General Thoughts about Menopause
What is Menopause?
The menopause is sometimes referred to as the change of life. It is the cessation of menstruation. However, I prefer to refer to it as a transition, or perhaps a triumph in life’s rich tapestry of events. Somewhere between the ages of 45 and 55 years (average 51 years), a woman experiences a normal cessation of menstruation – the menopause. Long before this relatively abrupt event happens, there are hormonal and physical changes in her body. These changes in body structures and functions evolve further in the postmenopause. It is a common misconception that the menopause is a precipitous event, where one day a woman is feminine, vital and sexy and the next day she is not. When these concepts are imagined of the menopause, they can become a self-fulfilling prophecy for some women. To acknowledge this prophecy is nonsensical.
There shows there are many natural ways of handling the normal changes of life in the menopause. Qualities of life such as femininity, sexuality, and confidence can often be maintained by simple, safe, and gentle means without recourse to prescription drugs, with their attendant risks. I shall identify some of the mechanisms whereby these goals can be achieved without resorting prematurely to hormone-replacement therapy (HRT), or by using estrogen replacement therapy (ERT) alone. I wish to present a clear and compelling argument that conventional HRT or ERT often has more risks than benefits. The use of bio-identical hormone replacement therapies is gaining momentum with its promise of greater safety and effectiveness.
Mind-Body (Neurohormonal) Controls
Significant hormonal changes occur in the body in the perimenopausal period (the period of time around the menopause). The ovaries are the site of the female hormone production and the source of the ova (eggs) in a pre-menopausal woman. Around the menopause, the ovaries begin to retire. In the menopause, estrogen production tends to diminish and eventually it all but ceases. Coincidental with this cessation of ovarian function, there are other glands in the body (e.g., the adrenal glands), that start to secrete more sex hormones. Also, fat stores in the body can add to hormonal changes.
Many people (including physicians) have forgotten that fat deposits in the body are hormone “depots.” Since more than 60% of the U.S. population is overweight, the modern pandemic of obesity cannot be ignored as a contributing factor to female hormonal problems. Furthermore, the widespread epidemic of the Metabolic Syndrome X (overweight, high blood pressure, abnormal blood lipids in variable combination with insulin resistance) causes menstrual problems and contributes to poor health in women of premenopausal, menopausal and postmenopausal age. The Metabolic Syndrome X is the key cause of polycystic ovary syndrome (PCOS or Syndrome O). In summary, the menopause is not a simple state of estrogen deficiency, as many people may believe.
There is a major change in the body’s hormonal “concerto” around the time of the menopause. This symphony or concerto is conducted by the pituitary gland. To aid understanding, we can consider this tiny gland to be the leader of the hormonal “orchestra.” The pituitary gland is situated at the front of the base of the skull, beneath the brain. This gland secretes hormones that drive the other hormone-producing glands in the body to work by secreting their own hormones. The pituitary gets its cues (neuro-hormonal) from the brain through its connections with the nervous system. Hence, brain and body are well connected through the control of hormonal secretions in the body. This is the concept of neurohormonal control (brain-hormone regulation). It is one clear pathway of the “mind-body” or “body-mind” connection. The concept of the inextricable linkage within the mind-body or body-mind shines through in this writings on natural medicine.
Precipitation of Menopause
The many factors that actually precipitate the menopause remain incompletely understood. Genetic or hereditary programming plays some role in the timing of the menopause, and there are families where premature (early) menopause occurs for reasons that are not entirely clear. In some circumstances, menopause may occur later than anticipated. Some women continue to menstruate until they are 60 years old. Table 1. shows factors that play varying roles in the occurrence of menopause.
EARLY MENOPAUSE LATE MENOPAUSE
• Underweight • Overweight
• Smoking • Metabolic Syndrome X
• Malnutrition • Diabetes mellitus
• Excessive exercise • Genetic factors
• Environmental toxin • Stress
• Genetic factors • Hormones from within and without
• Stress • Associated with fibroids and uterine cancer
• Cancer chemotherapy or toxic drugs • Lifetime estrogen exposure
• Hysterectomy or tubal ligation
Table 1. Some factors and issues that affect or are associated with the onset of early and late menopause.
