while permitting it to seep inside to the skin, which gradually absorbs it. A ring of adhesive holds the patch onto the skin. The amount of estrogen given to a woman can be controlled by the size of the patch and the amount of estrogen that is inside the reservoir. These quarter-sized patches must be changed twice each week, every three to four days, so that they deliver a constant amount of estrogen. Women change these quickly them­selves. They are worn on the hip, upper thigh, or lower abdomen.

One disadvantage of the patch is that it may irritate the skin under it, which is a problem for about one in twenty women. This problem can often be alleviated by moving the patch to a new spot on the skin each time a new one is applied. The advantage of the patch and the skin cream is the ease with which the doctor can check the amount of estrogen in the blood at subsequent follow-up visits to fine-tune the dosage to meet the needs of each individual woman. Pros and cons of HRT skin patches.

Menopausal Dressing – Tips and Advice

Hems go up and hems go down, but yours do not need to move, providing you have found a length the flatters you. Pants went in and out of fashion many times; today they seemed destined to be part of a woman’s wardrobe forever. Now they simply swing from sleek to wide like a pendulum. All women like to adopt what is in style and to be fashionable, but if it isn’t right for you, our best advice is don’t do it.

Well, a role demands a few costume changes that, in every instance, complement the role. An artist dresses differently from an accountant; a home-maker dresses differently from a hard hat. In every case, it is important to determine what you want to look like and what flatters you. Have style; don’t be trendy. Style can be defined as your look that never goes in or out of fashion; trend is what you learn is in or out and follow when you have not selected your own style.

A stylish woman, at midlife or at any time in life, makes a strong statement about herself. She defines how she sees herself and how she wishes to be seen. It works for her as long as she does not pick a style that is out of sync with her physical frame or her age. When we try to adopt an unflattering look, we will often be uncomfortable with it. So go to your closet. Put together all the clothes that you live in and put them on one end of the rod. Take all the things you bought that you never wear (excluding dressy things for rare occasions). The group of clothing that you wear all the time consists of those that help to define your role. Study them carefully. Take an extra minute to consider each piece and whether you like yourself in it. Then add to them or subtract from them according to wear and tear, but learn to know them as your comfort-level clothing. If you do, then they are your style. Now, study the group of seldom-worn clothes and realize your mistakes.

If you still feel confused, visit a department store and meet with the personal shopper. Most stores offer this valuable service at no charge, and you will probably find out a lot about what you like, what looks best on you, and what goes with what. Remember, too, that just as you may want to change your cosmetic color palette, or your hair color, you may also want to consider whether the colors that you choose in clothing are still the best colors for you.

Figuring out your style should be an enjoyable experience, and one that will add to your confidence when you are choosing what to buy or what to wear. If an outfit “isn’t you,” forget about buying it, because ultimately you will not wear it. Mostly, have fun deciding your role and costuming it.

Sexual Problems around Menopause

For women who experience changes in sexual function during the years immediately preceding and following menopause, the com­plaints they bring to the physician’s office can be divided into five categories:

1. Loss of desire

2. Decreased frequency

3. Painful intercourse

4. Diminished responsiveness

5. Dysfunctions of their male partners

Let’s consider these individually, although sometimes these problems may be cumulative for any one couple.

Loss of Desire

Desire is a complex phenomenon. The psychological factors that in­fluence it are extremely important, including the nature of your rela­tionship with your partner. If you experience a loss of desire even though there is still normal hormonal activity in your body, your problem may require deeper evaluation and, perhaps, the help of a sex counselor. At the time of menopause, however, the decline of ovarian hormones often influences the components of sexual desire and arousal. So if your diminished desire is due to a loss of sensory perception through the local and central nervous system, changes in the rate of blood flow, less tension within the muscles, and the de­creased ability of the sexual glands to lubricate the vagina, you may be relieved to know that these changes respond very well to HRT. When adequate hormone therapy is introduced, desire and arousal normally return.

Decreased Frequency of Sexual Activity

Again, many factors are at work when you experience decreased frequency of sexual activity, and the majority of them are not hor­monal. Most are related to your lifestyle and your relationship with your partner. Together, you need to sort out such issues as fatigue, interest, time, competing activities, or other tensions in the relation­ship. Do you spend as much “bed time” as television time, or is a too-active social life competing with your sex life? If sex is important equally to you both, you need to work out a mutually satisfactory frequency pattern and set aside the time, create the mood, and satisfy your own and each other’s needs whenever possible.

Painful Intercourse

The solution to this problem must include your physician, for this problem is decidedly the easiest to address and, in most instances, it is related to decreased estrogen stimulation of the vaginal canal. Ap­propriate hormonal replacement almost without exception results in the disappearance of this uncomfortable symptom.

Diminished Responsiveness

This symptom is usually resulting from a decrease in estrogen and the subsequent lack of stimulation of nerves in the pelvic and vaginal area and in the brain itself. Estrogen treatment is of benefit in most in­stances, and is highly recommended.

Dysfunction of the Male Partner

A surprising finding from research shows that older women have more interest in sex than older men. Possibly one of the biggest problems facing the aging male is his decreased ability to become aroused and, as a result, to obtain or keep an erection for long periods of time. In many cases, this problem can be satisfactorily treated through sexual counseling, which we strongly recommend. Be reas­sured that even if your male partner is unable to obtain an erection, satisfactory sexual activity can still take place if you are motivated and instructed in other means of sexual gratification.

Achieving sexual satisfaction is largely dependent on your relation­ship with your partner. You can certainly appreciate the fact that you would not be turned on sexually or able to achieve orgasm if your partner was in pain, disabled, or obviously not enjoying the sexual activity. So it may be that when a man perceives his partner going through menopause; enduring sleep disturbances, hot flashes, and night sweats; feeling unaroused; or suffering painful intercourse, he begins to feel threatened. He may worry that you are losing interest in him because you no longer feel that he is attractive, wanted, or needed. Or he may just be concerned about you and not wish to upset or hurt you by making an issue of your waning sex life. It is true that in a strong relationship one partner suffers from the other partner’s ills.

It is important for you both to understand what is happening. Therefore, you should learn about and be willing to explain your problem. If you begin taking hormone therapy and feel relief, let your partner know that you feel better, that your sexuality is intact, and that you are interested in sex again. Knowing these things will often enhance his arousal and change problematic sexual activity back into the healthy and satisfactory sex life that you both enjoy. If you are single, HRT may stimulate you to consider and enjoy a new and invigorating sexual relationship.

Contraception during Perimenopause

Many women say that the best thing about menopause is that they need no longer worry about contraception. It’s true! But what is the best method of contraception if you’re between thirty-five and meno­pause? It is interesting to note that what may be a good contraceptive when you are young may not be as good when you are older.

