At the 2005 Menopause and You event, "Menopause and
You LIVE!", attendees submitted questions to Beverly
Vaughn, MD, gynecologist and medical coordinator of the
Menopause and You program. Here are her answers to those questions.
Are there any alternatives for taking oral medications for osteoporosis?
There are two nonoral medications. One is called Miacalcin,
which is a nasal spray. The other is Forteo, which is a daily
injectable. Some patients are better candidates for one over the
other. You should talk to your healthcare provider about which one may
be best for you.
After several years of using hormone replacement therapy (HRT), I’ve
stopped. How can I treat my symptoms (receding gums, dryer skin, loss of
muscle tone, and 3 a.m. hot flashes) more naturally?
This is a common and complicated question, and a good one for your
physician. Treating symptoms specific to your personal needs and being
mindful of your health history and current medications is very
The simplest answer is: you can't. Estrogen is important for dental
health, skin tone and moisture, as well as for hot-flash relief.
Other than good dental hygiene, I don't have another answer for
receding gums; a dentist or oral surgeon would be a better source of
information. For the skin: drink water;, avoid caffeine and
alcohol, which dehydrates the skin; avoid cigarettes, which damage the
skin's supportive structures and cause wrinkling; use a mild soap;
moisturize with a good lotion while skin is still damp; use sunblock SPF
15 at least; and eat lots of fruits and veggies. FYI, estrogen is
really important for skin health. It helps it retain moisture and keeps
the collagen from thinning. For muscle tone, the only answer
here is exercise, both cardiovascular and weight training but
particularly the weight training. The hot flashes may be helped
with alternatives to estrogen. First try eliminating caffeine, smoking,
spicy food and alcohol. Try adding natural soy to your diet through
the foods you eat. Relaxation (possibly yoga) and wearing layered
clothing can come in handy too.
Treatment with selective serotonin reuptake inhibitors (SSRIs), such as
Effexor, Prozac or Paxil, is one possibility. Treatment with a Clonidine
patch (low-dose antihypertensive) is another. So is short-term treatment
(six months) with Remifemin, an over-the-counter brand-name black
cohosh. (It's made by a German pharmaceutical company so it is
regulated; others from the health food store are not.) Also,
try vitamin E 400-800 I.U. daily.
Is the treatment for hot flashes different if you have a smaller
hypothalamus? Is HRT the only thing that helps?
No one measures the hypothalamus, as there is very little variation
between people. It is hard to explain why some people have more
significant symptoms than others and why some therapies are more
effective in particular individuals. There are certain women
for whom hormone therapy is the only thing that is helpful.
If I use black cohosh for six months and then stop, as suggested,
when can I start to use it again?
There is no clear answer for this question. It is an issue that has not
been looked into.
I've been hearing a lot about "isohormones" and their effectiveness on
many menopausal symptoms. Can you comment?
"Isohormones" are the same thing as "bioidentical hormones." These
are hormonal compounds that are made for the individual based on her
salivary gland levels of different hormones. There are several
problems with the bioidentical hormones. The first is that their
effectiveness has never been established. It is unclear if it is
better, the same as, or less than the traditional pharmaceutical hormone
therapy that has been used. Another serious concern is that not only has
their efficacy not been well-documented, but neither has their
safety. It is unknown when using the bioidentical hormones what the
risks are for breast cancer, stroke and/or heart attack. Since the
bioidentical hormones are classified by the FDA as vitamins, they do not
have to adhere to the same rigorous scientific controls and quality
controls that pharmaceutical companies are required to follow. This
is of particular concern given that there is no guarantee of the
actual content of the bioidentical hormones between the manufactured
batches. Even though estrogens produced by drug companies aren't thought
of as "natural," many are in fact produced from plant sources.
What about the vaginal supplement estradiol?
There are two kinds of estradiol supplements that are used vaginally.
One type, examples of which include Vagifem, Estring or Estrace cream,
are used for vaginal dryness symptoms only. These achieve very low
levels of estrogen in the blood stream. Given that this is true,
they are different from systemic estrogens, whether they are given
orally or by an alternate route. The likelihood of their causing a
significant risk is probably very small; however, the package insert
will list the same risks as for any estrogen because the information in
the insert doesn't make any adjustments for the route of administration.
Another type of vaginal supplement is FemRing. The FemRing is used
for both hot flashes and vaginal dryness. Because it is prescribed
for hot flashes, it does achieve a therapeutic level of estrogen
in the blood stream. It does need to be taken with progestins, like
Progestin/Progesterone, if you still have a uterus in place.
Is the amount of hormones in patches and creams, etc., comparable to
the amount in oral agents. If so, what is their advantage?
Each product has a variety of doses. It is hard to compare them
exactly to one another, but all of the doses are felt to be
effective for treating hot flashes. Some patients find that they
need higher doses than others. The advantage of patches, creams, or
vaginal rings is that there is a more even level of hormone in the
blood stream and, therefore, they may be more effective in
alleviating hot flashes. These alternative routes of administration
also bypass the liver and are not metabolized by it. This is
important because they seem to not have as much of an effect on
the clotting factors. This provides a theoretical advantage of
decreasing the incidence of stroke and pulmonary emboli.
