Menopause

A Natural Life Transition

Dr. Emily Maiella Naturopathic Physician

Menopause: permanent cessation of menses — point at which period ends for the last time. Perimenopause is the period before, during and after the cessation of menses. Usually begins in 40s, lasts about 7 years and ends 12 months after cessation of menses. Symptoms can last from 12 months, even up to 10 years.

By 2015, 50% of US women will be in menopause.

Age of onset averages at 51.4 years of age. With the average life expectancy >80 years old, Menopause currently comprises >1/3 of woman ’ s life. Women who are overweight tend to stop menstruating a little later in life; heavy smokers tend to stop a little sooner.

15% of US population does not report any signs of menopause.

• Cessation of menstruation prior to 40 is considered

premature menopause

; it is rare, usually hereditary. Women who stop menstruating or begin having irregular periods before age 40 should be checked out b/c it may be due to another health problem, such as an autoimmune disease, nutritional deficiency, chronic stress, or excessive athletic conditioning.

• If menstruation continues into the mid-50s, it is considered

late menopause

. Late menopause is also rare (except in women with diabetes), again often hereditary. Women who experience irregular vaginal bleeding at this age should discuss it with their healthcare practitioner because it can signal uterine cancer, for which they are also at greater risk. OCP ’ s can mask the onset of menopause because they artificially control a woman ’ s menstrual cycle.

Physiology of Menopause • Hormonal changes occur gradually in perimenopausal period. Ovarian production of P, E, DHEA and testosterone decrease. Although all hormones decrease, E will not decrease until 6 months to 1 year before true menopause. Actually, right before menopause, E will rise dramatically, and then fall again.

• Progesterone falls before E does, and it is now believed that menopausal symptoms are due to decreased P, or the change in E/P ratios.

• Ovarian follicles decrease (from 1-2 million at birth to a few thousand) and become more resistance to FSH stimulation. Less eggs, less follicles, until ceases altogether. Lack of estrogen negative feedback to pituitary results in increased FSH.

•

So the one lab test you want to do for menopause is FSH.

• Ovulation becomes irregular and as ovulation decreases, progesterone decreases. Menses becomes irregular (usually the cycles get closer together) then finally ceases d/t lack of hormone cycling, especially estrogen to build up of endometrium.

Hormones in post menopausal women … – Still have estrogen; made buy converting androsteridion produced by adrenal and ovary and aromatized into estrogen by muscle and adipose tissue. Estradiol levels can be as high as 100pg/mL. Premenopausal range is 50-300 pg/mL. High estradiol may be problematic because associated with some cancers.

– Progesterone production ceases.

– Androgen (estrogen and testosterone) production continues but in reduced amounts-both from ovaries and adrenals.

– 50% of Testosterone still made by liver skin, brain and muscle, BUT it needs precursors from the ovaries and adrenals to make the full conversions. Women with more fat and muscle tend to have an easier transition because of this. Some women (especially those with more fatty tissue) have even higher levels of estrone (one form of estrogen) after menopause than before.

– Maintain good adrenal gland health, and it may be enough to help you into a smooth transition into menopause. Some women have enough E just from the adrenals.

The Beginnings of Hormone Replacement Therapy (HRT)

• Began in the 1960 ’ s and popularized by Dr. Robert Wilson, an internist from NY and was convinced that by giving estrogen, can keep women happy, healthier and feminine. Wrote book called Feminine Forever. (a truly awful book) • Problem with Wilson ’ s premise is that estrogen was safe  thousands of women died from uterine cancer because he was convinced you didn ’ t need to oppose estrogen with progesterone. So, they came up with Provera, (synthetic progesterone) to oppose the estrogen, which utimately decreased the uterine cancers. The latest studies have proven this to be problematic as well  increases heart dz, strokes, dementia, breast CA; but effective in tx menopause sx, decrease colon CA risk and decrease osteoporosis. The risks are associated with long term use, i.e. more than 5 years. For short term use, belief is that benefits still outweigh risk.

The Women’s Health Initiative

• The

Women's Health Initiative (WHI)

is the landmark example of a highly publicized study that suffered from flawed design, as well as inadequate screening of study participants.

• Developed to study the long-term effects of non-bioidentical estrogens and progestin hormone therapy in postmenopausal women and specifically assess the risk of heart disease, hip and other factures, and breast cancer.

Women’s Health Initiative

• One hormone product used in this study was Premarin, which some consider "natural estrogens" because it comes from pregnant horse urine. However, Premarin's effects in the human body are different than the effects of bioidentical estrogens. Another hormone product used in the WHI study, Prempro, contains Premarin and medroxyprogesterone (a progestin).

Women

’

s Health Initiative

Of the approximately 16,000 female participants in this trial.

None were screened prior to the study to determine whether or not their own hormone levels were adequate. The Prempro portion of the study was stopped early due to an increased risk of breast cancer, heart disease, stroke, and blood clots. Soon after, the Premarin portion of the study was also stopped.

Women

’

s Health Initiative

• The publicity implied that these results applied equally to "all" hormones when, in fact, bioidentical hormones were not included in this study. In addition, some professional medical groups with financial ties to the pharmaceutical industry have promulgated the misinformation that all bio- identical and synthetic hormones behave in the same fashion, disregarding basic principles of physiology.

Women’s Health Initiative

Bioidentical Hormone replacement IS different. “Bio-identical” hormone. refers to the shape of the molecule itself rather than the source of the Hormones can be marketed as "natural" or "plant-based," yet not come near to being "bioidentical" to native human female hormones or performing as such in the body. Examples of this are the numerous proprietary HRT options being marketed as "plant-based" and "natural," as well as purely yam-based creams.

Our bodies are swimming in hormones that act somewhat analogous to keys in a lock, or pieces to a puzzle. Though this analogy presents a less than complete picture, it can be helpful toward a basic understanding of their action. The puzzle to which I refer makes up the big picture of who we are as human beings and how we operate. When we take in hormonal replacement therapy that doesn ’ t fit the original design that our cells have evolved to recognize, the end result simply may not feel or act quite right. Hence all those side effects, ranging from annoying and uncomfortable to downright dangerous.

