Menopause FAQs 9781550093520
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Geisinger Clinic is a multispecialty physician group practice with nearly 650 physicians located in central and northeastern Pennsylvania. The clinic’s mission is “to enhance the quality of life through an integrated health service organization based on a balanced program of patient care, education, research, and community service.” This mission is summarized: “Heal. Teach. Discover. Serve.” To learn more about the Geisinger Healthcare System visit www.geisinger.org
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FAQs* SERIES Also in this series Current Titles Low Back Pain FAQs Rheumatoid Arthritis FAQs Weight Management: Childhood and Adolescence FAQs Weight Management: Adults FAQs Depression FAQs Upcoming Titles Asthma FAQs Depression FAQs Hypertension FAQs Headache FAQs Insomnia FAQs Diabetes FAQs
*Frequently Asked Questions
MENOPAUSE
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Author Valerie Weber, MD
Series Editor Sandra A. Buckley
2007 BC Decker Inc Hamilton
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BC Decker Inc P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com © 2007 Geisinger Clinic and BC Decker Inc Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of the publisher. 07 08 09/PI/9 8 7 6 5 4 3 2 1 ISBN 1-55009-352-5 Printed in Canada Sales and Distribution United States BC Decker Inc P.O. Box 785 Lewiston, NY 14092-0785 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com Canada BC Decker Inc 50 King St. E. P.O. Box 620, LCD 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com Foreign Rights John Scott & Company International Publishers’ Agency P.O. Box 878 Kimberton, PA 19442 Tel: 610-827-1640 Fax: 610-827-1671 E-mail: [email protected] Japan Igaku-Shoin Ltd. Foreign Publications Department 3-24-17 Hongo Bunkyo-ku, Tokyo, Japan 113-8719 Tel: 3 3817 5680 Fax: 3 3815 6776 E-mail: [email protected]
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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.
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Introduction Many women in their 40s begin experiencing confusing symptoms—irregular bleeding, hot flashes, mood changes—which cause them to wonder whether these symptoms are due to the start of menopause, and if so, what effect this will have on their lives. However, some women probably haven’t given menopause, or “the change of life,” much thought until they find themselves in the midst of it. Women in their 40s and 50s, often referred to as the “sandwich generation,” are extraordinarily busy juggling careers, younger or grown children (and in some cases grandchildren), and caring for their aging parents.
The “Sandwich Generation” Menopausal women often handle: • Careers • Young children • Grown children (or grandchildren) • Aging parents • Body and mood changes
If they have spent any time thinking about menopause at all, it may have been just to look forward to a time when menstruation stops, without thinking much about the symptoms that may accompany menopause. Realizing that one is entering a new phase of one’s life, particularly in a culture that emphasizes youth and beauty, can also be an emotional challenge.
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In medical science, we understand the hormonal changes behind menopause, but we haven’t reached a complete understanding of all of the changes it causes on various organs in the body. And we have done a poor job of discussing it with our female patients. Women may feel afraid to bring it up with their doctors. Many physicians have had little real training or formal education in dealing with issues surrounding menopause. In addition, menopause has been getting a great deal of attention on television, in newspapers, and on the Internet as several high-profile medical studies have highlighted the side effects of hormone replacement therapy for controlling the symptoms of menopause. This has generated a lot of mixed messages and confusion.
Mixed Messages Menopause messages are everywhere! It can be hard to get a straight answer: • Television, newspapers, Internet • Medical studies • Your doctor • Friends and family
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About This Book This book should be helpful to anyone who wants to learn more about menopause and maintaining their health as they enter their middle years and beyond, particularly women of any age, their partners, friends, and loved ones. The information in this book will help you answer the following questions: • What is menopause? • How do I know if I am experiencing menopause? • What is “surgical menopause?” • What kind of changes might I notice during menopause? • Does menopause require “treatment?” • Should I take estrogen? • What other treatments are available for my symptoms? • How can I maintain my health as I age? • Am I at risk for heart disease? • Am I at risk for cancer? • Do I need to worry about osteoporosis? • Other “female” problems—how can I get help? • How can I talk to my doctor about these issues? At the end is a glossary of terms related to menopause.
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Contents 1. What Is Menopause? 2. How Is Menopause Diagnosed? 3. Is There Any Treatment for Menopause? 4. What Other Conditions Might I Be at Risk for During Menopause? 5. Menopause and Osteoporosis 6. How Are Depression and Anxiety Linked to Menopause? 7. How Can I Continue To Educate Myself About Menopause?
Glossary
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CHAPTER ONE
What Is Menopause? The word “menopause” literally means the cessation of menses (the monthly flow). Although the average age of menopause in the United States
The average age of menopause in the United States is 51.
is 51, menopause is really a transitional time that can last several years, and can take place anytime from the 40s through the late 50s. We call this transitional time perimenopause.
What is the relationship between hormones and menopause? During the reproductive years, a woman’s body produces many hormones. Hormones are “chemical messengers,” that act on specific organs in the body. A woman’s ovaries produce two important hormones—estrogen and
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progesterone. These two hormones act primarily on the uterus to regulate the menstrual cycle, but they also affect the brain, heart, bones, breasts, and other organs. When the ovaries stop making estrogen and progesterone, menstruation stops completely (Figure. 1-1).
What happens to a woman’s hormones that makes menopause occur? Let’s start at the beginning. When a young woman begins to menstruate, the pituitary gland in the brain secretes two hormones: FSH (follicle-stimulating hormone) and LH (luteinizing hormone). These two hormones act on the ovaries to begin the process of releasing an egg from the ovary each month. Under the action of these hormones, the ovary will produce estrogen and progesterone. These four hormones all work together in a very complicated dance to cause the growth and release of one egg each month. If pregnancy does not occur to put a stop to this process, each cycle ends with a menstrual flow. At puberty, it is estrogen that causes the breasts to develop, pubic hair
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A
B
Figure 1-1. Hormones affect the younger reproductive system during menstruation (A) and the older reproductive system during menopause (B).
to grow, and the female sexual organs to mature. At birth, each woman has all of the eggs in her ovaries that she will ever have (about 2 million). By puberty, about 300,000 are left. During a woman’s reproductive years, only about 400 to 500 eggs will reach maturity. The rest of the eggs slowly disintegrate over time. By the time a woman reaches her early 40s, these few remaining eggs begin to become less responsive to the hormones acting on them (LH and FSH). The ovaries then produce less estrogen and progesterone. In turn, the pituitary gland will produce higher levels of FSH and LH to try to stimulate the ovaries. These changes take place anywhere from 2 to 10 years before actual menopause. But over time, the ovaries produce less and less of these hormones. As we stated before, when the ovaries stop making estrogen and progesterone, menstruation stops completely.
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How will I know if I’m beginning to experience menopause? Most women notice changes gradually. The first symptom may be that their periods start to occur more frequently, as often as every 21 days, then sometimes stop for a few months. Hot flashes or flushes may also begin to occur at this time. This period of perimenopause may begin several years before actual menopause, and may continue for several years as well.
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What are hot flashes? Women describe hot flashes as a feeling of heat, beginning in the abdomen or chest and traveling up to the neck and face. The face may turn red and flushed, and beads of sweat may appear. A few women notice palpitations (a sensation of the heart beating faster) along with the hot flash. A hot flash may last anywhere from a few seconds to a few minutes. There is a lot of variation as to how they are experienced. The most disturbing type of hot flash occurs at night and disturbs sleep (night sweats). Some women may wake up drenched or feeling clammy several times during the night. Interrupted sleep can result in difficulty concentrating, fatigue, and irritability. Over half of all women will experience hot flashes during perimenopause. Scientists believe that hot flashes are caused by sudden surges of LH (leutinizing hormone, which we discussed earlier) in response to declining levels of estrogen. Women who have their ovaries surgically removed (surgical menopause) or have chemotherapy may experience worse hot flashes. This is because their menopause is very abrupt, with less time for the body to adjust.