Since women are less fertile in the later reproductive years, a contra­ceptive method that might have been 90 to 95 percent effective when you were twenty might prove to be almost 100 percent effective when you are 40. A simple barrier method, like the diaphragm, that you were worried about using in your younger years because of its poten­tially high failure rate, might be a good method later in life. Whatever method you choose, always discuss it with your family practitioner or gynecologist. To give you an overview, however, here are some important facts for women over the age of thirty-five about four different methods of contraception.

The Pill (The Combined Estrogen-Progestin Birth Control Pill)

Beginning in the late 1960s, several major studies were published suggesting that older women who use oral contraceptives (OCs) are at an increased medical risk. Subsequently, women didn’t want to take the pill, and physicians would often refrain from prescribing them. Most of these studies concluded that older women using OCs were at higher risk of heart attacks, hypertension, strokes, and overall mortal­ity. But these studies did not look at cigarette smoking, preexisting high blood pressure, and other factors that increase the risk of cardio­vascular disease, nor did they differentiate between the various kinds of birth control pills that were being prescribed. Indeed, virtually all the clinical studies were of women using the high-estrogen OCs that have practically disappeared from the market.

The new generation of pills, which have far less hormone in their formulation, are quite different. Another factor, not taken into ac­count, is the potential health benefits of OCs, which include appar­ently reduced incidences of uterine and ovarian cancer, pelvic in­flammatory disease (PID), anemia, and rheumatoid arthritis. Other benefits may include a reduced risk of fibrocystic and other benign breast diseases, improved menstrual cycle control, and relief of PMS, which tends to become more severe after the age of thirty-five. These facts are establishing a strong school of thought, teaching that a woman can continue taking an OC as long as she remains in good health and has no signs of hypertension, late-onset diabetes, uterine lining abnormalities, or other complications. It is also necessary that she have an annual medical screening with a comprehensive physical examination including a blood pressure check, pelvic examination, abdominal palpation, and cholesterol testing. If there is a family his­tory of diabetes, then blood sugar testing is also recommended.

In September 1989, a report from the Harvard Nurses Health Study that appeared in the Journal of the National Cancer Institute of­fered the greatest reassurance. It noted that women over age forty who have used oral contraceptives do not have an increased risk of breast cancer, even if they used them for prolonged periods of time.

As women age, however, there are certain other contraindications to taking the pill. A history of cardiovascular disease, liver cancer, breast cancer, diabetes, hypertension, obesity, or uterine fibroids would suggest the need for an alternate method of contraception. Above all, and without exception, smokers should not be taking OCs.

When considering an OC, the pill of choice is one of the new combined, or multiphasic, very low-dose pills. A pill with no more than 35 micrograms of ethinyl estradiol and a consistently low level of progestin, less than one milligram, should be considered. There is actually no persuasive evidence to suggest that one combination pill is better than another as long as you stay with the lowest steroid doses possible that still provide adequate contraceptive protection.

You might consider progestin-only contraceptives, which are being used more often by physicians for their over-forty patients. These are low dose OCs containing no estrogen. As a result, they are appropri­ate for midlife women with gall bladder disease or impaired liver function who would not be candidates for a combined OC. These particular pills are very rarely prescribed for younger women because of their higher failure rate (up to 2 percent) in preventing pregnancy and also because they tend to cause irregular bleeding due to their lack of estrogen. It would appear that the failure rate declines to about 1 percent in women over thirty-five and that older women are also less likely to experience irregular bleeding as a side effect. If all of the above precautions, indications, and clinical observations are carefully followed, older women can safely take birth control pills until the age of menopause and then simply switch to one of the alternate estrogen replacement therapies allowing for a continuum of birth control pill contraception until postmenopausal HRT begins. Of course, the kind of estrogen differs after menopause.

Intrauterine Devices

The intrauterine device (IUD) is an exceptionally good method of contraception despite the adverse publicity it receives. The design, particularly the monofilamentous tail, of the modern types of IUD that are available (like the Copper T or the Progestasert), and the fact that IUDs are being recommended for women over thirty-five who have completed their families, makes this population the most ideal for using this method of contraception. An IUD can be inserted after age thirty-five and changed every four to five years, making it an unobtru­sive, effective, and inexpensive birth control method. The risks as­sociated with the IUD include uterine perforation, which is rare, and pelvic inflammatory disease, which is also rare, particularly in stable monogamous relationships. The failure rates with IUDs in women who are over thirty-five are extremely low and the removal of the device is usually very easy. The IUD is a method that should be considered.

Barrier and Chemical Methods

Methods such as the diaphragm, condom, and spermicides offer realis­tic alternatives for many couples, given the older age of the individual and her consequent decline in fertility. These methods are not fail-proof, and it is wise to consider potential risks of pregnancy. The condom and spermicide (if it contains nonoxynol-9 as its active ingre­dient) are increasingly popular because they may prevent transmission of the AIDS virus. The greater availability and the wide acceptance of the condom makes it a perfectly satisfactory contraceptive choice for women over thirty-five.

Sterilization

Sterilization remains the most frequently chosen method of contracep­tion for women age thirty-five and older. Failure rates are low, but remember this method is permanent and should be undertaken only after you make a well-thought-out decision that you will not later regret. Newer methods of female sterilization have focused on achiev­ing safe, simple tubal occlusion created by placing a silastic (an inert plastic) ring, or clip, on the fallopian tube through an instrument called a laparoscope. It is a short surgical procedure that has few complications and is widely accepted by women.

Nonhormonal Treatments for Menopausal Symptoms

Although your body responds best to hormones and should be treated with them, if possible, nonhormonal drugs can play a role in offering relief from midlife discomforts. If you cannot take hormones for the reasons outlined below, however, there are other means of treatment that can be considered. We want to offer a word of caution here. It is important that you and your doctor investigate any symptoms that you have to try to learn their specific causes. If you have symptoms that may be caused by psychological or sociocultural factors, perhaps they ought to be treated with an educational or a psychosocial thera­peutic approach. In such a case, drugs would be an adjunct to other forms of therapy.

It is important as well that you receive treatment that is symptom-specific. Be careful with yourself. Don’t assume that all the symptoms that you have are related to menopause just because you are experi­encing menopause. Guided by your own introspection, and by the results of clinical tests, work with your physician to decide what’s what!

Even though nonhormonal drugs are not primary sources of relief for menopausal discomforts, your doctor might advise you to take them in the following situations:

– If you cannot use HRT for medical reasons

– If you do not get relief from HRT

– If you do not want HRT, but do want symptom relief

– If you cannot tolerate HRT because of side effects, such as nausea or fluid retention

It can be difficult to select the right nonhormonal drug for the treatment of climacteric problems. Often the physician’s choice rests more on guesswork than on the proven effects of treatment, as there are not enough studies that document conclusively the therapeutic efficacy of nonhormonal drugs.