Bioidentical hormones are those whose biochemical structure exactly duplicates those found "naturally" in the human body The molecules naturally produced in the human female body for which we most often seek replacement include the following: a) the three basic types of estrogen: estrone (E1), estradiol (E2), and estriol (E3); b) progesterone; c) testosterone and d) DHEA, an adrenal precursor to testosterone.

These truly "natural" hormones are available by prescription (or, in the case of progesterone and DHEA, over-the counter in low doses), and can also be readily titrated to a woman ’ s individual needs.

You cannot patent a naturally-occurring hormone!

Most of the mainstream studies have been performed on conventional HRT. In addition, pharmaceutical companies cannot take out a patent on what the majority of human women make effortlessly on a daily basis and, therefore, cannot generate large sums of money by packaging and selling them. This may explain why women are commonly offered prescriptions for non-bio-identical forms of HRT, while their efforts to obtain a prescription for bio-identical HRT can be met with varying degrees of skepticism.

• Most common forms still used today: Estradiol, CEE or conjugated equine estrogen (brand name is Premarin — Pregnant Mare ’ s Urine) Synthetic progesterones: (Medroxyprogesterone acetate or MPA brand name Provera) Progesterone is the natural form, it ’ s also called “ progestin ” .

• In very standard doses, the hormones are about 1/3 the equivalent to oral birth control pills.

OK…here we go!

• Approximately 20% of women experience no other symptoms than menstrual irregularity as they approach menopause. Those other symptoms can be physical, emotional, or psychological, and vary widely in frequency, duration, and severity. For some women, the symptoms are subtle and gradual; for others, they are intolerable because they interfere with daily living.

PMS and it’s relation to Menopause

• Many symptoms of premenstrual syndrome (PMS) are similar to those associated with perimenopause, making it confusing. Some women experience PMS-like symptoms for the first time as they approach menopause. • Those who have had PMS in the past may find that their symptoms (such as bloating, irritability, and headaches) get worse right before menopause.

• Menopause is a convenient catch all for a wide range of symptoms, but only two are thought to be uniquely characteristic of menopause: hot flashes and vaginal dryness. Many other symptoms may occur, but they can usually be attributed to other health issues that women tend to experience as they approach menopause.

Hot Flashes

• Hot flashes are the most common menopausal symptom (although few Asian women have hot flashes, which may be related to diet or genetics). Some women never have any, while others may have hot flashes continually for a few months to several years. They can be frequent or sporadic, usually last about three to five minutes, and usually cease within a year or two of the last menstrual period.

• A hot flash (vasomotor symptom) is a sudden sensation of warmth or intense heat, which flows over the face, scalp, and chest area. It may include reddening of the skin in the affected area, perspiration, increased or irregular heart rate, nausea, or feeling chilled when it stops.

• It ’ s a temporary shift in blood flow, in response to fluctuations in hormone levels. Hot flashes can also be brought on by diet, especially one high in refined carbohydrates, alcohol, and stress. • Night sweats are hot flashes that occur during sleep. Because night sweats interrupt sleep, they can contribute to fatigue and insomnia, and increased irritability and tension, all of which are frequently reported during menopause.

Vaginal Changes

• The lining of the vagina is very sensitive to changes in estrogen hormone levels. Estrogens encourage blood flow to the genital area and keep the walls of the vagina supple and elastic, and also help protect it against bacterial infections.

• As levels of the estrogen hormones begin to decline, some women experience vaginal dryness, itching, or swelling, and/or pain during sex. Leaking small amounts of urine while sneezing, coughing or strenuous physical activity may also occur. Due to changes in vaginal secretions, the ph also changes, furthermore increasing the risk of developing vaginal and urinary tract infections.

• After menopause, vaginal and genital tissue/ collagen become thinner, drier, and less elastic. Vaginal atrophy can also begin to occur.

Irregular Menstruation

• During perimenopause, menstrual bleeding may stop for several months and then return, or it may increase or decrease in duration, intensity, and flow. Over time, cycles typically get farther and farther apart, until menstruation finally ceases. Some women suddenly stop menstruating without any irregularities at all.

• Abnormal bleeding, including very heavy blood loss, thick clots, periods that last two or more days longer than normal, or bleeding between menses, may also indicate an underlying condition.

Sex Drive

• Irregular bleeding or vaginal changes can make women less interested in sex.

• Lot ’ s of interventions an tools to help with this. • Having more privacy after children leave the nest and not having to worry as much about pregnancy may rejuvenate the sex drive for some women.

• • • • • •

Sleep disturbances

, which may be related to hot flashes and night sweats.

Depression:

, often brought on by other circumstances or changes. The incidence is much lower among post-menopausal women.

Increased moodiness, irritability and anxiety

, related to fluctuations in hormone levels.

Impaired concentration and memory

disturbances and/or hormonal fluctuations. Brain size diminished by about 6% can be a result of sleep

Headaches

are more common among women than men, in general, primarily due to hormonal fluctuations. Migraines have been associated with PMS, but those cyclical symptoms can still occur during menopause.

Weight changes:

Increased fat accumulating around the mid section, with a sagging abdomen due to muscle loss. Decreased muscle, limiting overall strength and ability to grip

• • • • • •

Heart palpitations

, which are rapid or irregular heartbeats, may be related to stress, hot flashes or other hormonal fluctuations.

Skin changes

: As we age, our skin becomes drier, thinner and less elastic. 5 years post menopause, we have lost 30% of our callagen. The skin aging process can be accelerated by sun exposure and smoking.

Hair loss

: stress and other hormone imbalances

Increased risk of osteoporosis

: accompanies menopause. The majority of cases of osteoporosis are found in post-menopausal women.

Dental changes

, such as tooth loss, is especially common among post-menopausal women. Tooth loss could also be related to osteoporosis, whereby bone loss in the jaw alters the tooth sockets.

Increased risk of cardiovascular disease

: As women approach menopause, lipid levels change, increasing the risk of high blood pressure, abnormal heart rhythm, heart attack, stroke and coronary artery disease increases.

• At menopause our bodies become dependent on our adrenal glands for sex hormone production. If we are already dealing with chronic or long-term stresses, adrenal function will be compromised, further compounding the inter-relationships among various health conditions, hormone balance and symptoms.