Increasing evidence has emerged that lifestyle may play a major role in the timing and manifestations of the menopause. Predictably, poor lifestyle may lead to aggravated symptoms of the menopause and it causes many negative health consequences in the postmenopause. Any circumstance that challenges the harmony of body function will tend to make menopause a poor transition and aggravate disorders of menstrual function. There is some evidence that a “rocky” menopausal transition or troublesome PMS runs in families. In other words, the poorly adjusted or poorly balanced woman is a prime target for women’s menstrual woes. Much scientific literature supports these points of view which are not just “labeling exercises” for menopausal women (or the misguided notions of the andropausal author).
The Events of Menopause and Related Issues
This cessation of menstruation is (menopause) associated with a lack of ability to have children. Fertility of a woman, in general, tends to reduce with age. While this situation occurs also in men, it evolves in a slower fashion. It is not uncommon for virility to persist in men in their seventh decade of life and old men often procreate in modern society (the virile octagenarian is on the horizon).
Menstrual cycles begin at a variable age in puberty, as a consequence of intricate balances between the brain and the hormonal systems of the body. Minor variations in menstrual pattern or flow can be quite common and menstruation can be influenced by factors such as stress, illness, environmental toxins, nutrition or miscellaneous environmental changes.
The definition of when a woman becomes postmenopausal is somewhat open to debate. If menstruation has not occurred in a mature woman for one full year, then she is considered postmenopausal. Menopausal status is sometimes referred to popularly as “the change of life” and many changes in the physical makeup of the mature woman occur over an extended period of time which is sometimes referred to as the “climacteric” or “perimenopause.”
While the female climacteric is variable in its occurrence, menopause most often occurs in women in Western society around the age of 51 years. However, menopause can occur in the age range of 30 to 65, with most examples of menopause occurring in the 45- to 55-year-old age group. There is no precise definition of the climacteric, but its occurrence implies that there is a critical time in a woman’s life that occurs in proximity to the menopause.
It is common around the time of the menopause to have irregular uterine bleeding or sometimes changes in the menstrual flow. There may be episodes of heavy or light menstrual flow. However, excessive uterine bleeding should always prompt a visit to the doctor. Remember, cessation of menstruation can mean pregnancy, even in mature women. When healthcare givers mention the term perimenopause, they are usually referring to the period of several years prior to the menopause. In strict terms, perimenopause refers to the time periods both before and after the menopause.
What to Expect from Perimenopause (Climacteric)
Many readers of this newsletter may be attempting to anticipate or understand what they can expect during the menopausal period, whereas others may already have experienced the changes associated with the menopause. The transition of menopause can have a major effect on family members and close friends. Just as the events that occur through the menopause may be variable, the severity of symptoms or changes that a woman may experience through the menopause can be quite variable.
In Western societies, about one in five or six women goes through the menopause without major discomfort whereas approximately the same number have quite severe symptoms and require intensive supportive care. The remainder of women have variable discomfort of mild or moderate severity. It is not uncommon for a menopausal woman to seek the services of a healthcare giver because of the diversity of symptoms and signs that may produce concern in an otherwise healthy woman.
In brief, the menopause can be viewed as a journey of variable duration with very variable outcomes. Unfortunately, it is not easy to predict whether or not an individual will have severe menopausal symptoms, but some evidence implies that there is familial tendency—a difficult menopause in mothers sometimes predicts a difficult menopause in daughters (Table 2). However, this need not be the case!
TOUGH MENOPAUSE LIKELY SMOOTH MENOPAUSE LIKELY
• A history of PMS • Nulliparous (no children)
• Early or premature menopause • Never married
• Artificial menopause, often because of breast cancer treatment • Pregnancy in later years (30-40)
• A strong family history of “tough menopause” • High income and education
• Women with poor or adverse lifestyles • Well-adjusted women with healthy lifestyle
Table 2. Some generalizations about which women will have a “tough menopause” or a “gentle journey.” Please note, accurate predictions of the severity of menopause are not possible.
