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 non-oral 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 health care 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 3:00 am 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
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 health care 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
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
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 cancer?
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 non-hormonal drugs, such as the SSRIs,
that you may want to consider.
How much alcohol is too much? What are the effects of alcohol
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 description.
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 health care professional, causes that are
more serious like ovarian cancer need to be investigated.
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
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 too!
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
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 doctors.
This article is part of the Menopause and Youlibrary,
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 health care practitioner with your
specific concerns and questions.
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