Integrative Approaches to Menopause

– Why do integrative approach? 20-30% of women never fill HT Rx from doctors. Only 20% of those who fill continue at 2 yr. We want to consider alternatives because the alternative remedies are not associated with risks (heart dz strokes etc.) nor side effects (breast tenderness, bloating, vaginal bleeding) – o Why still use hormones? Because it is effective at decreasing menopausal symptoms, it decreases colorectal cancer risk, decreases fracture risk of hip and spine. – o Soy — recommended as whole food: 20-60 grams per day of protein. (ethnic diets, 50-150 mg/day) Most studies show 40-80 mg/d of isoflavones this converts to o.1 mg CEE.

A lot of studies.

– For reference, a standard dose of synthetic estrogen is 0.625 mg per day.

It’s all about Balance

Women, by nature, are made to be strong and resilient. These attributes are necessary components to enable them to bear and raise children. Women ’ s bodies have been created to be healthy and in harmony and balance. Strength, energy, productivity and glowing health should be enjoyed throughout all the stages of a woman ’ s life, from girlhood through mother/adulthood through to older age.

If our bodies ’ needs are not completely met from the food we eat, the amount of exercise we receive, and from reducing the stress in our lives, we may experience health difficulties. Diet, nutrition, exercise, and stress reduction are some of the basic changes women need to make in their lives in order to restore hormone balance.

Some women may need hormone supplementation to help bring their bodies back into balance.

Introduction to Endocrinology

A basic understanding of our hormones will begin the process of restoring our body ’ s natural synchronization. Hormones have too much impact on our lives to ignore. Every aspect of our lifestyle can affect hormone balance and, just as importantly, hormone balance can profoundly influence every aspect of our lives.

Estrogens

• Estrogens are some of the most powerful hormones in the human body. Almost all tissues in the body have receptors. Estrogens help the urinary tract, breasts, skin, blood vessels, and uterus to stay toned and flexible.

• Estrogen levels start to rise in girls before menarche, sometimes as early as age 8. Estrogen levels continue to rise in girls until they start menstruation, usually by age 11 or 12. It also starts the development of breasts and the growth of pubic hair and hair under the arms.

• In the 30s, and definitely into the 40 ’ s, most women begin to experience declining levels of estrogens and progesterone. With this decline, there is also a drop in fertility.

Estrogen and Weight

• Fat distribution changes as a result of decreasing estrogens. In particular, as estradiol production declines and estrone levels rise during and after menopause, women tend to show excess fat in a pattern similar to that seen in men new fat will be distributed.

—it appears around the belly. E actually controls where • As a woman's ovaries naturally produce less estrogen during perimenopause, fat cells in the body respond by producing more estrogen. This is the body's way of striving to maintain hormonal balance, but it can result in an increase not only in number of fat cells, but their size as well.

Estrogen and Weight

• This interaction between estrogens and fat cells helps to explain why menopause and its associated drop in estrogen production are often a time of weight gain, or fat redistribution. While estrogen therapy does not necessarily help women lose weight, it may help shift fat back to the chest and hips, rather than the stomach.

• Studies confirm that women who take estrogen have more muscle and less fat than those who do not.

Estrogen and Mood

• Estrogenis also a neuro-stimulant with anti depressive effects. • High levels of estrogen produce an imbalance in the system that aggravates or causes symptoms of tension and anxiety. • Some women with high estrogen levels may be predisposed to high levels of anxiety, and even panic attacks. • Low levels of estrogen can lead to episodes of depression and lethargy.

Estrogen:Progesterone

Estrogen/ progesterone ratio is really the key to proper regulation of mood. A study by Dr. Bronson found that deficiency of progesterone is clearly implicated as a primary factor in mid-life anxiety patterns. She observed that when estrogen levels were high and progesterone levels low, patients would exhibit extreme rage, followed by conciliatory, self-defeating demeanor.

This is because the largest concentration of progesterone receptors are in the limbic area of the brain, which is the center of emotion and also called the area of rage and violence by animal physiologists. Progesterone has a calming effect on the brain, which suggests that a deficiency leads to varying levels of anxiety, depending on the level of the imbalance. PMS and postnatal depression, both of which can occur with a sudden drop in progesterone and can include considerable anxiety.

Progesterone

• Progesterone (and E) is made by the ovaries of menstruating women. Progesterone is made by the corpus luteum starting just prior to ovulation. Progesterone is a precursor hormone that can be converted by the body into other steroid hormones. It prepares the lining of the uterus for the fertilized ovum and is necessary for the survival and development of the conceptus. Progesterone is produced in the placenta, which maintains pregnancy, and is secreted at a level of 300 to 400 mg a day during the third trimester. Progesterone is produced in smaller amounts by the adrenal glands and is an important component in the biosynthesis of adrenal cortical hormones.

Progesterone

• Before ovulation, the levels of progesterone are about 2 to 3 mg per day. At ovulation and the development of the corpus luteum, the production of progesterone rapidly rises to an average of 22 mg per day, with peak production as high as 30 mg per day, a week or so after ovulation. If fertilization does not occur after 10 or 12 days, then the production of progesterone falls dramatically, triggering the shedding of the lining of the uterus, resulting in menstruation.

Progesterone

During the menstrual cycle, estrogen and progesterone levels should rise from the time of ovulation until just before menstruation. If the levels of progesterone are inadequate, and only estrogen rises during this time, this imbalance can cause; low blood sugar levels, salt and fluid retention, blood clotting, fibroid and tumor development, increased cholesterol and triglyceride levels, allergic reactions, reduced oxygen levels in the cells, the retention of copper and loss of zinc. Low levels of progesterone also cause interference with thyroid hormone function, which may lead to weight gain and feelings of exhaustion.

Progesterone’s Functions

• act as a precursor of other sex hormones (i.e., estrogens and testosterone) • maintain secretory endometrium • protect against breast fibrocysts • act as a natural diuretic • help use fat for energy • act as a natural antidepressant • Helps to increase thyroid hormones • normalize blood clotting • restore libido

Progesterone function etc

• help normalize blood sugar • normalize zinc and copper levels • restore proper cell oxygen levels • protect against endometrial cancer • protect against breast cancer • stimulate osteoblast-mediated bone building • provide survival of the embryo and fetus throughout gestation • promote cortisone synthesis as a precursor in the adrenal cortex

DHEA

• Dehydroepiandrosterone (DHEA) is the most abundant naturally occurring steroid hormone secreted by the adrenal glands. It has been called the mother of all hormones because it watches over, supports, and regulates the functions of other steroid hormones. • The body uses DHEA to produce the sex hormones: testosterone, estrogen, progesterone and corticosterone. The function of DHEA aappears to be important in keeping the metabolic balance of youth (anabolism), and (catabolism). • Levels of DHEA are high in the developing fetus and continue to rise until about the age of 25. At this point, DHEA production drops off sharply. A woman at age 50 has less than one-third the DHEA she had at age 19.