Defining Menopause Menopause—when periods stop completely Perimenopause—a time of menopausal symptoms that begins several years before menopause and lasts several years after Surgical menopause—when periods stop because the ovaries are surgically removed
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CHAPTER TWO
How is Menopause Diagnosed? Generally, menopause is diagnosed by the history of the symptoms you are having, without any special testing.
How can I tell if what I am experiencing is menopause? If you are in the right age group (40s to late 50s), are experiencing hot flashes, and/or are having irregular periods, it’s a pretty good guess that you are experiencing symptoms of menopause (see Table 2-1). If the diagnosis is uncertain or your symptoms are not typical, your doctor may order a blood test to measure your level of FSH (follicle-stimulating hormone, discussed in Chapter 1). FSH is elevated in a menopausal woman.
Table 2-1: Me? Menopausal? Probable symptoms:
Possible symptoms:
Right age range: 40s–50s
Vaginal dryness
Hot flashes
Insomnia
Irregular periods
Emotional symptoms (forgetfulness, lack of concentration, irritability) Changes in breast size, firmness, shape Body hair changes Loss of bone mass
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Is there a general age when most women begin to have symptoms of menopause? Other than saying that menopause usually occurs anytime from the 40s through the late 50s, we can’t be much more specific. However, there are some factors that are more important and some that are less important related to when symptoms of menopause will begin (Table 2-2). We have found that • there is a tendency for women to follow a similar pattern as their mother, and • thinner women may go through menopause at a younger age than obese women.
Table 2-2: Menopause: When? More important
• Right age range: late 40s through late 50s • Family history: when your mother experienced menopause • Body size: thinner women may go through menopause sooner • Medical history: women who have had a hysterectomy or chemotherapy may go through menopause sooner Less important
• Age at first menstruation • Number of children you have had • Sexual history
Factors that appear to be less important related to when symptoms of menopause will begin are • the age at which you started menstruating, • the number of children you have had, and • your sexual history. Also, women who have had a hysterectomy or have undergone chemotherapy go through menopause earlier than they would have normally.
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What is premature menopause? We say that women who stop menstruating before age 40 experience premature menopause. Women who experience premature menopause and have not undergone a hysterectomy or chemotherapy should be evaluated
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by their doctor. An evaluation might determine if stress, an eating disorder, illness, or pituitary gland disorder might have caused menstruation to stop prematurely. Often a cause is not identified. Women who do experience premature menopause are more at risk for osteoporosis (thinning of the bones) (discussed in Chapter 5).
Besides hot flashes and irregular periods, what other changes might I notice? Estrogen affects many different organs in the body besides the ovaries. Therefore, lower levels of estrogen caused by menopause will affect other organs (Figure 2-1). There is a large amount of variability in how women experience (or if they experience) these symptoms: • Vaginal dryness. The lining of the vagina becomes thinner, less elastic, and drier. Over time, the vagina shrinks and narrows. Symptoms may include burning and itching, pain during intercourse, and urinary tract infections. • Insomnia. Hot flashes, stress, or diet can affect sleep. • Emotional symptoms. Forgetfulness, lack of concentration, and irritability are experienced by some women. There is some controversy as to whether these symptoms are because of a lack of estrogen. • Changes in breast size, firmness, or shape.
Figure 2-1. Several aspects of a woman’s body change during menopause.
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• Thinning of body hair. This might also be accompanied by an increase of facial hair. • Loss of bone mass. This is one of the more important changes, which can lead to an increased risk of fractures. Other changes may occur around this time, which may be related more to aging than to menopause itself. These include loss of bladder control (urinary incontinence),
loss of skin tone and wrinkling, and increased risks
for the development of cardiovascular disease, cancer, stroke, and osteoporosis. These conditions will be discussed in Chapter 4.
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CHAPTER THREE
Is There Any Treatment for Menopause? Unfortunately, there is no one “magic bullet” to make the symptoms of menopause go away. However, we will describe here certain treatments that can alleviate some of the symptoms. Most notably, we will explore the use of estrogen.
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When and why was estrogen first used to treat symptoms of menopause? The medical community began to explore treating the various symptoms of menopause with estrogen after the popularity of its use for contraception in the 1960s. We believed that in modern times, with women living long past menopause, many of the diseases that women were experiencing were partly due to a lack of estrogen. Of particular interest was the fact that after menopause, the rates of cardiovascular disease in women seemed to “catch up” to those of men. Before menopause, the rates of cardiovascular disease are much lower than those of men of the same age, and it was thought that estrogen must be responsible for these differences. After menopause, there is an increased burden of other chronic diseases too, including certain cancers, osteoporosis, and Alzheimer’s disease. Most of the enthusiasm for this approach came from some early studies showing that estrogen might prevent heart disease, prevent osteoporosis (thinning of the bones), and potentially prevent or slow the progression of Alzheimer’s disease. As time went on, however, many of the suggested
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No one “magic bullet” can make menopause symptoms go away— symptoms can only be alleviated.
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benefits of estrogen did not seem to hold up in larger, more thorough studies. These same studies suggested that estrogen might in some cases do more harm than good.
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Was estrogen prescribed for all menopausal women? At the peak of estrogen use in the late 1990s, approximately 35% of eligible women in the United States were using it to prevent postmenopausal symptoms and or disease. We often call this using hormone replacement therapy or HRT, for short.
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What does the medical community believe now? Should I take estrogen or not? In the past few years, many doctors with a large number of women patients who have been closely following the medical literature, have changed their recommendations to their patients regarding the use of estrogen. Let’s break down the facts about estrogen by benefits and risks to clarify some of these important issues. A summary is found in Table 3-1.
Table 3-1: Hormone Replacement Therapy with Estrogen: Risks and Benefits Benefits
Risks
Relief of hot flashes
Endometrial cancer if not taken
Prevention of osteoporosis
with progesterone Blood clots Breast cancer Gallbladder disease Possible risks Cardiovascular disease Ovarian cancer No risk or benefit Alzheimer’s disease Colon cancer
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Benefits • Relief from hot flashes. There is strong evidence that estrogen is very effective for the relief of hot flashes. For women with disabling hot flashes (for example, waking up more than once per night), estrogen is the most effective treatment. However, most experts recommend that it only be used during perimenopause (less than 5 years). • Prevention of osteoporosis. There is strong evidence that estrogen does prevent osteoporosis (thinning of the bones). This was confirmed in the Women’s Health Initiative study, published in 2002 and 2004. Risks • Risk of endometrial cancer if not taken with progesterone. There is strong evidence that for women with a uterus (women who have never had a hysterectomy), estrogen cannot be taken without progesterone. Prempro is the most common combination pill that combines both estrogen and progesterone. This is because there is an increased risk of endometrial cancer (cancer of the lining of the uterus). This risk is eliminated by giving estrogen in combination with progesterone in women with a uterus. For women without a uterus, estrogen can be given alone without any increased risk of endometrial cancer. • Risk of blood clots. There is strong evidence that estrogen increases the risk of blood clots in the legs and lungs. This risk is about three times the normal rate. In a large study called the Heart and Estrogen Replacement Study, for every 256 women treated with estrogen, one blood clot would be caused. • Risk of breast cancer. There is evidence of an increased risk of breast cancer in women with a uterus taking Prempro. This evidence came from more than 16,000 women studied in the Women’s Health Initiative, and the study results were released in the summer of 2002 with much publicity. The study was intended to investigate whether estrogen could reduce the risk of cardiac disease in postmenopausal women. The study had to be stopped early due to the increased risk of breast cancer seen in the women taking Prempro. In the spring of 2004, however, the second major report of the Women’s Health Initiative showed that for women with a uterus treated with
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Premarin (estrogen without progesterone), there was a slight reduction in breast cancer risk. Most experts do feel that, overall, estrogen use does increase a woman’s risk of breast cancer if taken for more than 5 years. • Risk of gallbladder disease. There is evidence of an increased risk of gallbladder disease in women taking estrogen. This can result in gallstones requiring surgical removal of the gallbladder. Possible risks Studies of these conditions and their relation to estrogen use were inconclusive: • Possible risk of cardiovascular disease. For years there were some studies that suggested that estrogen would reduce women’s risk of heart attacks. However, the Women’s Health Initiative showed actual increases in coronary heart disease in some women taking estrogen. In further reports from this study, it appears that cardiovascular disease is likely not increased or decreased significantly in most women taking estrogen. Therefore, most experts do not feel that estrogen should be used to prevent or treat cardiovascular disease in women. • Possible risk of ovarian cancer. One large study in 2001 suggested that risks of ovarian cancer may be higher in postmenopausal women taking estrogen. No risk or benefit Estrogen has not been proven to have any cause or effect on these conditions: • Alzheimer’s disease. Despite some initial promise, most studies suggest that there is no benefit to using estrogen to either treat or prevent Alzheimer’s disease. • Colon cancer. Results of trials are conflicting as far as colon cancer is concerned. We still don’t know if estrogen use has any effect on colon cancer risk.