As editor of the medical publication Maturitas, Dr. Utian analyzed the articles published over an eight-year span and discovered that more than 90 percent were about the use of hormones compared to fewer than 10 percent about the efficacy of nonhormonal medications. Further, in nine out of ten of the articles on nonhormonal medica­tions, physicians reported more side effects than benefits with these medications. Although very few nonhormonal medications currently available effectively combat climacteric syndrome problems such as hot flashes, some may work, and you should be aware of them.

There are seven kinds of nonhormonal medications. They include the following:

– Sedatives (for sleep)

– Tranquilizers (to induce calmness)

– Antidepressants

– Clonidine

– Propranolol

– Vitamin B6 (pyridoxine)

– Vitamin E

Sedatives may reduce the number of hot flashes you endure, but are less helpful in relieving irritability and emotional upset. Phenobarbital USP, alone or in combination with other drugs, seems to be effective and is available commercially as Bellergal tablets. However, sedatives are less effective than HRT in reducing menopause problems.

Tranquilizers comprise a large group of drugs that are often abused in the care of postmenopausal women when they are prescribed before HRT. When chosen as an appropriate treatment method, monitored, and used with educational and psychotherapeutic pro­grams—only if the “agitated states” are not biologically caused—they are helpful for women with excessive anxiety, irritability, insomnia, and related agitated states. The most often prescribed tranquilizers are Valium, Librium, Ativan, Xanax, Buspar, and some of the phenothia-zines.

Antidepressants are prescribed for the same reasons as tranquilizers; however, they are used in cases of severe depression. Among the most commonly used are Elavil, Nardil, Parnate, Sinequan, and Tofranil.

Clonidine has received attention because of its helpfulness in com­bating hot flashes. At first, it was manufactured in low dose as an antimigraine drug; and later it was made in high dose as an antihyper­tensive drug. Then, doctors reported that it appeared to reduce perimenopausal flushing. Some studies support this observation; oth­ers do not, but there is reason to hope that further research will find a nonhormonal treatment for hot flashes.

Propranolol (Inderal) is another drug that was studied for its effect on hot flashes, but it has not been found effective.

Vitamin B6 is sometimes suggested, because there is some evidence that the loss of sex hormones may cause a deficiency in this vitamin. Symptoms of such deficiency may include depression, emotional insta­bility, fatigue, disturbances in concentration, and loss of libido. These symptoms may respond to 50-200 milligrams of vitamin B6 taken daily. Do not take megadoses: The side effects may include altered tryptophan metabolism (tryptophan is the amino acid that maintains” normal nitrogen equilibrium in the body), which can be worse than the original problem.

Vitamin E, taken in megadoses, has gathered more than its share of claims for the relief of hot flashes. Many women claim relief, yet with careful comparative testing the vitamin did not pass the effectiveness test. As with other substances, anything taken in excess is risky busi­ness. I do not recommend megadoses of vitamin E, because liver problems may result.

Menopause and Skin Care

Estrogen thickens the skin. Additionally, it is the effect of estrogen on the exocrine glands that helps to keep the skin moisturized, plumped up, and smooth. Lacking estrogen, dryness and wrinkles result.

The skin also shows the results of aging in many ways that can be flattering, softening harsh features, and showing inner character. The deeper layer of the skin loses its moisture and elasticity, and so it shrinks. The outer skin, or epidermis, is now looser than the inner layer and so it hangs, or creases. How and when this aging happens depends on many factors. Your genetic makeup plays its part as does whether you had acne or another skin condition, and whether you smoke. The skin also has slower circulation so it may become blotchy, with broken capillaries, perhaps the result of hormonal ups and downs. The skin becomes lighter and rougher-textured from enlarged pores. Exercise provides help because it nourishes the skin and creates moisture.

Why do many women get upset every time a new wrinkle appears? Perhaps self-esteem gets in the way of reality. In your thirties, you laugh off the first laugh lines or crow’s-feet that spring up around the outer edges of the eyes, or the frown lines that mark the forehead. When you are fifty or more, the accumulation of sun, normal loss of elasticity, and the pull of gravity may cause the little vertical “stitches” that run around the upper lip. The skin may droop slightly under the chin, the jaw line may gather two small pouches on either side, and the skin on the neck may slacken.

You have more than twenty years between laugh lines and lip stitches. If you limit your exposure to the sun, protect against the sun when exposed, and apply moisturizer daily (many are prepared with sunscreen added for protection), you can delay the aging of the skin by many years. Once it begins, there is no cosmetic product that can rid you of wrinkles, age spots, or facial blemishes, although some can give you a mini-lift for a couple of hours.

Retin-A, the new “dream cream” on the market, is showing good results in removing tiny surface wrinkles and lightening brown spots. It is a product that may retard the effects of photoaging of your skin (the aging caused by sun exposure, which shows up as wrinkled, yellowish, rough, lax, and leathery skin with age spots and sometimes with fine veins that mar cheeks and nose). Before considering Retin-A, a visit to your dermatologist is essential for examination, explanation, prescription, and follow-up care.

Aging skin does not bother all women, and it need not bother you. If you can value the outward charm of aging along with the wisdom of your experience, then you will see the beauty and dignity of aging as you are. We are reminded of famous artist Georgia O’Keeffe, who died in her nineties and whose face grew more beautiful with age. We imagine she used a good moisturizer and little else on that interesting face.

Early Warning Signs of Menopause

Even though late-arriving PMS can be an early symptom of meno­pause, there are four other physical symptoms that can occur that are even stronger indicators of early menopause. We include them here so that you can be aware of them, but do not worry about them. They are all easily treated, if treatment is required.

Hot Flushes or Flashes

There is still a strange resistance among physicians to accept the fact that hot flashes can occur long before the end of menstruation—as early as age thirty-five. The symptom may cause you to feel warmth spreading across your face and throughout your body. It may be followed by perspiration, and then you may feel cold, or even begin to shiver. The hot flash can be so severe that you become drenched with sweat and feel emotionally drained. When it occurs at night it may awaken you from sleep and is accurately called a “night sweat.” Hot flashes can occur at irregular intervals, and, occasionally, with extreme frequency. They also vary in severity, from being a slight nuisance to causing a major disruption in the quality of your life. You might never connect these early flashes to menopause, because your menstrual periods will continue, but if you experience these symp­toms, be aware that your body is beginning its midlife transition on the early side.