Human growth hormone (hGH)

• Human growth hormone (hGH) is another hormone that is present in large quantities in our body (pituitary gland) when we are young, peaks in our mid-20s, but tends to disappear as we age. • The primary function of hGH in our youth is to help bones lengthen and expand to help us become taller, stronger-boned, and long-limbed. It also promotes growth by helping to transport and synthesize amino acids.

Human Growth Hormone

• hGH helps our bodies to use the protein we ingest for cellular repair and regeneration. Without hGH, our muscle and organ tissue would start to break down. • Human growth hormone supplementation is said to help elderly people lose 20 years from their biological clock, particularly in the area of bones and muscles.

Growth Hormone and Weight

Recent studies have demonstrated that there is an inverse correlation between body fat and growth hormone production. In general, the more body fat you have, the less growth hormone you release; conversely, the less body fat you have, the more growth hormone you release. Remember that in the menopausal years, losing fat around the mid-section is particularly difficult. Adequate growth hormone may actually help to decrease fat accumulation.

Growth Hormone

• Another study revealed that study showed that when growth hormone production is adequate, there is better regulation of cholesterol levels, blood pressure and glucose metabolism. 4

Testosterone

• Women with functioning ovaries produce, on average, three-tenths of one milligram of testosterone per day (men produce 20 times as much). • Testosterone ’ s role during pregnancy is in the development of the embryo. Testosterone signals the cells of the genetically male embryo to develop as a male.

Testosterone

• This small amount of testosterone is critical to the healthy functioning of most of the tissues in the body. • T is responsible for a sense of well-being, sexual libido, and vital energy. It is testosterone in a young woman that stimulates the growth of pubic hair and underarm hair. It also stimulates the skin to produce more oil, which contributes to teenage acne, but also gives shine to the hair and a healthy skin glow.

• There are testosterone receptors in the nipples, clitoris and vagina. These receptors make these areas sensitive to sexual stimulation.

Testosterone

• Testosterone ’ s other functions are to keep the cells of the body functioning efficiently, contributing to healthy bones and muscles.

• Postmenopausal women commonly experience a decrease in the amount of testosterone in their body, which results in symptoms of decreased sense of well-being, a loss of vital energy, and reduced sexual libido.

• Testosterone and estrogen are carried on the same protein in the blood, known as the sex hormone binding globulin (SHBG). Between 97 and 99 percent of testosterone is attached to this protein, so very little is left to produce any effect on the tissues in the body. Estrogen stimulates the production of more SHBG, which binds up more testosterone, leaving less available to work on the cells. When women take supplementary estrogen at menopause they actually tie up a little more of the testosterone that ’ s left. This can cause symptoms of testosterone deficiency.

Testosterone and Weight Gain

• Testosterone deficiency is also responsible for more sugar and protein from food to be converted to fat, so the natural tendency is to gain weight. Testosterone therapy may therefore help to improve sugar metabolism by directing more to the rebuilding of muscles, rather than to the conversion to fat.

Testosterone: It's Not Just For

Men Anymore!

• Replacing inadequate testosterone with natural testosterone can help protect the heart, improve mental alertness, make bones stronger, and revive a sagging sex life.

• When given in proper doses, it will not cause facial hair to grow or any feelings of aggression.

Vulvar Lichen Sclerosus

• Vulvar lichen sclerosus is a chronic disorder that most commonly affects post-menopausal white women. It is a progressive deterioration and atrophy of primarily the vulva and labia minora. Earlier research indicated that the disorder can be successfully reversed with a topical testosterone treatment. A more recent study demonstrated that the level of dihydrotestosterone (a testosterone metabolite, but not testosterone) was quite low in the subjects who responded to the treatment. This finding suggests that perhaps dihydrotestosterone is somehow related to the healing process.

Symptoms & Causes of Testosterone Deficiency

Testosterone levels typically decline by approximately 50%. This decline is largely attributed to the fact that menopause causes the ovaries to stop producing testosterone, but it is further compounded by the fact that the adrenal glands also stop producing two other hormones, androstenedione and DHEA, which are converted to testosterone within cells throughout the body. However, a variety of other conditions can cause the decline to begin much before menopause, and some women begin to experience these signs as early as their 30s.

pre-menopausal decrease in women's testosterone

 Childbirth Birth control pills*   Endometriosis Chemotherapy Ovarectomy Surgery (adrenal stress) – Medications* that interfere with the bio-availability of testosterone such as: » Provera (norlutate) and Tamoxifen (nolvodex) » Drugs such as Prozac or Zoloft that alter the brain's serotonin transmitters » Some psychoactive drugs or other antidepressant and antipsychotic medications   Psychological trauma and depression Chronic abuse of substances such as alcohol, cocaine, or narcotics

Testosterone and Libido

• Many post-menopausal women lose interest in sexual activity, primarily due to diminished testosterone levels. Researchers have consistently reported that women who receive testosterone replacement therapy after menopause have an increase in: – Sexual drive and response – Frequency of sexual intercourse – Number of sexual fantasies – Level of sexual arousal.

Testosterone and Cardiovascular Health

• Medical research has yielded accumulating evidence that testosterone plays an important role in cardiovascular health, especially in protecting against atherosclerosis and heart disease.

• Dr. Wright's summary of Danish research indicates that bioidentical testosterone actually decreases cholesterol levels, improves circulation, and slows the tissue break down associated with aging. • Dr. Wright also notes that cholesterol-reducing drugs may sometimes do more harm than good, since testosterone and other steroids are derived from cholesterol. By reducing cholesterol, such drugs can actually throw the body's hormones off balance and lead to other disorders, such as chest pain and impaired cardiac function. Bioidentical testosterone supplements may be able to reduce circulating cholesterol more safely than these drugs.