Reviewing the Problems of the Menopause
Table 3 highlights the main symptoms and signs that occur in many women around the menopause and defines the serious medical conditions that tend to present themselves after the menopause. It is estimated that as many as 80% to 90% of all mature Western women will experience hot flashes at one time or another around the menopause. Hot flashes are part of the instability that seems to occur in blood vessels as a consequence of hormonal changes around the menopause. They can vary in intensity.
1. SYMPTOMS OF THE CLIMACTERIC
Psychosocial • Depression
• Loss of concentration
• Poor libido
Vascular • Hot flashes
• Night sweats
“Shrinkage” or atrophy • Vaginal dryness
• Urinary dysfunction/urethral syndrome
• Postmenopausal bleeding
• Thin dry skin, dry hair, brittle nails
2. DISEASES OF POSTMENOPAUSE
• Cardiovascular Disease
• Age-Related Cancer
• Cognitive Decline
• Specific Risks of HRT (conventional)
• Residual risks of HRT
Table 3. Symptoms, signs and problems associated with the menopause, perimenopause and the climacteric
Emergence of Natural Medicines
A number of natural remedies have emerged recently with good scientific evidence to support their use as potential or viable alternatives for standard conventional hormone replacement therapy (ERT, HRT), or perhaps even bioidentical hormone replacement therapy (BHRT or BioHRT). There has been a change in the attitudes and characteristics of patients who see healthcare givers. This change has included a self-reliance of patients to look for natural means of addressing medical disorders. There is an ever-increasing move for patients to seek natural options in favor of synthetic pharmaceuticals. This change in treatment paradigms has been forced on many physicians by their patients.
An important component of this change in treatment paradigms towards a natural approach has been patient education. There is increasing recognition of the disadvantages of conventional medical treatments and the media reinforces constantly the opinion that drugs and surgery have considerable limitations. In many sectors of medicine, patients have increased feelings of disenchantment with modern, conventional healthcare. Drug prescriptions or usage directly account for at least 100,000 deaths per year in the USA. I propose that modern medicine could make a major focus on natural options for dealing with the female climacteric without dismissing some of the benefits of the allopathic or conventional medical approach.
Dietary Supplements for Menopause
Of the many natural agents proposed for the management of the menopause transition, most scientific support rests with the use of soy isoflavones and black cohosh (www.naturalclinician.com). There is some evidence that extracts of red clover may be at least as effective as soy isoflavones in controlling certain symptoms of the menopausal transition. This is because of the similarities of the active ingredients of soy and red clover – the isoflavones. Other promising data exists on the benefits of Vitamin E, B complex vitamins, evening primrose oil and Dong quai for menopause and PMS. However, the scientific support for the use of these latter substances in natural ways to a healthy menopause and PMS is somewhat anecdotal, in comparison with the use of natural agents such as soy, red clover and black cohosh.
There are several other botanical extracts or derivatives that may play a role in the symptomatic relief of menopause and PMS. These natural extracts include L-theanine (found in green tea) and herbs such as passionflower, lemon balm, skullcap and valerian root. These natural agents have a general ability to “calm” body functions and they may act as a “natural balancing act” for the body (adaptogens or biological response modifiers). This anti-stress effect on body functions is reflected in the use of the term “adaptogen” by practitioners of herbal medicine. Adaptogens are natural substances that may facilitate body changes that can challenge stress and its metabolic consequences. In other words, adaptogens assist in balancing body functions by modifying biological responses.
My strong opinion is to attempt to use simple, gentle and natural means to deal with the normal transition in life of the menopause. There are groups of patients who suffer greatly in the menopause and they may require more specific treatments, such as hormonal replacement therapy. In future newsletters I shall continue to dissect the complexities of the perimenopause, as I continue to finish my book on this subject.