How can I minimize night sweats so I can get a decent night's sleep?
Wear light cotton garments, and avoid caffeine and alcohol. If
these measures aren't useful, you may need to try medication,
whether it is hormone therapy, Clonidine, one of the SSRI's or
Neurontin (an anti-seizure medication).
What is the cause of frequent urination and urination when sneezing?
Urinary concerns are common among women of all ages. Frequency of
urination is different from loss of urine when coughing and
sneezing. Frequency may be caused by a high intake of fluids,
caffeine, alcohol, carbonated beverages, and/or smoking. There are
other dietary bladder irritants as well, and you can speak with your
healthcare provider about this for more detail. The loss of urine
with coughing and sneezing is caused by a change in the anatomic
relationship of the bladder and the urethra. Sometimes in
conjunction with this there is pelvic relaxation or a "dropped
bladder." For more information, see Understanding
Female Urinary Incontinence.
What can I use for vaginal dryness, burning and itching?
First, the cause of the vaginal dryness must be established. If it
is simply decreased estrogen, then any of the topical estrogen
products should suffice. Other causes of these vaginal
symptoms could be yeast infection, other vaginal infections, or
allergic reactions to soap, bubble baths, shower gels or detergent.
If the symptoms are primarily external, skin disorders such as
eczema and psoriasis must be looked for. There are other
conditions of the vulvar area that cause burning and itching such as
vulvar cancer, so this would need to be evaluated as well.
My bones ache, especially my hips and knees. Is this normal?
Is it normal in menopause to be stiff and have aches and pains?
It is very common after menopause to have an increase in arthritis and
have more joint pain. Increased physical activity, including
exercises that improve flexibility and stretching, may be
beneficial. Keeping weight under control is also
beneficial, particularly for the hips and knees, as there is a lot
of wear and tear on these joints.
Is bad cramping and chills normal during menopause?
If the cramping is related to your period, it is not unusual. Some
women find they have increased cramping during perimenopause. If it
doesn't seem to be period related, you should be evaluated for
another cause. Some women experience chills after they've
had a hot flash, and this is perfectly normal. If it doesn't seem
that the chills are in any way related to hot flashes, then other
medical problems should be eliminated.
I experience migraines and have been told this is a symptom of
perimenopause. Will this subside once I reach menopause?
Migraines are certainly a symptom that can occur in some women in the
perimenopause transition. They should be treated with appropriate
medication as any other migraine would be if they are severe and/or
interfering with your day-to-day activity. They should subside once
you have entered into menopause.
Is it normal to have a discharge each day while using Vagifem? What
are the recent reports on this product regarding endometrial
Vagifem, when used as a maintenance therapy for vaginal dryness, should
be used twice weekly. It is very common for women to notice a
vaginal discharge when using this or any other vaginal product. There is
debate about whether or not vaginal estrogens that are used for
vaginal dryness put women at increased risk for endometrial
cancer. Though this risk is probably small, some practitioners feel
it is appropriate for women who are using vaginal products,
particularly if they are not using hormone therapy by another route
and taking progestin/progesterone with it, that they be given
a progestin/progesterone product every three months to protect
the uterine lining.
I've been on HRT for 7 years. I am worried that I've been on it too
long. How can I go about transitioning to more natural measures, or
should I be concerned at all?
The first question is, why did you start HRT? If you started only
to prevent heart disease and/or osteoporosis, then you should
stop. If hot flashes were a problem and they were mild, you should stop.
If they were severe, you should consider the pros and
cons. By severe I mean that you felt they interfered with your
quality of life. The recommendation is that women stop after
five years. This is based on the small increase in heart attack,
stroke and breast cancer in women taking estrogen and progestin.
If your symptoms were severe, you should discuss with your doctor
whether or not you want to stop or continue, understanding that
there may be a risk. There is no one way to stop. I would
suggest weaning. This can be done either by changing to a lower
dose or taking your medicine every other day, then after a time
taking it every third day, then stopping. I definitely wouldn't
recommend stopping abruptly. You can certainly add more soy to your diet
and try black cohosh, which should be helpful. There are also
nonhormonal drugs, such as the SSRIs, that you may want to consider.
How much alcohol is too much? What are the effects of
Two glasses of wine a day is considered moderate. The effects of too
much alcohol are many: addiction, heart failure, liver disease,
osteoporosis and dementia.
Is there such a thing as one-stop doctors?
There are many internists and family practitioners who have an
interest and expertise in women's health and who may fit this
How can you maintain mental sharpness or overcome fuzzy thinking?
Keeping your mind active is one suggestion. This means reading
material that is challenging, doing crossword puzzles, taking a
class. The other suggestion is to ensure that you're getting
enough sleep. Sleep deprivation is a prime cause of decreased
mental acuity. Stress can also contribute. If you are on any
medications, I would review them with your physician to make sure
that they are not the cause.