Testosterone and osteoporosis

• Athletes and body builders have used testosterone-like drugs for years to strengthen and enhance muscles and bones. Recent research suggests that testosterone may increase the bone's ability to retain calcium. What we do know is that women who experience rapid bone loss are typically deficient in both estrogen and testosterone.

• According to Dr. Wright, a recent study indicated that "women with osteoporosis who took a combination of estrogen and testosterone increased their bone density, an effect previously only demonstrated with progesterone." In

The Testosterone Syndrome

, Dr. Eugene Shippen and William Fryer concur that the total hormone picture increasingly shows that both testosterone and estrogen are "independent and additive determinants of bone density."

Testosterone and

Muscle Tone (Leaky Bladder)

• Testosterone contributes to overall muscle tone. • Well before menopause, some women begin to leaky bladder. This problem most likely relates to diminished testosterone levels, because the pelvic muscles are particularly dependent on testosterone. Many women find that using a testosterone cream, coupled with Kegel exercises, helps to strengthen and tone those muscles again.

Correct hormone imbalances

– o Testosterone deficiency – o Progesterone deficiency – o Estrogen hormones deficiency or excess – o Thyroid hormones deficiency – o DHEA deficiciency – o Cortisol excess – o Insulin excess.

Women and Sleep

• The powerful role that hormones play in sleep helps us understand why so many women have difficulty falling asleep, or staying asleep, especially during times when their hormones are fluctuating. • Medical conditions potentially linked to chronic sleep deprivation are a weakened immune system, hypertension, heart disease, type-2 diabetes, and even obesity, Daily sleep deprivationof course can lead to daytime fatigue, irritability, brain fog, increased anxiety, and depression.

Women and Sleep

• Sleep disruptions are some of the most common symptoms of perimenopause, and restful sleep eludes many menopausal women for a variety of reasons. • two-thirds of women complain of insomnia during the years leading up to menopause. • Women wake up repeatedly during the night because they need to urinate or have a hot flash or night sweat, or for no apparent reason at all.

• This is especially true of women who are particularly sensitive to fluctuations in estrogen levels, which can cause bothersome symptoms that interfere with getting a good night ’ s sleep.

Women and Sleep

• Estrogens have been shown to enhance REM sleep, increase the time spent in REM sleep, and reduce the time it takes to get to REM sleep • Placebo-controlled studies involving post menopausal women found that estrogen therapy helps women to fall asleep faster, decreases wakefulness after falling asleep, and increases total sleep time.

Mental Clarity

• Most women report feeling mentally foggy or dull before they sense any of the physical symptoms of menopause. As they begin to experience irregular hormonal fluctuations, they find that they are tense and moody, have poor concentration and memory, feel an overall loss of well-being, and experience difficulty sleeping. • Notice that many of these symptoms overlap with those of clinical depression.

Mental Clarity

• During perimenopause, some women struggle with depression-like symptoms for the first time; others who have had previous episodes of depression may find that their symptoms reemerge. Moreover, as with PMS/PMDD, women with a mood disorder may find that previously successful treatments may seem to stop working with the onset of menopause. Mood-related symptoms may reemerge and mood swings may become more pronounced.

• Notably, few people (healthcare practitioners included) discriminate between symptoms that arise from the loss of hormones versus those attributable to other factors. Especially during this stage of life, women should investigate hormonal therapy (herbal or otherwise) as a key element in the treatment of their depression or mood related symptoms.

Perimenopause and Depression

• Two recent studies evaluated the onset of depression during the perimenopausal transition.

• The first study followed 436 women without a history of depression, over 8 years. Correlation of hormonal changes with any new onset of depression was recorded. 116 women developed an increase in depressed moods and 59 met the clinical criteria for a diagnosis of depression. 108 women denied depression.

Menopause and Depression

• • The women who developed depression were 2.5 times more likely to develop clinical depression during the perimenopausal transition compared to premenopause. In addition, their depression symptoms during perimenopause were associated with greater variations in serum estradiol levels, higher body weight, increased hot flashes. The associations with serum estradiol were considered significant.

Freeman E, Sammel L. Lin H, Nelson D. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2006;63:375-382. [Fulltext PDF | Fulltext HTML]

PMS as a predictor

One the more interesting aspects of the Freeman et al. study was that PMS in the reproductive years was a significant predictor of the onset of depression during perimenopause.

Perimenopause and Depression

• The second study is a prospective cohort of women both with and without histories of depression. The risk of new depression was almost doubled in women entering perimenopause, compared with premenopausal women. This difference appeared to be associated with the presence of hot flashes.

• Cohen L, Soares C, Vitnonis A, Otto M, Harlow B., et al. Risk for new onset of depression during the menopausal transition: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry. 2006;63:385-390. [Fulltext PDF | Fulltext HTML]

Phytoestrogens Plants manufacture thousands of chemical compounds vital to the health and function of the plant. Those chemical compounds, generally known as micro-nutrients, are consumed whenever the plants are eaten. One of these class of chemical compounds manufactured by plants are known as phytoestrogens. Over 300 plants contain phytoestrogen compounds.

Phytoestrogens

There are several sub classifications of phytoestrogens; the following partial list… Lignans: Veggies, fruits, nuts, cereals, spices and seeds, esp flax seeds Isoflavones: Spinach, fruits, clovers, peas, beans, esp soy.

Flavones: Beans, green veggies and fruit

Phytoestrogens

• Chalcones: Licorice root • Diterpenoids; Coffee • Triterpenoids ; Licorice root, hops • Coumarins; Cabbage, peas, spinach, licorice, clover • Acyclics; Hops

Isoflavones

• Isoflavones have a similar structure to endogenous steroidal sex hormones. They have the ability to bind to estrogen receptors on human cells, and in women, they have a preference for binding to the beta form of the estrogen receptor. As a result of this, they preferentially express estrogenic effects in the central nervous system, blood vessels, bone and skin, and they do so without causing stimulation of the breast or uterus.

Isoflavones

• Soy isoflavones are 1/400th to 1/1000th the potency of estradiol. However, because they structurally related to endogenous estrogens, they are able to mimic some of the effects of estrogen, but to a significantly less degree. • Uniquely, isoflavones may also act as anti estrogens, much like “Selective Estrogen Receptor Modulators” (SERMs). Isoflavones can be thought of as one of natures’ SERMs. Therapeutically, isoflavones may alleviate menopause symptoms, and lower the incidence of osteoporosis, coronary artery disease, breast and uterine cancer.