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Are there still situations, then, when estrogen is prescribed? Yes. For most women, the strongest reason for using estrogen is to treat disabling hot flashes that can’t be helped through other means or to treat osteoporosis when other therapies can’t be tolerated. Even then, doctors
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generally recommend that estrogen only be used for a few years. Estrogen is not prescribed at all to prevent cardiovascular conditions. You should keep in mind that it is you and your doctor together who should make any decisions regarding use of estrogen, taking into account your own preferences, medical history, and risk factors. There is no cookie-cutter approach! For women with a uterus on estrogen alone (without progesterone), the risk/benefit equation is different, and each individual should have a discussion with her physician.
I’ve been taking estrogen for years and I feel fine.Should I stop taking it? Many women feel fine taking estrogen, which they started years ago either to treat hot flashes or to prevent osteoporosis. What’s most important is that a woman be informed of the possible increased risks and benefits in an
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individualized discussion with her doctor. For women who wish to stop hormone replacement therapy, consult with your doctor to taper off the medication slowly, over a period of 1 month, to decrease the chance of recurrent hot flashes.
Is taking the new “lower dose” formulations any safer? At this point, it is not known whether lower doses of prempro or premarin, or taking the medications on an every other day basis, are any safer.
When I first went through menopause, I was moody and fatigued. Will those symptoms return once I stop taking estrogen? Current evidence indicates that estrogen does not seem to help moodiness and fatigue. It is important to recognize that these types of symptoms could
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be related to depression or anxiety and may need treatment, or these symptoms may be related to sleep disturbances from hot flashes.
Estrogen Stats • Peak use was in the late 1990s—35% of eligible women used it • Currently, estrogen is only recommended for 5 or fewer years (during perimenopause)
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My doctor and I have decided to stop estrogen. Now I’m having hot flashes again! What other treatments are available? Some new alternatives to control hot flashes have been tested and are effective (Table 3-2). None work quite as well as estrogen, but many women will find them of some benefit. In most women, hot flashes will subside after a few years, and if they are only a minor nuisance, no treatment at all may be needed. • Venlafaxine (Effexor). Venlafaxine (Effexor) has been shown to relieve hot flashes. This drug can also be used to treat depression. • Paroxetine (Paxil). Paroxetine (Paxil) is another antidepressant that has been shown to work for hot flashes. • Clonidine. Clonidine is a medication used to treat high blood pressure and may help women with hot flashes as well. It is available as a pill or a patch.
Table 3-2. Estrogen Alternatives • Venlafaxine (Effexor®) (antidepressant) • Clonidine (high blood pressure medication) • Plant-derived estrogens (phytoestrogens) (food and other herbal supplements) • Self-awareness (keeping a diary of hot flashes to recognize triggers; dressing in layers; avoiding caffeine)
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• Plant-derived estrogens (phytoestrogens). Soy is probably the best known of the phytoestrogens. Others include ginseng and black cohosh, which you can purchase at drug or health food stores. These may be helpful, but because they are estrogens, we don’t know whether the risks of these medications are the same as other estrogens. Therefore, you should try them with caution and only if other treatments haven’t worked, and after speaking with your physician, as herbal products can interact with other medications you are taking. • Self-awareness. Hot weather, caffeine, or stress may trigger hot flashes. Keeping a diary of your hot flashes and what may lead to them may help you eliminate triggers. Many women find that dressing in layers, keeping cool, and avoiding stress and caffeine may help.
I was taking estrogen to control vaginal dryness. If I no longer take estrogen, what other alternatives are there to this problem? Besides oral estrogen supplements, there are other possible solutions for the dryness, irritation, and pain with intercourse that can occur when estrogen levels fall and the vagina lining thins: • Moisturizers and lubricants (Replens, Astroglide), • Topical estrogens (creams applied directly to the vaginal lining), and • A vaginal ring (Estring).
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CHAPTER FOUR
What Other Conditions Might I Be at Risk for During Menopause? Many of us live our lives as if nothing can ever happen to us. We can be so involved in our careers, families, and other obligations that we may not realize it’s been years since that last physical exam. Others may have a regular doctor, but leave the responsibility for wellness into the hands of the health care provider.
W
hat most people do not realize is that they are in control, to a large degree, of their own health. While it’s true that we can’t do anything
about our genetic background, our health problems, to a large degree, will be determined by our habits and lifestyle choices. Ask yourself the following questions, give yourself honest answers, and score yourself accordingly: • Do I smoke? (-3) • Do I use alcohol excessively (more than two drinks daily, or binge drinking on the weekends)? (-1) • Do I get regular physical activity? (+1) • Am I overweight by 5 to 20 pounds? (-2) • Am I 25 pounds or more overweight? (-3) • Am I exposing myself to sexually transmitted diseases such as HIV? (-1) • Do I wear seatbelts? (+1) • Have I had my blood pressure checked within the last year? (+1)
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Who’s In Charge of Your Health? You can’t do anything about your genetic background, but most of your health problems will be determined by your habits and lifestyle choices.
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• If I am over 50, have I had screening for colon cancer? (+1) • If I am over 40, have I had regular mammography? (+1) • Have I had a pap smear within the last 2 years? (+1) • Have I had a cholesterol screening within the last 5 years? (+1) • Am I up-to-date on my immunizations? (+1) Total up the numbers above. If you scored on the “minus side,” you are in need of a health evaluation and tune-up, and need to take better care of your health. There is much you can do to enhance it. Menopause is an ideal time to start reforming your habits and taking serious charge of your health. In the rest of this chapter, we’ll discuss some of these health issues in depth (see a summary in Table 4-1). Two other very important health issues for menopausal women—osteoporosis and depression and anxiety—will be discussed in their own chapters.