Abnormal Periods

Another early warning sign may be an unexplained change in the nature of your menstrual flow or menstrual pattern. You may notice that the amount of bleeding lessens each month and, eventually, stops entirely. It is a comfortable way for menopause to start. Sometimes the periods stop abruptly, which gives you no advance warning of meno­pause approaching. Other less convenient changes can occur in your menstrual period. For example, it can last for seven days one month and only three the next, or you may go for an unusually long stretch of time without periods. As a result, you never quite know where you are in your cycle, and your period can take you by surprise. Sometimes your period may not only be irregular in onset and duration but the amount of bleeding may vary: heavy one month; light the next. In some instances, the bleeding can be so heavy that you feel weak, dizzy, or otherwise concerned, and you may need to see your physician.

Bladder Control

You may notice that as menopause approaches you seem to have less control over your bladder. This problem may start as a little leaking of urine during moments of muscular stress, such as during exercise, running, or jogging, or simply when laughing or sneezing. It is a common occurrence when estrogen levels in your system begin to drop, which may cause a slackening of your muscular pelvic floor and of the control mechanism of the bladder as well.

Changes in Short-Term Memory

Recently, decreasing estrogen levels were linked to changes in short-term memory. The ability to remember immediate events, like the items on your shopping list, or to recall where you left your car keys or sunglasses can be attributed to declining estrogen levels. Unfortu­nately, not all lapses of memory can be blamed on this common symptom, but if you are experiencing short-term memory loss more often, don’t panic. Consider that it might be a warning that meno­pause is approaching.

Risk Factors for Heart Disease

Diabetes

Diabetes affects blood vessels, increasing the risk of their becoming narrowed by deposits of the fatty substance atheroma. This in turn may lead to blockage of arteries by blood clots causing a coronary thrombosis (heart attack) or stroke. After the menopause women with diabetes have three to five times the risk of a heart attack and twice the risk of a stroke when compared with women without diabetes. These risks may be reduced by careful control of diabetes, avoiding obesity and taking HRT.

High blood pressure

Regular blood pressure checks are important to identify women with raised blood pressure, because high levels are linked to heart disease and strokes.

The average blood pressure is 120/80 millimetres of mercury but it rises with age so that a measure­ment of 140/90 is acceptable in the postmenopausal group. Sometimes a treatable cause for high blood pressure is found but, in most cases, it runs in families with no clear identifiable reason. If you are overweight or smoke, losing weight or stopping smoking may be suffi­cient to control the blood pressure.

If your blood pressure is high on at least three consecutive occasions, your doctor will probably recommend that you take daily treatment to reduce it. Many people find daily drugs difficult to take as they usually feel otherwise well – high blood pressure, in itself, does not give rise to any symptoms. However, it is important to realise that treatment is aimed at prevention – stopping the development of heart disease is a much more effective medicine than treating a heart attack.

High cholesterol

Cholesterol levels below 5.2 milli-moles per litre (mmol/l) indicate a low risk of heart disease, levels above 6.5 mmol/l denote a greater risk. The average measurement of cholesterol is around 5.6 mmol/l. A well-established link exists between heart disease and high cholesterol in men, but for women an association remains uncertain and the risk appears to diminish with increasing age. However, there is evidence to suggest that lowering cholesterol reduces heart disease. Modifying your diet is the best treatment; drugs are available but many have unwanted side effects. Routine tests of cholesterol are controversial because other risk factors, such as obesity or smoking, need to be taken into account. Many do-it-yourself kits produce unreliable results so go to your doctor or well-woman clinic for a more reliable test.

Personality

Aggressive and ambitious people -so-called type A personalities -appear to have twice the risk of heart disease compared with the calmer type B personalities.

Previous heart attack

As with angina, a previous heart attack shows the presence of existing heart disease. The already weakened heart is more susceptible to further damage

Special cases Arthritis

Increasing evidence suggests that HRT reduces the impact of arthritis by increasing bone density. This is true for both osteoarthritis and rheumatoid arthritis; although HRT does not reverse the process of the disease, it is a useful adjunct to conventional therapy.

Alzheimer’s disease

Results of recent studies suggest that long-term use of oestrogens can reduce the risk of developing Alzheimer’s disease and may also reduce the severity of the condition.

Smoking

Smoking is a risk factor for heart disease and osteoporosis, but it is included under this separate heading because its effects are even more wide reaching. More than 9,000 women die each year from lung cancer directly related to smoking. It is also linked to cancers of the cervix and bladder. Smoking affects the way that your body uses oestrogen, so that oestrogens are broken down at a faster rate than usual. Women who smoke have an earlier meno­pause, by one or two years, than women who do not smoke, so they are at greater risk of oestrogen deficiency. Campaigns to stop smoking have been very successful in the overall population but unfortunately smoking is on the increase in young women, the group most vulnerable to its long-term effects.

Early menopause

Women who have an early meno­pause – before the age of 45 – are considered to be a ‘high-risk’ group for the consequences of oestrogen deficiency, because they are particularly susceptible to osteo­porosis and heart disease. An early menopause is caused by failure of normal ovarian function, which has been linked to certain genetic disorders. Treatment with radio­therapy or chemotherapy for con­ditions such as leukaemia may also induce ovarian failure. The diagnosis is made on the basis of menopausal symptoms and is confirmed by a simple blood test to measure hormone levels.

Preventive action against oes­trogen deficiency should begin as soon as possible. Women choosing to take HRT are advised to continue treatment at least until the age of 50 but may wish to take it for longer.

Hysterectomy

Removal of both ovaries at hyster­ectomy induces an immediate menopause which can be treated with oestrogen replacement or alternatives. Studies show that women who have this ‘surgical’ menopause develop more severe menopausal symptoms than those who have a ‘natural’ menopause. This may be because the body does not have the usual time to adapt to hormonal fluctuations.

In most hysterectomy operations the ovaries are not removed, but even this can trigger a menopause about four or more years earlier than the natural menopause. Without the evidence of irregular periods or other changes in the menstrual cycle, it can be difficult to assess the onset of the menopause, although hot flushes and other symptoms are sufficient indicators.

Young women whose periods have ceased

Periods often cease in women who exercise excessively or who are anorexic and whose oestrogen levels fall. Many doctors consider that this group should be offered HRT to protect against the long-term con­sequences of oestrogen deficiency.

Menopause and Hair Care

There is no need for your hair to look less than wonderfully luxuriant at midlife. It’s true that individual hair shafts begin to thin and fade and become dryer when you are about forty. Changes in your hair after menopause generally are the result of hormonal changes. You can counter these changes by giving your crowning glory better care, and a new and more flattering cut and style. You can try to stop drying it further with electrical tools, harsh chemicals, poor diet, poor circula­tion, and too much exposure to the elements.