When Soy meets Girl

• Soy — has been recommended as whole food: 20-60 grams per day of protein. (ethnic diets, 50-150 mg/day) Most studies show 40-80 mg/d of isoflavones this converts to o.1 mg CEE. A lot of studies.

– Great for bone and heart health! Improves lipid profile, bone density, does not stimulate endometrium, associated with decreased risk of breast cancer. – Decreased risk of breast cancer due to phytoestrogen effects (10 times weaker) and many other anti-carcinogenesis factors.

– Only caveat is that some studies looking in vitro showed that high concentration of soy isoflavones promoted dysplasia. So, women who have history of breast CA or increased risk, should moderate their intake of whole foods soy. – FLAX: based on randomized study of 25 patients o.625 CEE or standard dose of horse estrogen.

 40 grams per day crushed in food, Flax seed group was equivalent on

The SERM effect of Soy

• Fermented soy isoflavone pills will contain lower amount of isoflavones but may be better absorbed. Genestein has a 6-fold greater affinity for the beta estrogen receptor than for the alpha receptor. That is why it may act differently in different tissues depending on the nature of the estrogen receptors in that tissue. It may act as a pro estrogen in the bones but an anti-estrogen in the breast (again, serm-like)

Downside to Soy

Soy contains phytates and trypsin inhibitors, and could interfere with thyroid function.

Cooked soybeans are difficult for some people to digest causing gas and stomach upset.

Downside to Soy

Trypsin inhibitors can block the enzymes needed for protein digestion. When the protein is improperly digested, then the fermentation and gas production ensues. However, many researchers believe that so few trypsin inhibitors are left behind after processing the soy food into a supplement, that for most people, their digestion is not affected.

Soy and Thyroid function

The genistein and daidzein in soy can also inhibit thyroid hormone synthesis. High soybean diets have been implicated in diet induced goiter. This problem is not likely to occur in an average amount of soy in a varied diet. In some susceptible individuals, or in some who take very high doses of nutritional supplementation of soy isoflavones (above 200 mg per day), it is prudent to be aware of this potential interaction.

Soy and Breast Cancer

• Genistein is also an inhibitor of tyrosine kinases. The tyrosine kinases appear to play a role in cell proliferation and transformation. The inhibition of tyrosine kinase may have beneficial effects in the treatment of cancer. • Isoflavones have been shown to inhibit aromatase. By doing so, they can block the conversion of androstenedione to estrogen thereby another mechanism in reducing the estradiol in the serum and less available estrogen to bind to estrogen receptors.

Phytoestogens and Bone Loss

• Studies have reported that women with high soy diets had a lower risk for osteoporosis. This current report provides additional compelling evidence demonstrating that 54 mg of genistein per day, along with 500 mg of calcium and 400 IU of vitamin D for 2 years can increase the BMD of the lumbar spine and femoral neck. Further evidence is provided by the decreased urinary markers for bone resorption and the increased circulating levels of bone formation markers.

Pytoestrogens and Bone Loss

More than twice as many women had side effects in the genistein group and discontinued treatment because of these symptoms. That said, these side effects are considerably less than those reported for many women who utilize bisphosphanates for bone loss. Although I would not consider genistein an adequate treatment for women with osteoporosis. I would consider genistein an important treatment for osteopeninic women under 65, before they arrive at the age where they are at increased risk of age related fractures.

Estrogenic Herbs

• Arctium lappa: alterative, estrogenic • Angelica sinensis: digestive, anti-spasmodic, hormonal tonic with analgesic, uterine-relaxing properties • Dioscorea villosa: anti-spasmodic, digestive that contains phytoprogesterones (pregnenolone and diosgenin); spastic contractions and nausea in the abdomen; yellow skin and conjunctiva; boring pain radiating from the umbilicus and tenderness. bettter with pressure • Glycyrrhiza glabra: contains phytoestrogens and steroidal estrogenic saponins capable of balancing female hormones; best limited to the first half of menstrual cycle or menopausally 2-3 weeks out of the month to avoid bloating and water retention

Estrogenic Herbs

• Humulus lupulus: a bitter, digestive herb that contains phytoestrogens • Leonurus cardiaca: specifically indicated for uterine pain or atony associated with anxiety, tension and heart palpitations • Medicago sativa: nutritive, contains phytoestrogens capable of providing some estrogenic activity when estrogens are low and competes for estrogen binding sites when estrogens are high.

Menopausal Formulas

General menopause: powdered herbs: Angelica sinensis [2 parts], Arctium lappa [2 parts], Dioscorea villosa [1 part], Glycyrrhiza glabra [2 parts], Leonurus cardiaca [1 part]; SIG: 2 caps.

3x/day or 30 drops tincture of same formula 3x/day Menopause/hot flash/anxiety tincture: Angelica sinensis [1 pt], Chamaelirium luteum [1 pt], Cimicifuga racemosa [1-2 pts], Glycyrrhiza glabra [1/2 to 1 pt], Hypericum perforatum [1 pt], Leonurus cardiaca [1 pt], Medicago sativa [1/2 to 1 pt], Salvia officinalis [1-2 pts], Viburnum prunifolium [1/2 to 1 pt], Vitex agnus castus [2 pts]; SIG: 3-5ml 3x/day away from meals and before bed (can add Taraxacum officinale and Berberis aquifolium)

Another Hot Flash Formula

• Centella asiatica[2 parts], • Leonurus cardiaca [2 parts], • Mentha piperita [3 parts], • Rosemarinus officinalis [1/2 part], • Rubus idaeus [2 parts], • Salvia officinalis [3 parts], • Thymus vulgaris [1 part]; infuse 1 Tbsp. herb mixture in 1 pint of boiling water; SIG: 2-3 cups per day

Suppositories for Vaginal Dryness/elastisity

• Angelica sinensis, powder [1 Tbsp.] • Cupressus sempervirens essential oil [10 drops], Dioscorea villosa, powder [1 Tbsp.] • Glycyrrhiza glabra, powder [1 Tbsp.] • Humulus lupulus essential oil [10 drops], Medicago sativa, powder [1 Tbsp.] • vitamin E oil [2 Tbsp.]; melt 1 oz. cocoa butter and stir in other ingredients OR, simply use a bit of estriol cream, which you can get through a compounding pharmacy.

osteoporosis tea

• Avena sativa [2 parts], • Capsella bursa-pastoris [1 part], • Equisetum hymenale [1 part], • Medicago sativa [2 parts], • Rumex crispus [2 parts], • Taraxacum officinale (leaf) [2 parts], • Urtica spp. [2 parts] • infuse 1 Tbsp. of mixture per pint of boiling water; SIG: 2-3 cups/day

Homeopathic Remedies

• Actea reacemosa/ Cimicifuga : violent headache as if top of head is torn off; neck, back muscles sore. Overall, great menopause remedy.