Table 4-1: What Other Conditions Can Occur During Menopause? Heart disease Breast cancer Colon cancer Cervical cancer Ovarian cancer
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Am I at risk for heart disease during menopause? Yes! Heart disease is common in postmenopausal women. In fact, heart disease is the leading cause of death in women. It is responsible for more deaths of women each year than all other causes combined. For years there has been a perception (and doctors used to be taught this in medical school) that heart disease is uncommon in women. This is not true. In fact, in the last two decades, the number of deaths from cardiovascular disease in women has surpassed that in men (Figure 4-1) and by age 65, the risk of death from
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Figure 4-1. Cardiovascular disease mortality trends for women and men, United States 1979–2000.
cardiovascular disease in women goes up while the risk of death from breast cancer goes down (Figure 4-2). In fact, more women should be concerned about heart disease. In a 1997 survey done by the American Heart Association, 61% of women in all age groups (and 72% of those between the ages of 25 and 34) responded that cancer was their primary health concern. Fewer than 10% of women considered cardiovascular disease to be the greatest risk to their well-being. This same survey also found that only 38% of physicians had discussed heart disease with their female patients, and only 20% of the female patients surveyed reported that a health care professional had given them information on cardiovascular disease in the past 12 months. Apparently, there is a huge disconnect from what patients and doctors perceive to be the risk of cardiovascular disease to a woman’s health and reality. One reason cardiovascular disease in women is so under-recognized is because women often do not have the typical symptoms of heart disease.
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Figure 4-2. Risk of death from cardiovascular disease and breast cancer.
The classic symptoms of a heart attack (like chest pain) often don’t occur in women. Women may experience shortness of breath, fatigue, weakness, or jaw pain instead, and therefore may not recognize that they may have a heart problem. As a result, women are often diagnosed later than men. There is also some data (although this is a controversial area in medicine) suggesting that women with established heart disease may be treated less aggressively than men, and may have poorer outcomes. It is important to listen to your
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body and discuss any new symptoms with your doctor.
How can I reduce my risk for heart disease? Because a woman’s risk for heart disease begins to increase around the time of menopause, it is an important time to take stock of your risk factors and change those that you can. Of course, family history is an important risk factor that you can’t control. One important risk factor is having a member of your immediate family (father, mother, sister, or brother) with early heart disease (before age 55 if male and under age 65 if female). Other than this
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factor, most other risk factors are modifiable, including smoking, high blood pressure, obesity, diabetes, lack of exercise, and high cholesterol. Let’s talk about these risk factors one by one. Diabetes. There is an epidemic of type 2 (adult onset) diabetes in the United States that is closely related to the growing problem of obesity. Diabetes is present in 4.5% of white women, 9.1% of black women, and 10.9% of Mexican-American women (Figure 4-3). The incidence of diabetes increases after age 45.
Figure 4-3. Diabetes incidence.
Diabetes is a very powerful predictor of the risk for heart disease in women. We don’t know exactly why persons with diabetes tend to develop heart disease at such a high rate. We do know, though, that if diabetes can be discovered early and controlled, the risks are decreased. If you are overweight, over 40, and have a family history of diabetes, you should have a yearly fasting glucose level checked as a screen for diabetes.
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High Blood Pressure. Many women have high blood pressure—also known as hypertension—but aren’t aware of it. High blood pressure is very common in the United States. It is estimated that by age 70, nearly 80% of women will have high blood pressure (Figure 4-4). The higher your blood pressure is, the greater your risk of heart disease and stroke. Generally, no symptoms accompany high blood pressure. Therefore, if you are not screened for it, it can be present and damage your blood vessels, heart, and kidneys, leading to future problems. Being overweight increases the risk of having high blood pressure. The good news is that you can often easily control it with weight loss and dietary changes, along with medications.
Figure 4-4. By age 70, nearly 80% of women will have high blood pressure.
Smoking. One in four women above age 18 smoke. Smoking is to blame for as many as 50% of all coronary events in women. The risk is elevated even in women who only smoke 1 to 2 cigarettes a day! Studies show that women who smoke are at risk for a heart attack 20 years earlier than in other women, especially if other risk factors like family history or obesity are
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.
present. The good news is that if you are able to quit, your risk returns to normal within 3 to 5 years. Smoking combined with using oral contraceptives (being on “the pill”) is one of the most dangerous things a woman can do to her health—the risk of having a heart attack is elevated by 30 to 40 times normal in such women. If you smoke, you should know that there are several effective methods to help you quit. If you have tried to quit before and were not successful, take heart—most successful ex-smokers have tried to quit 3 to 5 times before being successful. It’s the most important thing you can do to reduce your mortality from heart disease and other diseases, including lung cancer and emphysema. High Cholesterol. Approximately 50% of women over age 20 have cholesterol levels that are above their ideal range (known an hyperlipidemia). After menopause, the levels of total cholesterol and low-density lipoprotein (known as the “bad cholesterol”) increase. Beginning around age 40, women should be screened for high cholesterol with a simple blood test. If it is elevated, a change to a diet lower in calories and fat is indicated. There are also several effective, easy-to-take medications available to treat high cholesterol. Several studies in women confirm that treating high cholesterol reduces the risk of heart disease—and some studies have shown that women benefit from these medications even more than men. Diet. The Nurse’s Health Study followed over 80,000 women nurses over time and found that there was a relationship between the amount of saturated fat in the diet and the risk of heart disease. Women with a higher intake of fruits, vegetables, fish, poultry, and whole grains, and a lower intake of red meat, sweets, and fried foods had a significantly lower risk of coronary artery disease (CAD). Obesity. In the United States, 46 to 68% of women are overweight, and 22 to 37% are obese. How do you know if you are overweight or obese? Most
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experts these days use the Body Mass Index (BMI) to measure obesity. A BMI of 20 to 25 is normal, a BMI of 25 to 30 is overweight, and a BMI of over 30 is obese. Table 4-2 will help you determine your BMI. The bad news is that the rates of death from cardiovascular disease and even cancer increase with your BMI. The good news is that weight loss can reverse
Table 4-2: Determining Body Mass Index Find your height in the left-hand column. Move across the row to your given weight. The number at the top of the column is the BMI for that height and weight. BMI
19
20
21
22
23
24
25
26
27
28
29
30
35
40
Height (in.)
Weight (lb.)
58
91
96
100
105
110
115
119
124
129
134
138
143
167 191
59
94
99
104
109
114
119
124
128
133
138
143
148
173 198
60
97
102
107
112
118
123
128
133
138
143
148
153
179 204
61
100
106
111
116
122
127
132
137
143
148
153
158
185 211
62
104
109
115
120
126
131
136
142
147
153
158
164
191
63
107
113
118
124
130
135
141
146
152
158
163
169
197 225
64
110
116
122
128
134
140
145
151
157
163
169
174
204 232
65
114
120
126
132
138
144
150
156
162
168
174
180
210 240
66
118
124
130
136
142
148
155
161
167
173
179
186
216 247
67
121
127
134
140
146
153
159
166
172
178
185
191
223 255
68
125
131
138
144
151
158
164
171
177
184
190
197
230 262
69
128
135
142
149
155
162
169
176
182
189
196
203
236 270
70
132
139
146
153
160
167
174
181
188
195
202
207
243 278
71
136
143
150
157
165
172
179
186
193
200
208
215
250 286
72
140
147
154
162
169
177
184
191
199
206
213
221
258 294
73
144
151
159
166
174
182
189
197
204 212
219
227
265 302
74
148
155
163
171
179
186
194
202 210
218
225
233
272 311
75
152
160
168
176
184
192
200
208 216
224
232
240
279 319
76
156
164
172
180
189
197
205
213
230
238
246
287 328
24
221
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the progression of CAD, improve your cholesterol and blood pressure, and reduce the risk of diabetes. A reduced-calorie, reduced-carbohydrate diet plan, along with exercise, is the healthiest way to keep off weight for good. Physical Inactivity. Higher fitness and activity levels in women lower the risk of death from all causes, including heart disease. The Nurse’s Health Study found that exercise lowered the risk of CAD, and that even light to moderate activity was associated with a lower risk of heart disease. If none of this sounds easy…it’s because it’s not! But the reasons have been laid out for the need for close attention to your health at this age. It’s important that you have a physician who will listen to your concerns and begin working with you to reduce your risk factors for heart disease. We will discuss how to work with and talk to your doctor in Chapter 7.
