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Menopause is a time of transition at the end of which a woman's child-bearing years are completed. The ovaries cease to produce eggs, and estrogen is gradually withdrawn. Menopause is generally considered to begin two years before the last period, and end two to three years after it. A woman can expect to be beyond childbearing when her periods have ceased for a full year between ages 48 and 53.

The first signal of approaching menopause occurs when periods become erratic. As estrogen levels begin to decline, the monthly cycles become shorter, and the flow is heavier. When there is not enough estrogen to stimulate a cycle, a period is missed. Once menopause is over, the ovaries are small and shrunken, but, and a very important but, they continue to produce androgens, the hormone of the libido, and very small amounts of estrogen. PMS after age 40 can also be a signal of gradual estrogen withdrawal.

This gradual withdrawal of estrogen is all perfectly normal. Many women are hardly aware of it; others are thankful that their periods will soon cease. Some women suffer from heavy bleeding problems. Check that there is sufficient vitamin A in the diet; a dietary deficiency is linked with heavy flow. Increase the amount of iron-rich foods to avoid anaemia; the RDA is 10 milligrams for women age 51 and over. Keep a record of period dates, flow patterns, heavy clots, and so on. There is a slight risk that heavy bleeding can signify precancerous changes in the endometrium (uterus lining). Visit the physician for a check-up.

The Bad News

Estrogen seems to protect women from heart disease; it is not fully understood how. When estrogen production wanes, this protection is removed. By age 65, women have the same risk of heart disease as men. Women are more likely to have angina (chest pain), which is an early warning signal. Yet often there are no warning signals at all. The same risk factors for men apply to women:

  • Family history of heart disease.
  • Smoking.
  • High blood cholesterol.
  • Weight gain.
  • Lack of exercise.
  • Stress.
  • High sugar intake.

The following are specific women-only risks:

  • Early menopause before age 45.
  • Surgical menopause.
  • Low estrogen levels.
  • Use of the birth control pill.

Cardiologists now stress that all women at midlife should be aware of the risk of heart disease. The key factor is screening. The treadmill test involves walking at an increasingly brisk pace on a treadmill to monitor blood pressure, heart and breathing rate. Angiography uses X-rays on a television screen to show how advanced heart disease might be. Early diagnosis is a must. Keep in mind that exercise and a healthy diet reduce the risk of heart disease and most symptoms of menopause. Now is the time to get fit, and stay fit, before sailing serenely through midlife.

The Good News

Male hormones such as testosterone fuel the sex drive and promote a sense of well-being. The ovaries continue to produce testosterone into old age, as do the adrenal glands. When estrogen levels drop, some effects of testosterone start to show through. Facial hairs appear, particularly on the chin; sometimes on the chest and abdomen. Head hair becomes thinner, loses its colour, and when it falls out, is replaced more slowly. Are hair loss and an increased risk of heart disease an appropriate price to pay for testosterone? How much do women gain from an increased sense of well-being?

Stress is defined as "an emotional state which affects the body." When a person is faced with a challenge, the adrenals pour out stress hormones (adrenaline and noradrenaline), which speed up the heart and breathing rate. More oxygen can be rushed to the muscles; extra fats and sugars enter the blood for fuel. The mouth dries, the pupils dilate, sweating stops. All systems not needed to cope with the challenge shut down. This is known as the fight or flight syndrome. The extra energy available helps to either to fight the challenge and win it, or to take flight from the challenge if it presents too much of a threat.

Testosterone has been called the winner hormone, because the level in the blood raises when a challenge is won, or a difficult problem solved. The relaxed mood which follows winning shuts down the further secretion of stress hormones. There follows a natural surge of testosterone, with its high, a strong sense of wellbeing. The testosterone surge helps convert the extra fats and sugars back into stored energy. All body functions return to their normal pace. It can be seen that stress hormones and testosterone work in opposition.

However, in some cases, the person remains stressed, even if the challenge is won. The stress hormones continue to pour out, and no natural surge of testosterone can then occur. A few women cannot relax. They remain tense, anxious, and uptight. It is now thought that testosterone secretion might be blocked by such prolonged stress, and that the ravages from those unabated stress hormones can damage the cardiovascular system, thus speeding up the aging process. The sequence of events goes something like this:

  • The stress hormones continue to pour out, and fats and sugar remain in the blood...

  • This causes an unhealthy build-up of sugar and cholesterol in the blood...

  • This unhealthy build-up increases the risk of plaque forming in the blood vessels...