• Arsenicum album: insomnia; anxiety on going to sleep • Calcarea carbonica: pale, flabby, relaxed, cold, tiresome from overwork; as an intercurrent remedy • Camphor: flushes of heat and sweat in a warm room; limbs and abdomen very cold; suffers from cold when uncovered and copious sweat when covered

Homeopathic Remedies

• Glonoinum: hammering of head, worse in warm room, heat of sun; cannot lie in bed • Lachesis: a main remedy; severe h/a radiating from occiput to front of head; palpitation of heart and pulsation's of body; hypersensitive to touch; flushing • Oophorinum: nervous; acne rosacea or other skin problems • Pulsatilla: irritable temper, changeable; weeps telling symptoms • Sepia: cold, fidgety; spiteful, tired of affection, dislikes sympathy; sudden hot flushes with sweat, weakness and tendency to faint • Sulphur: tiresome; losing weight; skin course and dirty; as an intercurrent remedy

What’s in the research?

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Black Cohosh/St. John’s wort

• A prospective, non-randomized, open-label observational study conducted over two years, in Germany. The purpose of the study was to evaluate the use, safety and effectiveness of black cohosh alone or in combination with St. John’s wort on menopausal symptoms.

Black Cohosh/St. John’s wort

• 6141 women at outpatient gynecology offices were treated with recommended doses of black cohosh, Remefemin (1 cap 2x/day) or Remifemin plus combination with St. Johns wort (1 or 2 tablets 2x/day) at the discretion of the clinician.

Black Cohosh/St. John’s wort

• Treatment responses were assessed on the menopause rating scale (MRS), an established standard for evaluating menopause symptoms. The primary effectiveness variable was the change in the MRS subscore PSYCHE (including depressive mood, nervousness, irritability, impaired performance and memory) from baseline to month three.

• Women receiving combination therapy had significantly higher PSYCHE scores.

• The symptom scores improved in both groups. The changes in the PSYCHE symptoms were greater in the combination therapy group than in the black cohosh only group at month 3 and 6. The greatest effects, with both treatments, were seen with hot flushes and night sweats and these were similar. Results were evident at month 3, and even more so, at month 6.

• Briese V, Stammwitz U, Friede M, Henneicke-von Zepelin H. Black cohosh with Maturitas 2007; 57(4): 405-414.

or without St. John’s wort for symptom-specific climacteric treatment – Results of a large-scale, controlled, observational study.

Black Cohosh

• There are at least 8 or more randomized control trials.

• Works as a phytoestrogen, reduces vaginal dryness.

• Most effective dose is 40 mg/day, or two times per day.

St. John’s Wort and Hot Flashes

A study of St John’s Wort liquid extract showed a statistically decline in hot flashes severity, duration and frequency in the SJW group compared to placebo at week 8.[1] Another double blind randomized clinical trial demonstrated that after 3 months of treatment, women in the St. John’s wort group reported significantly better quality of life scores, and significantly fewer sleep problems compared to placebo. [2]

• The SJW and Black Cohosh studies have been plentiful, too many to list.

MACA

Lepidium Peruvianum/meyenii Maca is a traditional plant common to the Andes Mountains and has been used for centuries to enhance fertility, improve sexual function, improve energy and more. Maca belongs to the mustard family and is considered an adaptogen —helping us to adapt to a variety of stressors.

MACA

Lepidium Peruvianum/meyenii • A systematic review was done to assess the clinical evidence for or against the efficacy of maca for sexual dysfunction. The review included only randomized clinical trials comparing maca to a placebo in men or women with sexual dysfunction.

Maca and sexual dysfunction

• Four randomized controlled trials (RCT) met the inclusion criteria. • Two of these trials suggested a positive effect of maca on sexual dysfunction or libido in menopausal women.

• One other RCT did not show effect of maca in cyclists.

Maca cont

• The fourth study assessed the effects of maca in men with erectile dysfunction and did show significant effects.

• While the evidence is limited, there does appear to be some effectiveness of maca in improving sexual function.

• Shin B, Soo Lee M, Jin Yang E, Lim H, Ernst E. Maca (L. meyenii) for improving sexual function: a systematic review. BMC Complementary and Alternative Medicine 2010;10:44

Maca on anxiety, depression and sexual dysfunction

A small randomized, double-blind, placebo controlled, crossover trial of fourteen postmenopausal women was completed using 3.5 gm of powdered Maca for 6 weeks and matching placebo for 6 weeks. Measurements of estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and sex hormone binding globulin (SHBG) were taken at baseline, and weeks 6 and 12. The Greene Climacteric Scale was used to assess the severity of menopause symptoms.

Maca on anxiety, depression and sexual dysfunction

RESULTS: Serum concentrations of estradiol, FSH, LH and SHBG were similar in both groups. The Greene Climacteric Scale revealed a significant reduction in psychological symptoms including anxiety, depression and sexual dysfunction after Maca consumption compared with baseline and -placebo. These findings were independent of androgenic or alpha estrogenic activity present in the Maca using assays to measure hormone-dependent activity.

Brooks N, Wilcox G, Walker K, et al. Beneficial effects of Lepidium meyenii (Maca) on psychological symptoms and measures of sexual dysfunction in postmenopausal women are not related to estrogen or androgen content. Menopause 2008;15(6):1157-1162.

Maca on anxiety, depression and sexual dysfunction

These results add to the growing body of evidence utilizing Maca for menopause symptoms. There was significant effects on anxiety and depression but in this study it appears to be independent of any measurable influence on sex hormones or SHBG and presumably therefore independent of any action related to the activity of beta-sitosterol, found in Maca. The effect on depression and anxiety are consistent in several studies and it is thought that the flavonoids in Maca inhibit monoamine oxidase activity. The improvement in sexual function in postmenopausal women observed in this study is consistent with research using Maca in men and also in rodents.