Am I more at risk for cancer during menopause? Not necessarily. The most common types of cancer affecting women are breast, lung, endometrial, and colon cancer. Other cancers unique to women, but less common, include cervical and ovarian cancers. Cancer screening is
Q A
an important part of your overall health maintenance regimen, whether or not you are menopausal. The idea behind cancer screening is to detect cancer at an early stage, before it causes symptoms, and hopefully at a time when it is curable. Let’s talk about the different types of cancer that affect women and what screening is available. Breast Cancer. Approximately 180,000 women are diagnosed with breast cancer each year in the United States. About 44,000 women die each year of breast cancer, making it second only to lung cancer in cancer deaths among women. There is very strong evidence that regular screening can reduce your risk of dying of breast cancer.
How is breast cancer screening done? There are three primary methods of screening for breast cancer: mammography, breast exam by a doctor, and breast self-exam. A mammogram
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is an X-ray of the breast that can detect early changes of a cancer before it can be felt by an exam (Figure 4-5). Although the breast is exposed to small amounts of radiation, it is not enough to increase the risk of cancer.
Figure 4-5. During a mammogram, the breasts are compressed between an X-ray plate to flatten the tissue and allow abnormalities to be seen.
The exam takes just a few minutes. You will be asked to change into a gown. Your breasts will be compressed between an X-ray plate to flatten the tissue and allow abnormalities to be seen. It is somewhat uncomfortable, and may be more so just before or during your period when the breasts are slightly tender. Many women therefore avoid making their appointment during this
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time of the month. Radiologists read the films and the results are communicated to your physician. Sometimes additional views are needed to look closer at an area of question. If the study is normal, it should be repeated yearly. Mammograms are covered by most insurance, including Medicare and Medicaid. The American Cancer Society has a toll-free number offering information about low-cost mammograms (1-800-ACS-2345). There is strong agreement that women between the ages of 50 to 70 benefit from yearly mammograms, but there is still controversy about whether (and how often) women younger than 50 need mammograms. In younger women, the breasts are denser, and as a result there may be more “false positives” in these younger patients (a false positive is a test showing an area of concern, but found not to be cancer following a biopsy). A clinical breast examination is an exam done by a doctor or nurse to check for lumps that can be felt. This is important and you should have this done on a yearly basis. The breasts should be inspected for any changes in size or shape, then the breasts should be felt (including all the way up into the armpits) to feel for any lumps. Breast self-examination is a simple way of finding changes in your breasts (Figure 4-6). It is best to perform a breast self-exam once a month, at the same time each month. It is not a substitute for mammography or exams by a doctor, but many women who examine their breasts regularly have detected small changes and have been able to alert their doctors of problems early. Colon Cancer. Colon cancer is a common but, fortunately, preventable disease. It is the third most common cause of cancer death in both men and women, and approximately one-third of people who develop it die of the disease. Screening tests make it possible to detect cancers at an early, treatable stage. In contrast to some other cancers, colon cancer is often detected through screening, because most cancers start as small benign tumors called adenomatous polyps, which grow over a period of as much as
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Figure 4-6. Correct hand motions and positioning for breast self-exam
10 years. If caught during this stage, they can be removed before they turn into cancer. Regular screening can reduce your risk of developing colon cancer by up to 90%! You may be at increased risk for colon cancer if you have • a family history of colon cancer, • prior cancer or polyps of the colon,
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• inflammatory bowel disease (ulcerative colitis or Crohn’s disease), • a diet high in fat and red meat and low in fiber, or • an addiction to cigarettes. Screening for colon cancer involves the following tests: • fecal occult blood test • sigmoidoscopy • barium enema test • colonoscopy The fecal occult blood test is a simple test that can be done by a woman at home. Your doctor will give you a kit with cards that you send to a lab. The lab will test the stool for hidden blood that may indicate a polyp is present. The test’s accuracy is somewhat limited, but if you use it every year, it can reduce the risk of dying from colon cancer. Sigmoidoscopy allows the doctor to view the lining of the rectum and the lower part of the colon. A thin, lighted tube is inserted into the rectum. To prepare for the test your doctor will ask you to use an enema a few hours before the procedure. It can be performed in your doctor’s office. The risks of the procedure are low and it is effective in reducing your risk of cancer if performed every 5 years or so. One disadvantage, though, is that the entire colon cannot be visualized. For this reason, some doctors do this test in combination with a barium enema test, which provides a detailed X-ray picture of the entire colon and rectum. Colonoscopy is often the preferred test because it allows for direct viewing of the entire lining of the colon and rectum. Preparation involves cleansing the colon with a laxative the evening before the procedure. Patients are given a mildly sedating drug before the procedure. Current recommendations are that this test be repeated in 10 years if normal. If a polyp is found, it can often be removed at the time of the test. A new test, called virtual colonoscopy, involves a computed tomography scan (CT or “CAT” scan) of the colon. At this
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time, it does not appear to offer an advantage compared to colonoscopy, as the preparation is the same, and a tube must still be inserted to do the test. In addition, if an abnormality is found and a biopsy of a polyp is needed, a colonoscopy will need to be done in addition to the virtual colonoscopy. What test to do and what age to begin screening will depend on your risk factors and preferences, as well as the availability of these procedures in your area. In general, screening of some sort should begin at age 50 and continue as long as your general health is good. Cervical Cancer. Cervical cancer screening with pap smears has been common in the United States over the past several decades. Because of pap smears, deaths from cervical cancer in the United States have become quite uncommon. Women who have never been screened have the greatest risk of invasive cervical cancer. The two most common means of screening for cervical cancer include the pap smear and the ThinPrep. A pap smear is performed by scraping the cervix using a spatula. A sample from inside the opening of the cervix is taken with a round brush. The spatula and brush are then placed on a glass slide and reviewed under the microscope in a certified laboratory. Standard pap smears will detect anywhere from 50 to 90% of abnormalities. In 1996, the ThinPrep was approved as an alternative to the standard pap smear. This method is more sensitive, and allows the false negative rate (that is, the chance that the test will come back negative when there is a problem present) to be greatly decreased. The ThinPrep can also simultaneously test for HPV (human papillomavirus), the virus that is responsible for most cases of cervical cancer. No matter which test is used, if a test is abnormal, further evaluation will be done, usually by a gynecologist, and generally with a technique called colposcopy, which allows for direct visualization of the cervix and biopsy of abnormalities. Cervical cancer screening with either the pap smear or the ThinPrep should begin after the onset of sexual intercourse, but no later than age 21. Women
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should have the tests annually on initial screening if conventional pap smears are used and every 2 years if ThinPreps are used. In women with three or more normal tests in a row who are over age 30, the interval can be extended to every 2 to 3 years. In women over age 65, or for those who have had a total hysterectomy for benign disease, a pap smear is no longer needed. Pelvic examinations should still be done on a regular basis, negotiated between patient and doctor, especially if gynecologic symptoms develop.