There is no need for your hair to look less than wonderfully luxuriant at midlife. It’s true that individual hair shafts begin to thin and fade and become dryer when you are about forty. Changes in your hair after menopause generally are the result of hormonal changes. You can counter these changes by giving your crowning glory better care, and a new and more flattering cut and style. You can try to stop drying it further with electrical tools, harsh chemicals, poor diet, poor circula­tion, and too much exposure to the elements.

If you love your hair, it won’t disappoint you. True female baldness is a rare problem; it usually has a genetic base, if it occurs. Hair loss, when caused by disease, will usually regrow and be as healthy as it was before. Since you were very young, you have been losing 50 to 120 hairs each day. Thus, about 30,000 hairs per year are replaced by new ones. As we age, sometimes the replacement process is slower. Usually, past forty, the replacement hairs are a lighter, or faded, version of the ones you lost. The texture and consistency may also change. If you crash diet regularly, your hair will rebel against the lack of nutrition by becoming dry and brittle. If you combine your internal abuse with normal aging changes, and then add external abuses of over-styling or improper coloring or perming techniques, you can’t expect your hair to care for you.

First, you should know that everyone eventually turns gray. We lose pigment as we age, and by fifty, half of the population is gray-haired. Well-cared-for gray hair can look chic, stunning, and appealing de­pending on its condition and styling. Frizzy, dry, flyaway gray is not flattering. A long bob of gray hair is just too much of a good thing. A shorter blunt cut, good conditioning to make it shine, and a color rinse to heighten, deepen, or lighten the gray, if necessary, is all you need.

On the other hand, if gray is not your favorite color, change it early. When you find you are spending more time jerking gray hairs from your head than washing it, it’s time to consider color. If you like the gray coming in naturally and appreciate the salt and pepper stage, leave it alone. If you are thinking about coloring your hair eventually, skip the salt and pepper stage. Simply go from your hair color back to your hair color, by gradually adding color as your natural color fades. You can enjoy your hair color for a lifetime. Did you always want to find out whether blondes have more fun, or redheads are more exciting? Then switch colors, but first make sure the color you. choose is flattering to you. Often a change in hair color means a change in makeup palette.

For hair-care harmony, use as few electrical appliances on your hair as possible. If you use a dryer, keep it at least six inches away from your head. Turn off the dryer just before your hair is completely dry. If you use rollers, curlers, or bobby pins, don’t pull on the hair excessively. Use quality hair-care products that are right for your type of hair. Practice good nutrition and meet the recommended daily requirements for vitamins A, B, C, D, and E, which may have espe­cially good effects on your hair. HRT helps as well. Cover your hair in the sun and wind and rinse it after you swim to get rid of pool chemicals.

Menopause Guide – What Midlife Means to You

Menopause is an event common to all women. For some women, it is not difficult, but for many it arrives with complications, both physio­logical and psychological.

Menopause is an event common to all women. For some women, it is not difficult, but for many it arrives with complications, both physio­logical and psychological.

Today, a healthy fifty-year-old woman can reasonably expect to live for another thirty to forty years. Doctors are now becoming more aware of the need to help women turn these postmenopausal years into quality years.

In an ideal scenario, long before menopause, each woman would have found her ideal physician. Over the years, she would have been able to sit for hours with her doctor and acquaint him or her with all the details relevant to her medical history. She would visit the doctor with a complete list of pertinent questions and the doctor would have all the right answers and take the time to share them with her.

Yet, how many women actually have this experience? Very few. One reason is because the medical care for women at midlife has been so haphazard. Physicians are only now beginning to understand the female climacteric—that ten-year transitional period surrounding menopause. Perhaps many women feel that they are lucky if they can get through menopause, by themselves, without seeking the often complicating and shifting views of doctors.

So much happens in your life when you are approaching and experi­encing the years that surround that milestone—menopause—that oc­curs around the age of fifty. Your work life may be gearing up or down. Your children may marry and leave home. You may have to handle your parents’ illnesses or death. You may become a grand­mother for the first time. You will also experience menopause. It is apparent that an incredible amount of change will be going on in your life.

In an effort to learn how women view menopause, the International Health Foundation surveyed four hundred women in each of five countries: Belgium, France, Great Britain, Italy, and West Ger­many—a total of two thousand postmenopausal women. The results of the 1970 survey concluded that for many women, menopause is a period of disorientation, physical discomfort, and emotional upheaval. The postmenopausal period was described as a time when women could not feel as content as they had in their premenopausal state. Further, the survey revealed that menopause is more difficult for women who lack the social supports that more affluent women have available to them. Women who engaged in activities such as those described in my program seemed to bounce back better from “the menopause crisis,” as the study termed it.

I want to assure you that menopause is not a “crisis.” It is, however, a transitional process that occurs on social, emotional, and medical levels. To make menopause a comfortable transition, I believe that doctors must offer preventive medical programs to women over the age of forty-five that prevent estrogen deficiency and its subsequent medical and psychological problems, as well as offer a way to affirm productive attitudes and actions for midlife women.

Today, nearly twenty years after the International Health Founda­tion’s survey, women still are not sure what to do about menopause. A 1987 Harris Survey showed that American women are confused and misinformed about menopause and its treatment. The survey results were compiled following telephone interviews with five hun­dred women between the ages of forty-five and seventy, evenly di­vided among ten major U.S. cities: Boston, New York, Washington, Atlanta, Seattle, Los Angeles, Phoenix, Chicago, Memphis, and Hous­ton. These are all cities in which the best of American medicine is provided. The interviews covered the subject of menopause, its treat­ment, its symptoms, and other related women’s health issues. Sixty percent of the interviewees were postmenopausal, 22 percent were experiencing menopause, and 16 percent were premenopausal.

The dismal findings indicated that a very small percentage of the women knew the long-term consequences of estrogen deficiency.

Fewer than half of the study participants could name a single treatment for the common menopausal symptoms that affect more than 85 per­cent of all women at menopause such as night sweats, vaginal dryness, and hot flashes.

Although this menopause survey drew similar responses through­out the country, there were some interesting regional differences. For example, the highest level of confusion about effective treatment of menopausal symptoms was in the Southeast, where a significant num­ber of women mistakenly believed that antidepressants, aspirin, and tranquilizers were effective therapy. The Northeast registered the highest number of women who were unable to name any form of treatment. Just 40 percent of the women in the West knew about the role of the ovaries and estrogens in preventing osteoporosis—a seri­ous degenerative condition of the bone that afflicts women—which made them the most knowledgeable group about hormone replace­ment therapy in the country!

These survey results reflect a high level of confusion among women about menopause. How can a woman get the medical help she needs if she is not informed about what is happening to her, what to expect, and how to get help when help is needed?