What's with all the bloating? Any remedies?
If it is cyclic, then it is most likely hormonal. Symptomatic
treatments like vitamin B6 (300 mg daily, but no more) can be
helpful. A mild diuretic may also be needed. If it seems to
be more abdominal and not cyclic, it could be related to your GI
tract. It is more difficult to digest carbohydrates with age
and this can result in bloating. It is important to ensure
that you have enough fiber and water in your diet. This will help with
motility and decrease bloating. Intestinal disorders such as
irritable bowel syndrome and lactose intolerance need to be
considered. If the bloating is persistent and doesn't change
with therapies suggested by your healthcare professional,
causes that are more serious like ovarian cancer need to be
Why does 3 a.m. seem to be the "magic hour" for awaking during the
Actually, everyone has a different time that they are awakened. The
question is why are you waking up? Is it because you have to
go to the bathroom (once or twice a night is normal after age
50)? Is it because of hot flashes? Do you wake up stiff and
achy? You may be waking up because of arthritis. Many medications
can cause sleep difficulties. Depression and/or stress are also common
reasons for waking in the middle of the night. The specific problem
needs to be addressed.
Is there any reason not to stop using birth control at age 52?
Yes, if you are using birth control pills you begin to increase your
risk of stroke and clotting. The estrogen in birth control
pills is about six times more potent than the estrogen in hormone
replacement therapy. If you still get periods and need
birth control, I would suggest another method such as condoms,
diaphragm, IUD or cervical cap. A birth control pill that
contains only progestin (the "mini pill") is another option.
Is there any benefit to a pill package that causes no period?
Sure. It's nice not to get a period. This is particularly true for women
who have heavy flow. It will decrease the chance they may be come
Are multivitamins important after 52? Why? Which are best? Is
it necessary to take a daily calcium supplement? What multivitamin would
As we age we don't absorb vitamins as readily. Any multivitamin is
fine. It is best to take one without iron unless you are anemic.
Daily calcium requirements are 1,200 to 1,500 mg. This can be
consumed with a combination of calcium rich foods and
supplements. The supplements need to be taken 3-4 times a day,
since your body can only absorb 300 to 400 mg at a time.
Examples of Calcium Rich Foods
The numbers indicate the mgs of calcium contained in the serving size
1 cup skim milk: 302
1 cup 1% low-fat milk: 300
1 cup 2% low-fat milk: 297
1 cup whole milk: 291
1 cup buttermilk: 285
1 oz. Swiss cheese: 272
1 oz. cheddar cheese: 204
1 oz. American cheese: 174
1/2 cup 2% cottage cheese: 77
1 cup low-fat plain yogurt: 415
1 cup low-fat yogurt with fruit: 345
3 oz. sardines with bones: 345
3 oz. salmon with bones: 99
3 oz. shrimp, canned: 145
4 oz. tofu, processed with calcium sulfate: 145
1 cup oysters: 90
1/2 cup collards: 179
1/2 cup kale: 103
1/2 cup bok choy: 126
1/2 cup turnip greens: 126
1/4 of a 14-inch cheese pizza: 332
1/2 cup macaroni and cheese: 181
1 cup cream of mushroom soup made with milk: 191
1 cup cream of tomato soup made with milk: 168
1 taco: 174
1 cup cheese: 124
1 tbsp. blackstrap molasses: 137
Source: National Dairy Council
How are soy products different in their effectiveness to help
menopause symptoms? Are soy tablets safe to take? Dosage?
Don't take soy pills. They are not that helpful. Soy milk,
tofu, edamame beans and dried soy nuts are the best
source. You may need to drink a quart of soy milk or eat
the equivalent of a pound of tofu. Many women feel they get
benefits from eating less. Remember, it's a great source of calcium
Is there a diversity of menopause symptoms for certain ethnic groups?
Yes, there seems to be a difference in hot flashes, though not in other
symptoms. In the U.S., African American women and Hispanic women
seem to have slightly worse symptoms than Caucasian. Asian
American women have the least. The frequency and severity of
flushes changes in different parts of the world. For instance, in
Britain it is higher than in the U.S. There is probably more at
work than ethnic differences.
How does having a partner that smokes affect me?
There can be an increase in respiratory symptoms such as asthma from
secondhand smoke. Also, your risk of heart disease and lung cancer
are increased. Click
here to find out more about risks.
Do women with cystic breasts worsen at perimenopause or menopause?
At perimenopause they may become tenderer. After menopause the symptoms
How can I tell if I have thyroid disease?
Symptoms include fatigue, weight loss, weight gain, thinning hair, dry
skin, and irregular periods, to name a few. The only way to
diagnose thyroid disease is by having a blood test (TSH) ordered by your
This article is part of the Menopause and You library,
a Web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own healthcare practitioner with your
specific concerns and questions.
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