  • Plaque formation speeds up the aging of the cardiovascular system...

  • The results can include hardening of the arteries, high blood pressure, and heart disease.

Learn to relax! By midlife, most women have accepted the fact that nobody wins all the time. For those who have constantly lost, (sadly this happens), avoid looking back on painful events. Reliving past miseries can increase the ravages of stress, and suppress testosterone. Practice yoga, take regular exercise, do whatever activity helps relax the mind and produces a sense of well-being, a testosterone "high."

Many women find that they have an increased zest for life after menopause. They feel more feisty and experience a greater sense of well-being. Often, they become more assertive at work and in their relationships. This increase in feistiness may be, in part, due to the male hormones now showing through.

More Good News

The ovaries continue to produce small amounts of estrogen for 10 years or more after menopause. Long before they slow down, estrogen is produced in the adrenal glands and fat cells. After menopause, the adrenal glands are the main source of estrogen. They produce a type of androgen which is converted to estrone (a type of estrogen). This conversion process is complicated. Two factots help to speed it up:

  • Exercise.
  • Having "a little flesh on the bones."

Keep in mind that a certain amount of fat cells is necessary to support hormone activity. Being underweight for age is never advisable, and particularly not at midlife. The good news is that women with "a little flesh on the bones" experience less symptoms of menopause.

Hot Flashes

Hot flashes are the most common symptom of menopause. They are also known as hot flushes because they are like sudden waves of heat, with sweating over the face, neck, chest, or throughout the body. A hot flash feels like a tiny charge of electricity. A mild flash lasts less than one minute, may produce no sweat, and does not upset normal activity. A moderate flash causes sweating for two to three minutes, with a desire to stop activity and cool down. A severe flash involves heavy sweating for three minutes or more. There can be shivering, nausea, and palpitations. Severe flashes can cause distress, irritability, and a feeling of being unable to cope.

On average, hot flashes last less than two years, but a few unlucky women have them for five years. Keep in mind that most estrogen withdrawal is gradual, and most hot flashes are mild to moderate only. Wearing jackets or other outer clothing which can be removed during a hot flash helps to keep the body cool. Exercise helps to raise the body's tolerance to sudden heat. An increase in exercise makes it possible for many women to just shrug off the discomfort and carry on.

With moderate to severe flashes, there is heavy sweating at night. Drink plenty of liquids to replace what is lost. Night sweats can cause great strain on a woman's general health. Waking up drenched several times each night is not pleasant. Worse is the exhaustion which comes from the lack of sleep. Severe flashes are due to a sudden drop in estrogen. If the quality of life is seriously affected, consider estrogen replacement therapy, ERT. ERT is very effective at relieving the symptoms; it replaces the natural estrogen which is being withdrawn.


"Osteo" means bone, and "porosis" comes from Greek for porous. Osteoporosis is loss of bone density; the bones become thinner and fracture more easily. Women (and men) begin losing bone mass at around age 35. Women have lighter bones to start with, so have a higher risk of fracture. One reason why exercise programs carry a warning to start slowly is to avoid fracture.

Apart from aging, there is no specific cause of osteoporosis. Estrogen withdrawal seems to speed up the process. So does being underweight with no fat cells to produce estrogen. Booklets in the physician's office are devised by drug companies to sell ERT. They over-stress estrogen withdrawal and plug into a woman's fears of becoming frail and helpless. With exercise and increased calcium in the diet, the risk of osteoporosis can be reduced.

Risk factors to avoid:

  • Diet low in calcium.
  • Physical inactivity.
  • Cigarette smoking.
  • Being underweight.
  • Heavy use of alcohol.

Calcium: Calcium is essential for bone formation. Women (and men) tend to consume only one-third of the calcium they need. Calcium works best if obtained from food. Check that there is sufficient Vitamin C and D in the diet because they help increase calcium absorption. Avoid fluoride and calcitonin supplements; they can be toxic. Find and stick with a reliable diet plan; these are detailed in most magazines.

Milk is a good source of calcium. Two glasses daily supply 500 mg of calcium. If there is milk intolerance, or the taste is disliked, be sure to eat the dietary calcium equivalent. The RDA for calcium is 1,500 mg; the equivalent of one and one-third quarts of milk per day. Calcium supplements can be taken: 1 gram per day from age 35 until menopause; and 1.5 grams daily after menopause. Reduce the amount of alcohol, caffeine, and carbonated drinks; avoid excessive intake of protein.