Goals of the Right Exercise Program

As our bodies age, we can lose aerobic capacity, flexibility, and strength. Studies have shown that calcium and vitamin D are necessary for healthy bone growth, but must be combined with exercise to be fully used by the skeletal system.

As our bodies age, we can lose aerobic capacity, flexibility, and strength. Studies have shown that calcium and vitamin D are necessary for healthy bone growth, but must be combined with exercise to be fully used by the skeletal system. There are appropriate goals for your exercise program that need to be reached through properly selected and executed activities; otherwise your exercise program may not serve your body well and may even be injurious.

Exercise should be incorporated into your lifestyle on a regular basis and should be structured to accomplish these five specific goals.

1. To increase your heart and lung efficiency

2. To increase your muscle strength

3. To increase your muscle tone

4. To increase your muscle endurance

5. To increase your flexibility

Meeting These Exercise Goals

Two kinds of exercise are necessary in order to meet your goals: aerobic exercise and weight-bearing exercise. Aerobic exercise in­creases your oxygen capacity, because it is a way of exercising that demands extra oxygen. It stimulates beneficial changes in the respira­tory and circulatory systems of your body, ultimately making your lungs and your heart work more efficiently, and it is equally important in maintaining your cholesterol and blood lipids at normal levels. Exercise will elevate the HDL cholesterol—the good cholesterol—for most women, and lower the triglycerides. It should also lower the LDL, or bad, cholesterol levels. These changes help cleanse the blood of fats that can block arteries and put you at risk for heart disease.

Aerobic exercise also burns more calories and helps you to reduce body weight and fat. Aerobic exercises include walking, running, jogging, cycling, swimming, cross-country skiing, and dance programs that are designed to use oxygen. The treadmill, the stationary bicycle, the cross-country ski machine, and the stair machine are all capable of helping you get a good aerobic workout when you use them properly, working at 70 to 80 percent of your maximum heart rate for at least twenty minutes, three times a week.

Weight-bearing exercises, those loosely defined as activities that work against gravity, are vital to bone health. Women turn to walking, cycling, golfing, playing tennis, and dancing, to name a few activities that make them lift, push, pull, bend, and stretch. Weight lifting, weight training, and body building also help to save, build, and even rebuild bone. Some studies show that weight-bearing exercises and muscle contractions generate stress on the bone that is necessary to prevent bone loss. Other studies have shown that the decrease in bone density in older women may be halted, or even reversed, when women exercise regularly. Today, women are “pumping iron” as never before, using free weights, barbells, and weight disks, or using weight machines such as Nautilus or Universal at health clubs. (It is important that well-trained instructors teach you how to use the equip­ment.)

Choosing Your Exercise Plan

If you are ready to make a lifelong commitment to exercise, begin by choosing aerobic activities that are fun for you and combining them with weight-bearing activities that interest you. Try various activities to see which ones get you moving both physically and psychologically. Then, combine various activities and, to keep your level of interest high, vary the combinations.

For example, you may work out a warm-up, aerobic dance routine, and cool-down exercise program that you do three days a week and alternate it with a weight-lifting routine on the intervening days. Or you may walk vigorously three days a week and cycle two days. However you set up your exercise program, vary it when the least bit of boredom creeps in and try new activities or group activities to stimulate your interest.

How Much Should You Exercise?

It depends on whether you have been exercising regularly or are about to begin. Your level of fitness right now and your medical evaluation determine where you begin. When you begin to exercise, or when you begin a new activity, it is important that you start at a low level of participation and build up very slowly. Soreness or injury that sets you back days, weeks, or months is a greater deterrent to achieving fitness than taking it slowly and steadily, gradually increas­ing the time and the intensity to get to a point of physical fitness sooner. Remember the parable of the tortoise and the hare? Here, too, it is the persevering tortoise that wins.

How Often Should You Exercise?

Plan to exercise four times a week from twenty to forty minutes per session, and try not to slip below three times a week. Remember, you have made a commitment to your own good health and there just has to be time for it. If need be, write your exercise period into your datebook just as you would any other important appointment, and keep it!

Determining Your Menopause Dietstyle

When you follow the Menopause Dietstyle program you are taking responsibility for your own body and body image. Once you determine your Dietstyle Program, learn the total number of calories you can consume, and select the number of calories you will expend through exercise—you can then forget about counting calo­ries! It’s easy.

When you follow the Menopause Dietstyle program you are taking responsibility for your own body and body image. Once you determine your Dietstyle Program, learn the total number of calories you can consume, and select the number of calories you will expend through exercise—you can then forget about counting calo­ries! It’s easy. We will teach you how to customize your dietstyle through appropri­ate food allowances and exchanges. Once you start doing this repeat­edly, you will soon be able to judge portion size by sight. The ability to “judge” a portion will become second nature: Half orders and shared orders will become an integral part of your home and restau­rant dining. Of course, no one should begin any dietstyle or exercise program without consulting her physician.

Before you can individualize your dietstyle, it is important to know where in the Menopause Dietstyle you should begin. So, it’s time to categorize yourself. Be honest. Using your current weight and your current exercise program, put yourself in one of the three catego­ries listed below.

Average/Active

Are you of average body weight and an active exerciser? Find out by checking your weight range prescribed by your height and body build in the weight chart.

Is your minimum output of exercise at least thirty minutes, four times per week, at 60 percent to no more than 75 percent of your maximum heart rate? (That rate is calculated by subtracting your age from 220 and taking 60 to 75 percent of that number.) Thus, if you are fifty years old, you do the following equation:

220 – 50 (your age) = 170 (your maximum heart rate)

Now, take 60 percent of 170 and you learn that 102 is the lowest number of heart beats per minute that you should aim for when doing aerobic exercise. Take 75 percent, which is 128, and never exceed that number. Calculate your rate now. If, after doing your calcula­tions, your answer to both these questions is yes, you fit comfortably into the Average/Active Dietstyle category and you can consume up to 2,000 of the right calories per day to maintain your current weight.

A woman falls into this category if she does not exercise three to four times per week for at least thirty minutes at 70 to 80 percent of her maximum heart rate on a regular basis. Here, the operative word is regular. If you are this woman, the consumption of 1,600 calories per day should maintain your average body weight. A change in your exercise pattern from occasional to active will create significant weight loss.