Women: Get Wise About Health Risks • More than half think cancer is the greatest health risk • Fewer than 10% think cardiovascular disease is the greatest health risk • Fewer than half of doctors talk to female patients about heart disease • By age 70, 80% of women have high blood pressure • Half of all coronary events in women are caused by smoking • In the United States, 46-68% of women are overweight, and 22-37% are obese • About 180,000 women are diagnosed with breast cancer each year; 44,000 die • Colon cancer is the third most common cancer in men and women • The lifetime risk of developing ovarian cancer is 1 in 70, and 25,000 cases are diagnosed each year in the United States • In an average year, 60,000 people die from influenza
Ovarian cancer. In the United States, more than 25,000 cases of ovarian cancer are diagnosed each year. The lifetime risk of developing ovarian cancer is approximately 1 in 70. The incidence of ovarian cancer increases with age, with the highest proportion of cases diagnosed in women ages 50 to 59. Unfortunately, there are no good options available for screening women for ovarian cancer. Strategies such as pelvic ultrasound and tumor
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markers (known as CA-125) have not been found to be good screening tests to detect ovarian cancer at an early stage. However, in women with a strong family history of ovarian cancer, CA-125 testing may be indicated. There are
Q A
several ongoing studies that are looking at these issues.
Are Immunizations Important during Menopause? Yes. For most of us, the term “immunization” makes us think of the shots our children received as babies. Not so! Adults still need to make sure they are up-to-date with their immunizations. As many as 50,000 to 70,000 adults (especially the elderly) die each year from infections that are preventable through immunizations. The most common of these are pneumonia and influenza. Experts recommend that age 50 (whether or not a woman is menopausal) is an ideal time for adults to evaluate their immunization needs. Let’s review some of the common immunizations that adults need (summarized in Table 4-3): Influenza. This immunization is given yearly to prevent influenza, or “the flu,” a viral illness that is seen in the winter months. Each year the vaccine contains different components based on strains circulating in the world that are likely to cause disease in the upcoming year. They are prepared from highly purified, inactivated virus and cannot cause infection. The vaccine is up to 80% effective
Table 4-3: Vaccines for Adults Tetanus-diphtheria vaccine (all adults, every 10 years) Influenza (flu) vaccine (adults 50 and older) Pneumococcal vaccine (adults 65 and older) Hepatitis B vaccine (adults at risk) Measles mumps rubella (MMR) vaccine (susceptible adults) Varicella (chickenpox) vaccine (susceptible adults) Vaccines for travelers (variable)
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at preventing influenza. Most people aren’t aware that, in an average year, as many as 60,000 people in the United States die from influenza. Influenza causes symptoms such as high fever, cough, headaches, body aches, and severe fatigue. Current recommendations state that all adults benefit from receiving the vaccine. It is especially important that persons over age 65 receive the vaccine because this group has the highest risk of death from influenza. Persons younger than 65 who have problems with their immune system and those with chronic diseases such as diabetes, heart disease, or asthma should receive the vaccine regardless of age. The vaccine should not be given to those with a history of a severe allergy to eggs. Pneumonia. This vaccine prevents the most common forms of pneumonia— those that are due to bacteria called Pneumococcus. This vaccine should be given on a one-time basis to all persons at age 65. It should also be given to those 50 and older who have chronic diseases or a problem with their immune system. If given under the age of 50, it should be repeated again at age 65. Tetanus. Tetanus is a wound infection caused by a bacterial toxin found in the soil. This disease is rare in the United States, but can be seen in adults that never completed the childhood vaccination series. This vaccine should be given once every 10 years. Hepatitis B. This vaccine prevents Hepatitis B, which is one of the most common causes of liver disease and cirrhosis in the United States. It is spread through contact with an infected person’s blood or body fluids, and can be spread through sexual intercourse. Persons at risk for exposure, such as those that work around blood products (health care workers, child care workers), and other high-risk individuals should receive this vaccine. It is now being administered to all persons in childhood. MMR (Measles, Mumps, Rubella). The MMR vaccine protects against measles, mumps, and rubella. If you were born before 1957 you are
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considered to have natural immunity against these diseases. If you were born after 1957, you may need a booster if you have no record of having received this vaccine in the past. Varicella. This vaccine protects against Varicella Zoster, more commonly known as “chicken pox.” If you had chicken pox as a child, you do not need the vaccine. If you are unsure whether you had chicken pox, your doctor can check your blood for immunity, as most adults are immune even if they don’t recall having had chicken pox. If your blood test is negative, you should receive the vaccine. It is especially important for health care workers, teachers of young children, daycare workers, and women of childbearing age to receive the vaccine if required because they are at an increased risk of catching the disease from children and varicella in adults can be quite serious.
Q A
Do vaccines cause side effects? It turns out that most vaccines cause only minor side effects. Unfortunately, many people have common misconceptions about vaccines. The most common side effect of vaccines is a mild fever or tenderness at the site of the vaccine for a few days. If you have any concerns about vaccines you should discuss them with your doctor.
Q A
I have been having problems controlling my urine.What can be done about this? Many older adults think of urinary incontinence, or bladder control problems, as an inconvenience or a normal part of aging. Furthermore, many people are embarrassed to discuss this topic. However, bladder control problems are not a normal part of aging. They are a serious medical issue that can make going about your life difficult. Many treatments are available to help most causes of this problem.
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What kinds of bladder control problems are there? There are several types, depending on the cause: • Urge incontinence. Urge incontinence happens when the urge to urinate comes on suddenly and strongly. It can be caused by neurologic problems such as stroke or Parkinson’s disease, urinary infections, or other medical conditions. • Stress incontinence. Stress incontinence happens when sneezing, coughing, lifting, or laughing cause your urine to leak. This is generally caused by weakening of the muscles around the bladder opening as a result of childbirth or surgery. It is the most common cause of urinary incontinence in women. • Mixed incontinence. Mixed incontinence is a combination of stress and urge incontinence. • Overflow incontinence. Overflow incontinence occurs when the bladder cannot be emptied fully, usually because of a neurologic injury or diabetes, causing urine to leak from a full bladder. • Functional incontinence. Functional incontinence occurs when the bladder is working normally but the person has difficulty getting to the bathroom on time, due to problems such as arthritis, impaired mobility, or memory loss. Several treatments are available, depending on the cause. Your doctor will first take a thorough history and do a physical examination, including a pelvic examination. It is important to tell your doctor about all medications you take, including herbal medications, over-the-counter medications, and caffeine. Your doctor may ask you to keep an incontinence diary, and will likely check your urine for infection. If you and your doctor are not able to tackle this issue together, your doctor may send you to an incontinence expert. Several techniques exist that can help patients with this problem, depending on what is causing it (see Table 4-4).
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Table 4-4: Strategies for Dealing with Urge Incontinence Behavioral Special exercises to strengthen the sphincter muscles Gradually prolonging the time between bathroom visits Maintaining a reasonable fluid intake Medicine Prescription medication to relax the bladder or tighten the sphincter A review of the medication you take for other conditions that can affect bladder control Surgery To restore the support of the pelvic floor muscles To reconstruct or compress the urinary sphincter Absorbent products and devices Worn internally to support the bladder and improve control
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CHAPTER FIVE
Menopause and Osteoporosis Osteoporosis, or thinning of the bones, is a common disease affecting 8 million people, mostly women, in the United States alone. About 40% of all postmenopausal women will, at some point, experience a fracture due to osteoporosis, with the most frequent locations being the hip, the spine, and the wrist. If the osteoporosis is severe enough, these fractures can occur spontaneously, or with what would normally be a minor bump or fall.
What is osteoporosis? Osteoporosis means bone thinning (Figure 5-1). A lot of us think of our bones as being frames on which the rest of our body hangs but, in fact, our bones are organs that are constantly changing and remodeling. Bones have two major cells. Osteoblasts lay down bone framework and build up bone with calcium. Osteoclasts break down bone. Estrogen has an important role in blocking the osteoclasts from breaking down the bone and helping to transport calcium into the bone. After menopause, when estrogen levels drop, women generally begin experiencing rapid bone loss (Figure 5-2). This bone loss can be accelerated by the following factors, which may make you at an increased risk for osteoporosis: • lack of dietary calcium • lack of vitamin D • lack of weight-bearing exercise • smoking
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Figure 5-1. Osteoporosis means bone thinning.