Red Ginseng and CVD

This study evaluated the effects of red ginseng on menopausal symptoms and risk factors for cardiovascular disease in menopausal women.

Randomized, placebo-controlled, double-blind clinical trial, 72 postmenopausal women who were randomly assigned to either red ginseng or placebo for 3 months. The red ginseng product given was 3 gm per day which included 60 mg of ginsenosides.

The Kupperman index and the menopause rating scale were used to assess subjective symptoms.

Cardiovascular risk factors were assessed with serum lipid testing, C-reactive protein and the thickness of the carotid artery intima-media. Serum estradiol levels were also tested.

After the 12 week treatment period, the KI for the red ginseng group significantly reduced from 18.93 to 13.32 compared with the placebo from 15.21 to 15.10. The Menopause Rating Scale score dropped significantly from 12.45 to 8.32 in the ginseng group compared with 10.23 to 9.26 in the placebo group. The hot flash score also reduced significantly in the red ginseng group.

There was a significant decrease in total cholesterol from 138.11 to 108.82 compared with the placebo, from 128.52 to 128.03. The drop in LDL was also significant in the red ginseng group compared to placebo but there were no significant differences between the two groups for HDL cholesterol or C-reactive protein. The estrogen levels were not considered to be affected by red ginseng. • The carotid intima-media thickness was significantly reduced in the red ginseng group compared to placebo.

Young Kim S, Kyo Seo S, Mi Choi Y, et al. Effects of red ginseng supplementation on menopausal symptoms and cardiovascular risk factors in postmenopausal women: a double-blind randomized controlled trial. Menopause 2012;19(4):461-466

Red clover helps anxiety/depression

109 postmenopausal women were randomly assigned to take either 2 capsules daily of a red clover extract totaling 80 mg of isoflavones, or a placebo, for 3 months. At the end of the 90 days, there was a one week break, and the two groups switched to take the opposite pills for another 3 months. Their anxiety and depressive symptoms were measured using two common research methods. These measurements were taken prior to the start of the red clover or placebo, then again at 90 days and 187 days.

After taking the red clover extract, women had a significant reduction (improvement) in the scores in both of the rating scales, with a 75% reduction for anxiety and 78.3% reduction for depression using the HADS tool, and an 80.6% reduction in the total SDS score. Conclusion, isoflavones (phytoestroen) helped to ease the decreased estrogen status in the therefore promoting estrogen’s interactions with neurotransmitters that affect mood and cognitive function.

• Reference • Lipovac M, Chedraui P, Gruenhut C, et al. Improvement of postmenopausal depressive and anxiety symptoms after treatment with isoflavones derived from red clover extracts. Maturitas 2010;65:258-261

Valerian for Hot Flashes

Double blind clinical trial, 68 menopausal women with the chief symptom of hot flashes received 225 mg of valerian, three times per day and the other group placebo, for 8 weeks. Symptom diaries (although the questionnaire and specifics of this were not reported in the study) were kept. Results were recorded by the participants and collected by the researchers. After 4 and 8 weeks of treatment, the evaluation of results showed a meaningful difference between the valerian group and the placebo group.

At week 4 and week 8 post-treatment, the valerian group had significantly less severe hot flashes compared with the placebo group. There was no significant change in severity of hot flashes in the placebo group compared with baseline. In addition, at week 4 and 8 post-treatment the valerian group had significantly fewer hot flashes compared with the placebo group. Contain some flavonoids, which are phytoestrogenic components and therefore it is a reasonable hypothesis that it may reduce menopause symptoms.

Nutrafem for Hotflashes

Nutrafem: combination of botanical extracts derived from Vigna radiate (mung beans) and Eucommia ulmoides bark. This phase II, double-blind, randomized, placebo-controlled, multicenter clinical study was conducted in 131 postmenopausal women who had at least 21 hot flashes per week. One group received the product containing 75 mg of E. ulmoides plant extract and 150 mg of V. radiate plant and was given 2 capsules morning and night for 12 weeks, the other placebo.

The botanical combination reduced the number of vasomotor symptoms by 46% from baseline compared with 26% in the placebo group. 43% percent of women taking the botanical had at least a 50% reduction in the number of symptoms compared with only 6% in the placebo group.

Mung beans are familiar to many, as a dietary source of nutrients-whether in sprouted form or other use. High in protein and essential fatty acid content. E. ulmoides is rich in polyphenolic compounds such as lignans and flavonoids.

Garcia J, Gonzaga F, Tan D, et al. Use of a multi-botanical (Nutrafem) for the relief of menopausal vasomotor symptoms: a double blind, placebo-controlled study. Menopause 2010; 17(2):303-308.

Exercise, the best menopause medicine

Regular physical exercise will: – Retain and regain muscle mass – Improve the supply of oxygen to mitochondria – Reduce stress (lower cortisol) – Improve balance and coordination, reducing the likelihood of falls – Build stronger bones (if weight-bearing exercise) – Boost human growth hormone (HGH) levels, naturally – Improve the quality of sleep – Help control blood sugar – Long endurance exercise, (marathon running), is not the best way to prevent or reverse the effects of aging. It causes muscle fatigue, with additional "wear and tear" on your body, and does not build muscle.

Paxil for Hot Flashes??

• No Meaningful Reduction in Hot Flashes Compared to Placebo • Women in the paroxetine clinical trial started with about 10 hot flashes per day. After 12 weeks, those on paroxetine had 4 hot flashes per day compared to 5-6 for the placebo group. Members of the FDA advisory committee said such a marginal difference between the drug and placebo would not be meaningful to women.(New York Times) That is why they voted against approval.

• However, the FDA approved the paroxetine drug against the opposition of an FDA advisory committee voting 10-4 against approval March 2013. (5-17) • Not only is paroxetine, (Paxil) medically ineffective for treatment of menopausal symptoms (a hormone deficiency state), it is one of the most addictive of the SSRI drugs, and the FDA has warned that withdrawal from paroxetine can be severe. Side effects: increased suicidal activity , loss of libido and sexual dysfunction.