Overweight/Nonexerciser

This category is for women who are 25 percent above their average, or ideal, body weight. This dietstyle will enable you to achieve significant weight loss. It is impor­tant to understand the unalterable fact that 3,500 calories constitute one pound of body weight. Therefore, in order to lose one pound of body fat per week, you must consume 3,500 fewer calories per week. The most you should ever try to lose per week for a healthful and long-term effect is two pounds, which means eliminating 7,000 calo­ries per week through diet or burning more calories through in­creased exercise. Once you fully understand the expenditure of calo­ries through exercise, you can understand the whole secret of weight loss. No magic, just mathematics! As a woman in this category of the Dietstyle, you will need to drop your calorie intake to 1,000 calories per day and add exercise to your daily routine. If you are more than 40 percent over your desired body weight, for faster weight loss you can drop to the 800-calorie-per-day dietstyle and add regular exercise to your program until you reach your appropriate weight. Then return to the 1,000-calorie dietstyle. You should never consider eating fewer than 800 calories per day, and these calories need to be carefully balanced between the six basic food groups.

What is Male Menopause?

First, let us consider some of the unusual behaviors. It is more than a cliche that some men in mid-life crisis give up their conservative Oldsmobile for an expensive Ferrari, or move out of their home, leaving their wife and family for a woman half their age. You see these men all over the place, looking out of place as they relate romantically to women the ages of their daughters or nieces. The occurrence repeats itself too often to be ignored. Why is it happening?

First, let us consider some of the unusual behaviors. It is more than a cliche that some men in mid-life crisis give up their conservative Oldsmobile for an expensive Ferrari, or move out of their home, leaving their wife and family for a woman half their age. You see these men all over the place, looking out of place as they relate romantically to women the ages of their daughters or nieces. The occurrence repeats itself too often to be ignored. Why is it happening?

Does it result from a man’s need for outside recognition of his accomplishments, power, and attractiveness? Is it a salve to soothe a sense of failure or dissatisfaction with his life? Is he trying to escape from facing his own mortality? Does the recognition and fear of aging and thoughts of diminished skills and physical prowess lead some men into a phase of frantic and erratic behavior?

Probably all the above! On the one hand, a highly successful man may feel that he has peaked and worries about his future growth and development. Where can he go now? He knows that since he has reached the peak, he has to fight to stay there. He has reached a serious period of transition in his life and is unsure of his future direction. These situations differ for each man and seem to be more of a problem for some than for others. Yet our social scientists tell us that for each man a time of personal evaluation arrives. For many, it is a manageable thought-provoking time. For others, it is incredibly frightening. The man of awareness and reason will value the reap­praisal that is appropriate to this period of life. Others, unable to deal with this time of personal questioning and uncertainty, turn emotional turmoil into a series of dramatic life changes that temporarily mask their discomfort.

This time of life may be experienced differently by men and women because of how they perceive themselves and their needs at midlife. It may be that men have a crisis of performance, whereas women suffer a crisis of appearance. Some men seek reassurance by continu­ally surrounding themselves with material objects to serve as remind­ers of success. Sometimes a man seeks a new relationship with a younger woman. A young adoring mistress may boost his ego. But, what of loyalty at home?

Is a man’s home life not living up to his needs as he perceives them? Can he move easily from his sophisticated dynamic work environment to his more static home life comfortably? Can he continue to enjoy, even relish, the comfortable relationship with his lifelong mate or is he seeking titillating renewal with a younger, or a different, woman? Can he age comfortably with his home life intact? Many men can; some men just cannot; other men seem to want to have both: their Mrs. and their mistresses.

The fear of aging and death seems to be much worse for men than for women, perhaps with some justification. Statistics prove that men die at a younger age than women. They experience more heart at­tacks, and they may actually be the weaker sex! We know that around the age of fifty, women are experiencing many great changes in family and friend relationships. They also are often changing or leaving jobs, and if the children no longer live at home and the “empty nest” is a reality, they may have more time for hobbies, sports, or just for themselves. For some women this change is welcome; for others it is fraught with the stress of readjustment.

A man has an even bigger problem to face. He has to watch as his male peers, friends, old school mates, business partners, competitors, and family members are struck down around him with diagnoses of diabetes, heart disease, cancer, and other medical problems. These events bombard him again and again with the fact that life—his life—is finite. The vulnerable male, so bombarded with news of illness and death, reads the obituaries and attends the funerals in ever-increasing numbers and his thoughts fill with the question, “Is that all there is?”

Although women experience illness and death among their family members, friends, and coworkers, too, somehow they seem to handle these matters with greater equanimity. In men, these experiences seem to result in conflict as they think about and fear the changes occurring within their own life. They confront their own circum­stances, their own life patterns, and their own mortality. Part of this “change of life” for them is also influenced by the changes happening to their partners. Maybe these changes are worse for some men be­cause of how they were nurtured. Whereas women can freely express emotion, men were often told not to cry. So, they don’t cry at the loss of father, mother, or even their youth. When men’s emotions become bottled tightly inside themselves, the bottled-up mess may eventually explode.

Sometimes the fallout can be highly productive. It can drive them toward a new career, to a new and exciting activity, or to new levels of intimacy with a much-loved partner. Or it can lead to disaster—to a broken marriage, a failed business, a sense of worthlessness, feelings of inadequacy, and even suicide. Sometimes it manifests itself as a need for more “toys,” more trips, more women, more of anything that says to them, “You are still virile, you are still exciting, you still turn me on, you are still young!”

Young is the important word: It is the important feeling. It means growth, potential, and promise. It offers the hope of immortality!

How to Take HRT

The choice of different regimens for HRT depends on whether or not you have had a hysterectomy.

Women with a womb

Continuous oestrogen plus cyclical progestogen

This is the most common regimen. Oestrogens are taken continuously, without a break, either daily in tablet form, once or twice weekly in patch form, a gel or, occasionally, as an implant. Progestogens are added every month, either as a 10 to 14 day course of tablets, or as a double patch combined with oestrogen, replaced twice weekly for two weeks. Calendar packs are available to help you remember when to take the progestogens.

The choice of different regimens for HRT depends on whether or not you have had a hysterectomy.

Women with a womb

Continuous oestrogen plus cyclical progestogen

This is the most common regimen. Oestrogens are taken continuously, without a break, either daily in tablet form, once or twice weekly in patch form, a gel or, occasionally, as an implant. Progestogens are added every month, either as a 10 to 14 day course of tablets, or as a double patch combined with oestrogen, replaced twice weekly for two weeks. Calendar packs are available to help you remember when to take the progestogens. If oestrogens and progestogens are prescribed separ­ately, most doctors recommend that you begin the progestogen course on the first day of every calendar month. All these regimens should result in a withdrawal bleed near, or shortly after, the progestogen course. You should report any bleeding occurring at other times to your doctor.