Inactivity speeds up the rate of calcium loss. Inactivity is a known factor in thinning bones. Lifting weights thickens bone by increasing blood flow, which stimulates the bone-building cells. Studies on 80-year-olds and over in weight-bearing programs found that their strength, stamina, and endurance increased enormously. Lost flexibility and grace of movement returned. Stretching programs avoid shortening of the spinal bones, and the risk of compression fractures. These can be seen on elderly women (and some men) who were unaware of the benefits of exercise, and developed what was known as a "dowager's hump." As their bone loss increased, they also lost body height.

Women who have exercised all their lives never will have the low bone density that ultimately results in osteoporosis."

  • Dump the frail image.
  • Go lift some (light) weights.

Smoking/drinking: Cigarette smoking and over-use of alcohol are choices. Though dependency may be real and urgent, any addiction can be broken if the addict truly desires to be rid of it. Local hospitals or clinics run free programs to help. The findings of a recent study show that it is never too late to give up smoking. Not only is the risk of osteoporosis reduced, but that of heart disease and certain cancers as well.

The first five years after menopause are said to be the time of maximum bone loss, though this is not proven. It could be that some midlife women are overwhelmed with work or depressed, and so become physically inactive. A recent study found that combining exercise with low doses of estrogen was the most effective way of preventing bone loss. If there are family members with fractures, consider a bone density scan. New drugs, such as tamoxifen, are being explored as another protection against osteoporosis.

Vaginal Changes

Estrogen plumps up the reproductive organs, keeping them soft and moist. With estrogen withdrawal, the tissues gradually lose some of their moisture. The first place this may be noticed is in the vagina. The walls become thinner, shorter, and less robust. Less cervical mucus is produced, which can add to dyspareunia, painful intercourse. If there is sudden estrogen withdrawal, a woman as young as 50 can find that she no longer desires to make love because it hurts.

Try external lubrication first, and check for infection or a yeast condition which is asymptomatic. If the pain persists, the vagina can be made more robust with estrogen creams. These are available by prescription only. They must not be used as a sexual lubricant; the skin of the penis can absorb estrogen and some men have developed breasts. Relief from the symptoms occurs within a month. For some women, the creams are not sufficient; in these cases, ERT will bring effective relief.

Dyspareunia is not inevitable at menopause. Its medical name is vaginal atrophy; the very term offends. Just as some mature vaginas cannot sustain very prolonged thrusting, so some mature penises cannot sustain very prolonged erections. The point is that a woman is often made to feel less feminine, less desirable, by the natural changes at menopause. The very threat of vaginal "atrophy" can be overwhelming, and stampede her into ERT when a little lubrication is all that is required. Mature men tend to be treated with more dignity. It is rare to hear offensive terms about erection loss, and then only in jokes. With the approach of old age, all tissue starts to atrophy, regardless of gender and estrogen loss.

The Big Debate

To take estrogen replacement therapy, or not? That is the big debate for women at midlife. The four conditions of menopause for which ERT is recommended are:

  • Protection against heart disease.
  • Protection against osteoporosis.
  • Protection against hot flashes.
  • Protection against vaginal dryness.

The following is a list of possible risks of ERT:

  • Cancer of the uterus.
  • Cancer of the breast.
  • Severe bleeding and blood clots.
  • Liver problems and gallstones.
  • Raised blood pressure.
  • Surgery, if appropriate, to reverse some of these effects.

For severe hot flashes, and/or early surgical menopause, ERT can be a blessing and a boon. Exercise and an appropriate diet, plus natural estrogen produced from the adrenal glands and fat cells, all reduce the risk of other problems. The following is a list of benefits claimed for ERT:

  • Mental tonic effect.
  • Improved short-term memory.
  • Enhanced sexuality.
  • A more robust vagina.
  • Increased sexual sensation.
  • Stronger pelvic floor muscles.
  • Improved bladder tone.
  • Smoother, less wrinkled skin.
  • Firmer, plumper breasts.
  • Improved general muscle tone.
  • Less general body deterioration.
  • Altogether, an enhanced quality of life.

Well, that sounds terrific! Why not go for it? Advertisements for ERT use the term "supplements." This makes them sound rather like vitamin or mineral supplements, something which is fairly harmless to take as a booster. ERT works by delaying menopause. The body is tricked into responding as if there were no natural withdrawal of estrogen. So the breasts swell, the vagina produces fluids, and cervical mucus is profuse at mid-cycle. The uterus lining builds up and breaks down, with no cessation of periods. Most women do not appreciate having periods almost unto the very grave. Try to avoid ERT until periods have altogether stopped.