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• excessive alcohol • excessive caffeine • low body weight (weighing less than 125 pounds) • low estrogen levels • certain medications (steroids, seizure medications) • certain diseases (hyperthyroidism, certain gastrointestinal disorders) • family history of osteoporosis
Figure 5-2. Bone density over time.
What’s the big deal about a fracture? Besides being painful, and often requiring surgery, fractures can lead to permanent disability, nursing home placement and, in many cases, death when they occur in older women. If you have a hip fracture, you have an extra 20% chance of dying in the next year, unrelated to any other medical problems you already have. And about half of the people who survive a hip fracture are permanently disabled, never returning to their previous level of function.
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How Important Are Healthy Bones? If you have a hip fracture, you have: • An extra 20% chance of dying in the next year, unrelated to any other medical problems you already have • A 50% chance of becoming permanently disabled and unable to return to your previous level of function
Q A
What can I do to prevent osteoporosis? You will notice that many of the items we just mentioned are within your control. The most important things you can do to minimize your risk of osteoporosis include the following: • Get enough calcium. This is important beginning at age 20 and throughout your life, but especially around the time of menopause. Women in this age group should get at least 1,200 mg of calcium daily. There are a lot of good sources of calcium in the diet (see Table 5-1).Calcium supplements are also an easy way to get this amount of calcium daily (see Table 5-2). If you take a supplement, it is important to take only 500 to 600 milligrams at any one time. More than this is not absorbed. • Get enough Vitamin D. Vitamin D is an essential fat-soluble vitamin that is required so that the calcium you do get is absorbed by your body. The easiest way to make sure you are getting enough Vitamin D is to take a multivitamin that contains 400 IU of vitamin D daily.
Table 5-1: Significant Sources of Calcium in Food 8-ounce glass of milk = 300 milligrams 2 ounces of Swiss cheese = 530 milligrams 6 ounces of yogurt = 300 milligrams 2 ounces of sardines with bones = 240 milligrams 6 ounces of cooked turnip greens = 220 milligrams 3 ounces of almonds = 210 milligrams
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Table 5-2: Calcium Supplements Type of supplement
Details
Calcium citrate
Best absorbed Take on an empty stomach Common brand: Citracal
Calcium carbonate
Most common type Least expensive Take with food Common brands: Tums, Caltrate
Calcium lactate, calcium gluconate, calcium phosphate
Have very small percentages of elemental calcium
Oyster shell, bone meal, dolomite
Not recommended because they may contain lead or heavy metals
• Avoid drinking alcohol regularly. • Avoid smoking. • Get regular weight-bearing exercise. Weight-bearing exercise is any activity you do on your feet that works your bones and muscles against gravity such as walking and jogging.
Osteoporosis: Who and Where? About 40% of all postmenopausal women experience a fracture due to osteoporosis, most frequently in the: • Hip • Spine • Wrist
How do I know if I have osteoporosis? Unless you have already had a fracture, there are no symptoms of osteoporosis. One possible early sign is a loss of height over time of one inch or more. Most experts recommend screening all women over age 65 with
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either a heel ultrasound or a bone densitometry (also known as DEXA) scan (Figure 5-3). You should also be screened if you are over age 50 with two or more risk factors for osteoporosis.
Figure 5-3. Machinery used for bone densitometry (DEXA) scans and heel ultrasounds.
Q A
What is the treatment for osteoporosis? If you are found to have osteoporosis, your treatment will begin with calcium, vitamin D, and trying to reverse any risk factors that you have. In addition, there are several safe medications available that will decrease your risk for fractures. These include the following: • Bisphosphonates.
Bisphosphonates are the best-studied class of
medications. They have been shown to reduce all fracture types and are well tolerated if taken correctly. You must take this medication with a full glass of water and should not lie down within 30 minutes after taking the medication to avoid the rare side effect of esophageal ulceration. They are very safe and effective medications and are convenient, as you only need to take it once per week. The most common bisphosphonates are Fosamax (alendronate) and Actonel (risedronate). • Selective Estrogen Receptor Modulators. Evista (raloxifene) is the most common Selective Estrogen Receptor Modulator and has been shown to
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reduce spine fractures However, you must take it daily, and it can cause side effects such as hot flashes and increase the risk of blood clots. • Estrogens. Estrogen has been shown to prevent fractures as well, but because of possible side effects that we discussed in Chapter 3, it is no longer recommended as the first medication of choice for osteoporosis. • Miacalcin. Miacalcin is taken through the nostril in an inhaled form. It is used daily. It is less effective than the other classes of medications, but is used when other medications cannot be tolerated.
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CHAPTER SIX
How Are Depression and Anxiety Linked to Menopause? You’re irritable and tired—but how do you know if this is menopause or if you are suffering from depression? (Table 6-1) Depression is an extremely common medical condition that causes a number of symptoms, both psychological and physical. Nearly 25% of women will experience this condition during their lifetime, and not just during menopause. The predominant symptom is a persistently sad or anxious mood, accompanied by irritability, difficulty sleeping, and physical symptoms such as fatigue, difficulty with memory, and loss of sex drive. It is very treatable, due to our increased understanding of how chemicals in the brain influence moods and feelings, with either medications or counseling, or both.
Treatments for Depression • Counseling • Prescribed medications—examples: Celexa, Zoloft, Paxil, Effexor • Alternative therapies—example: St. John’s Wort* *Currently not approved by the U.S. Food and Drug Administration
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Table 6-1. Depression or Menopause?
Q A
Depression
Menopause
Persistent sadness
Age range: 40s-50s
Decreased pleasure or interest in activities
Hot flashes
Weight loss or gain
Irregular periods
Waking too early or sleeping too much
Vaginal dryness
Fatigue
Forgetfulness, lack of concentration, irritability
Feelings of guilt or worthlessness
Insomnia
Irritability
Changes in breast size, firmness, shape
Trouble concentrating
Body hair changes
Recurrent thoughts of death or suicide
Loss of bone mass
How can I tell if I am suffering from depression? If you have any of the symptoms below, you may be suffering from depression: • sadness most of the day • decreased pleasure or interest in activities that you would normally enjoy • weight loss or gain • sleep disturbance (especially early morning awakening) or excessive sleep • fatigue • feelings of guilt or worthlessness • irritability • trouble concentrating • recurrent thoughts of death or suicide Risk factors for depression are female gender, a history of depression yourself or in a close family relative, and significant stressful life events. Variants of depression are also common, including
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• Dysthymia—a persistent low-grade depression with low self-esteem and low energy, and • Seasonal Affective Disorder (SAD)—regular variation of symptoms at a particular time of year (typically winter). The diagnosis of depression is based on the presence of all or most of the above symptoms and can be identified after a frank discussion with your physician. There is no medical test for depression, but your doctor will want to rule out conditions such as anemia and thyroid disorders that could masquerade as depression.
How is depression treated? Counseling alone is effective in some people with depression. However, many may need drug therapy. There are several very effective and safe medications commonly prescribed for depression (bonus: many of these
Q A
medications may also be effective for hot flashes!). Most patients with a first time episode of depression will be treated for 6 to 12 months. For these medications to be effective, it often takes 2 to 4 weeks of regular use. Alternative therapies, such as St. John’s Wort, may be effective but are still not well studied and are not approved by the US Food and Drug Administration.