More recently, long cycle HRT has been introduced. This involves taking oestrogens every day as usual, but only taking the progestogen course every three months, i.e. four with­drawal bleeds every year. Unfort­unately a week of placebo (dummy) tablets is included in the packet and some women notice a return of their symptoms during this time. As a result of this, some doctors recommend skipping the placebo week. The other disadvantage is that a relatively high dose of progestogen is necessary which can lead to side effects as well as heavy and/or prolonged bleeding. Despite this, long cycle HRT can still be useful for women who are not yet able, or are unable, to take the no-bleed HRT and who wish to reduce the number of withdrawal bleeds.

Continuous oestrogen plus continuous progestogen

One approach to overcome the regular withdrawal bleeds is to take a combination of oestrogen and pro­gestogen continuously – taking both hormones together prevents any thickening of the lining of the womb so a withdrawal bleed is unnecessary. Unpredictable bleeding is not un­common during the first few months, sometimes heavy and prolonged.

However, in most women who continue on this treatment, the bleeding usually settles within 12 months. Bleeding is less likely the longer a woman has been post­menopausal before she starts this regimen. For this reason, continuous combined regimens are only recommended for women who have been postmenopausal for at least one year. In these cases continuous combined HRT can be highly satisfactory, although missed pills are frequently associated with some spotting.

Postmenopausal women who have been taking cyclical HRT and who wish to change to a ‘no-bleed’ regimen should start the new tablets at the end of a withdrawal bleed, i.e. several tablets into a fresh pack of their old cyclical HRT. This reduces the likelihood of any further bleeding because the lining of the womb will be thin. A recent advance has been to give continuous oestrogens to women using the levonorgestrel-releasing intrauterine system (IUS), used for contraception. This has the particular advantage for women who are still menstruating and at risk of pregnancy. Further, the progestogen is released locally so side effects are few. Similar to other no-bleed regimens, irregular bleeding in the early months can be a problem but most women have no bleeding within one year. Although the IUS is used for contraception, at the time of writing it is not licensed for use as HRT combined with oestrogens.

As a result of the limited use of no-bleed HRT, the long-term effects of this treatment on cancer of the womb, or indeed on osteoporosis, heart disease and breast cancer, have yet to be fully evaluated.

Cyclical oestrogens

An early regimen advocated oes­trogen treatment for three out of every four weeks, omitting pro­gestogen therapy. This method is associated with increased risk of cancer of the womb and a return of menopausal symptoms during the oestrogen-free week. For these reasons it is neither safe nor effective. If you are using this regimen, see your doctor and change to a recommended one.

Women who have had a hysterectomy

Continuous oestrogen

Hysterectomised women have the advantage of not requiring proges­togens, which reduces side effects and maximises benefits. The choice of treatment is daily oestrogen tablets, once or twice weekly patches, oestrogen gel or six-monthly implants.

Doses of oestrogen

The correct dose of oestrogen depends on the reason for taking it. Relief of severe symptoms obviously requires a higher dose than relief of mild   symptoms.   Many   women wonder why levels of hormones are not tested; the simple answer is that, because normal levels of oestrogen vary so much, it is more appropriate to monitor symptom control. If symp­toms are not adequately controlled, the dose of oestrogen needs in­creasing; if side effects are a problem, the dose is too high. There is a minimum daily dose of oestrogen necessary to protect bone loss. The doses in the various preparations are as follows:

– 0.625 milligram conjugated oestrogens (daily tablets)

– 2 milligrams oestradiol (daily tablets)

– 40-50 micrograms oestradiol (once/twice weekly patches)

– 1.5 milligrams oestradiol – two metered doses (daily gel)

– 50 milligrams  oestradiol   (six-monthly implant).

Doses of progestogen

The correct dose of progestogen is critical because it can almost completely eliminate the risk of cancer of the womb. A minimum duration of 12 days of treatment is recommended but the dose depends on the type of progestogen:

– 0.7-2.5 milligrams norethisterone

– 150 micrograms L-norgestrel

– 10-20 milligrams dydrogesterone

– 5-10 milligrams medroxyproges­terone acetate

– 200-400 milligrams micronised progesterone.

When to start HRT

It is never too late to start HRT; older women with fractures or heart disease will still benefit. But the most rapid loss of bone occurs soon after the menopause and the risk of heart disease starts to increase, so the earlier you start HRT, the better. If you start HRT while you are still menstruating, some adjustment of the timing of the progestogen phase may be necessary to prevent irregular bleeding.

When to stop HRT

If you use HRT just to control menopausal symptoms you will probably need to take it for two to three years, although occasionally it may be necessary to continue for as long as five years. For long-term protection against osteoporosis and heart disease, at least five years, and possibly up to 10 years, of treatment are recommended. If you are happy taking HRT there is no reason why you should not continue treatment indefinitely, so long as you are aware of the possible increased risks associated with long-term use.

Facts about Midlife Metabolism

“You are what you eat” is never more true than at midlife when your metabolism slows down. At this age for many women, a period of dietary indiscretion or eating unwisely while on a vacation or during a time of stress can play havoc emotionally and physically. In other words, your midlife metabolism does not permit much fooling your­self with food.

“You are what you eat” is never more true than at midlife when your metabolism slows down. At this age for many women, a period of dietary indiscretion or eating unwisely while on a vacation or during a time of stress can play havoc emotionally and physically. In other words, your midlife metabolism does not permit much fooling your­self with food.

Beginning in your mid-thirties, and compounded by menopause, which usually begins in your early fifties, your food intake needs to be scaled back to accommodate your slower metabolism. Nature has rigged our basal metabolic rate (BMR) to slow down after the age of twenty-five, sliding between one-half and one percent per year. It happens gradually, so that it may be some time before you realize that you can’t eat the way you once did. If you continue to consume the same amounts and kinds of food that you have in the past, you will have difficulty keeping your figure.

This is the age when even those women who have not had to do so previously may begin each day with a new ritual: praying to the bathroom scale. They get on the scale gently to keep the pointer from going up too quickly or jiggling too much. Finally, they look at the dial on the scale knowing well that whatever the scale reveals will dictate their level of self-satisfaction for the day. “I’ve lost weight” equals “I like me.”

“Therefore, today I’ll dress nicely and I’ll look terrific. I’ll eat less and exercise more, and everything will go well with me today!”

Conversely, “I’ve gained weight” means “I’ve been bad.” A woman berates herself: “I’m so disgusted with me. No matter what I do, I can’t lose weight. I might as well eat whatever I like because I won’t look good today anyway.” Or it may mean, “I’ll try harder today to diet and exercise, but I’m still unhappy with myself.”

These feelings can influence the quality of a woman’s interpersonal contacts that day as well as her dietary behavior. They may even influence her interest in sex. Although the problems of being over­weight and having a poor diet affect high blood pressure, cholesterol, diabetes, and a host of other diseases and conditions, we also know that for many women diet is an important social and emotional issue.