In the 40s and 50s, ERT was taken long before menopause. The estrogen given was in high doses, and without progesterone. This high level of "unopposed estrogen" caused the uterus to go on building a hard thick lining. Without progesterone, the lining could not soften and break down. This was found to cause cancer of the uterus. Physicians are now aware of this unhappy outcome, but just in case: if taking ERT either before or during menopause, makes sure that progesterone is also prescribed.

Today, low doses of estrogen with progesterone are given. Some studies show that taking ERT for 15 years or more, or in high doses, can slightly increase the risk of breast cancer. Other studies show no such effect. It is all very confusing. Keep on the latest findings, which are usually well reported in the press.

All female tissue is "estrogen-dependent." It grows in response to estrogen. Unfortunately, so do female cancer tumours, and such benign growths as fibroids and endometriosis. ERT is still in the experimental stage. Not everything is known about its effects. The fears are that it could turn out to be another terrible mistake, as was DES. ERT is not for women with:

  • Known or suspected cancer in any of the reproductive organs.

  • Family history of estrogen-dependent cancers.

  • Other estrogen-dependent growths, fibriods & endometriosis.

  • Irregular, severe or unexplained bleeding.

  • Chronic jaundice or any other liver disease.

  • Severe varicose veins.

  • Diabetes mellitus.

  • Very high blood pressure.

  • Previous or present thromboembolism, or thrombophlebitis.

  • Very high concentrations of fat or cholesterol in the blood.

Yet ERT is splendid for controlling severe hot flashes and to relieve vaginal dryness. It is highly effective after surgical menopause with the very sudden withdrawal of estrogen. Where the quality of life is reduced by the mental and physical distress of menopausal symptoms, ERT may be well worth the known risks. Be very conscientious and have regular Pap smears, pelvic exams, and mammograms. ERT is powerful medication. Like most difficult decisions in life, it is an issue of risk/benefit ratio.

Testosterone Replacement Therapy

There is a recent, on-going debate about whether to give women testosterone as a supplement hormone at menopause. The two groups under consideration are women who suffer loss of libido after hysterectomy and those whose ovaries have been removed. It could be a very long debate: the case for giving testosterone replacement therapy (TRT) to midlife men who suffer a drop in libido is far from being resolved. Some of these men argue that as ERT (with its risks) is readily available to women, it is only reasonable that TRT should be available to men.

Women who take TRT for other reproductive ailments report that they have more energy and a greater sense of well-being. However, the side effects can be a problem: more and heavier facial hair growth, a deepening of the voice, shrinking breast tissue, and other masculine effects. These can sometimes be avoided by a lower dosage. The problem with taking TRT or ERT is that they interfere with the natural production of sex hormones.

Skin Changes

Skin changes at menopause are due to the normal aging process. The deeper layer of skin loses some moisture and elasticity, and starts to shrink. The surface skin is now looser than the inner layer, so it hangs or creases. Blood circulation slows, and the skin can become blotchy, with broken capillaries. Enlarged pores add a rougher texture. Exercise improves blood circulation, which helps nourish the skin and create moisture. However, skin changes can be made worse by sudden estrogen withdrawal.

Some skins age faster than others; it is not known why. There might be an inherited tendency. Studies show that smoking adds to the risk. It can be upsetting to know that skin thins and the tissue underneath dries. Yet this happens to men as well; notice the jaw line on the average midlife male. Keep in mind that thinning skin and sagging bits happen to both genders, regardless of estrogen withdrawal.

Retin-A, the new dream cream, removes tiny surface wrinkles and light brown pigment spots. The results are remarkable in some women, giving a more youthful appearance after one full year's treatment. Retin-A can cause redness, and an allergic response. Before considering Retin-A, see a dermatologist for examination, prescription, and follow-up care.

For deeper wrinkles and aging folds, a facelift or eye surgery removes the offending bags and sags. Consult an otolaryngologist or general plastic surgeon. Some women prefer the fascination of a face which tells of a well-lived life. Plastic surgery is an issue of esthetics and choice...and cost...and risk. Not all cosmetic surgery is a success.

Exercise tones up the circulation which, in turn, tones and improves the skin. An appropriate diet is another factor to help delay the aging process. Keep "a little flesh on the bones." The absence of fat cells means less estrogen to plump out and firm the tissues.

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