I feel anxious a lot. Is this part of menopause? A lot of women in the perimenopausal age group have very full plates, and everyone feels worried or stressed at some time or another. But when worry becomes excessive and anxiety is always present or difficult to control, an anxiety disorder may be present. Like depression, anxiety disorders are quite common, with twice as many women as men experiencing this disorder. The diagnosis is made when there is excessive worry and anxiety that is out of proportion to actual events. Many patients will also experience fatigue, insomnia, and other physical symptoms. Again, your physician will want to check for any possible underlying medical issues, but once ruled out, anxiety can be successfully treated with counseling, medications, or both. The most
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common medications that are used to treat anxiety are similar to the medications used to treat depression. Other medications such as the benzodiazepines (Valium and Xanax for example) are effective but cause sleepiness and possess the potential to become habit-forming, and so are usually avoided for long-term use. Other disorders related to depression include social phobias, panic disorder, and obsessive-compulsive disorder. If you are suffering from excessive worry, please discuss this with your doctor.
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CHAPTER SEVEN
How Can I Continue to Educate Myself About Menopause? Hopefully this book has helped you to take stock of your health at this important juncture in your life and has helped you chart a course to wellness. It’s important that you use this book as only one source of information and continue to seek out others, many of which are described below. Most importantly, you should find and see an understanding physician who will take into account your unique situation and give you individualized information.
How can my doctor help me navigate menopause? After reading this book, you may have a long list of issues that you want to discuss with your doctor. It’s important that you find a doctor who is able to help you with these issues. Here are some tips on working with your doctor. • Talk to other women about their menopausal symptoms. Ask for recommendations for doctors that have helped them with their symptoms. • Become an educated patient. You have already taken an important step by reading this book. Use information you obtain through reading or the Internet as a guide, but keep in mind it may not apply to you. Your doctor can help you decide if it does.
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• Write down your questions before your appointment. It will help you remember everything you would like to ask. • Be honest about your diet. You should also be sure to tell your doctor which over-the-counter medications, including alternative medicines or herbal supplements, you may be taking. • Don’t be afraid to take notes during the appointment. This is a great way to help you recall what answers the doctor gave to your questions. • Keep an open mind. Even though you are a well-educated patient, your doctor has the benefit of experience and objectivity. If your doctor suggests that you try something, discuss it openly with him or her if you are not comfortable, but in general give it a try—you may be surprised. Although it is true that “you are the expert on you” your doctor may have some additional insights into therapies that you may not have considered. • Don’t feel embarrassed when discussing sensitive topics. Chances are your doctor has heard it before! • Get a second opinion if you need one. Don’t worry about offending your doctor or hurting his or her feelings.
Don’t Go it Alone! • Talk to other women about their menopausal symptoms—ask for doctor recommendations, too. • Become an educated patient—read, research, ask. • Write down your questions before your doctor appointments—you don’t want to forget to ask anything. • Be honest about your diet—with yourself and with your doctor. • Don’t be afraid to take notes when you see your doctor—don’t rely on recall alone. • Keep an open mind to tips and techniques—you may be surprised. • Don’t feel embarrassed when discussing sensitive topics—your doctor has likely heard it before. • Get a second opinion if you need one—you won’t hurt anyone’s feelings.
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Where can I find more in-depth information on menopause? There are many good sources of information on menopause and related conditions. The following are just a few that are available. Menopause Essential Guide to Menopause, American Medical Association. Perry AR, ed. Chicago: Simon and Schuster, Inc.;1998. North American Menopause Society. Menopause Guidebook. Cleveland:The Society; 2003. Henkel G, Stumf PG, editors. The Menopause Sourcebook, 3rd ed. New York: McGraw-Hill/Contemporary Books; 2001. Love SM. Dr. Susan Love’s Menopause and Hormone Book: Making Informed Choices. New York: Three Rivers Press; 2003. The Hormone Foundation North American Menopause Society National Institutes of Health American Menopause Foundation National Women’s Health Information Center Osteoporosis National Osteoporosis Foundation Cancer Prevention and Screening CancerNet 1-800-4-CANCER National Cancer Institute American Cancer Society Immunizations Centers for Disease Control and Prevention (CDC) National Coalition for Adult Immunization
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Urinary Incontinence Foundation for Health in Aging Bladder Health Council of the American Foundation for Urologic disease or 1-877-OVERACT General Women’s Health National Women’s Health Resource Center
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CHAPTER ONE
Glossary Adenomatous polyp is a small benign tumor in the colon that can grow over a period of as much as 10 years. Often caught during screening. Alzheimer’s disease is a chronic progressive loss of memory due to a decrease of brain cell functioning over time. Barium enema is a procedure where an enema containing barium, which lights up on X-ray, is inserted into the colon. Pictures can then be taken that will demonstrate tumors, polyps, or other disorders. This procedure is less common because colonoscopies are more widely used. Bisphosphonates are potent medications that can reduce fractures in women with osteoporosis. Black cohosh is an herbal remedy used for hot flashes. CA-125 is a test which can be used to follow treatment response to ovarian cancer. Not recommended as a screening test. Colonoscopy is a more extensive screening test for colon cancer that is able to visualize the entire colon. Diabetes is a chronic condition that causes elevated blood sugar in the body. It leads to long-term health effects including heart disease and kidney disease, especially if not controlled. Estrogen is one of the primary female hormones that cause female sexual development. Menopause is characterized by a lack of this hormone. Fecal occult blood test is a test for hidden blood in the stool. Follicle-stimulating hormone (FSH) is one of the hormones released from the pituitary gland in the brain, which acts on the ovaries. It is elevated in menopause.
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Ginseng is an herbal remedy used for hot flashes. Hepatitis is inflammation of the liver, sometimes caused by a virus. Heart and Estrogen Replacement Study is a large medical study that was designed to sort out the benefits and risks of estrogen in postmenopausal women. Hormone is a substance secreted by a gland that affects specific tissues in the body. Hot flash is an uncomfortable sensation common around menopause, characterized by a flushed face and sweating. Human papillomavirus is a virus, spread through sexual intercourse, which can cause cervical cancer. Hyperlipidemia is high blood cholesterol and or triglycerides. Hypertension is high blood pressure. Hysterectomy is the surgical removal of the uterus. Incontinence is loss of ability to hold in urine or feces. Leutinizing hormone (LH) is one of the hormones released from the pituitary gland in the brain that helps to orchestrate the female monthly cycle. Mammogram is an X-ray of the breasts done to detect breast cancer before it can be felt. Menopause is cessation of menses, or the monthly flow. Generally, a woman is assumed to be through menopause when she has not had a period for one year. Night sweats are a type of hot flash that occurs at night and disturbs sleep. Osteoblasts are cells in the bone that are responsible for breaking down bone. Osteoclasts are cells in the bone that are responsible for building up bone. Osteoporosis is a disease causing thinning of the bones.
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Pap smear is a sample of cells from the cervix, or opening of the uterus, which is used to screen for cervical cancer. Perimenopause is the period of time leading up to menopause. The timing is highly variable and may be months to years in length. Phytoestrogen is estrogen from a plant source. Pneumococcal pneumonia is the most common cause of pneumonia, caused by the Pneumococcal type of bacteria. Premature menopause is the menopause that occurs in women who stop menstruating before age 40. Progesterone is an important female hormone that helps the uterus prepare for a possible pregnancy each month of the cycle. In hormone replacement therapy, it may be given along with estrogen to women with a uterus. Puberty is the onset of sexual maturity. Sigmoidoscopy is a method of screening for colon cancer that involves inserting a lighted tube into the colon. Surgical menopause is menopause that occurs because a woman has her ovaries surgically removed. ThinPrep is a newer method of cervical cancer screening that increases the accuracy of the test. Uterus is the organ in the female pelvis (also known as the womb) where implantation of a fetus occurs. The lining of this organ is shed each month (the menstrual flow) if no pregnancy occurs. Varicella is a virus that causes chicken pox. Women’s Health Initiative is a large trial designed to sort out the benefits and risks of estrogen in postmenopausal women.
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